A caveat is that CT misses gallstones about 20% of the time because the stones are nonradiolucent – and gallstones are the number one cause of acute pancreatitis in women. The laboratory parameter most predictive of gallstone pancreatitis is an alanine transaminase (ALT) level at least twice the upper limit of normal. Ultrasound is the best imaging method for gallstones and for evaluation of the size of the common bile duct, although it can be difficult to image the pancreas and gallbladder using ultrasound in an obese patient.
As soon as a physician has determined that two of the three Atlanta criteria for acute pancreatitis are present, the crucial next step is to immediately give a 1- to 2-L bolus of intravenous lactated Ringer’s solution, following up at an infusion rate of 250-300 mL/hr. This is the initial intervention in what gastroenterologists have lately begun calling "the golden hours" of management in acute pancreatitis in recognition that taking certain steps in the first 24 hours has a major impact on morbidity and mortality. For example, starting lactated Ringer’s solution in the first hour of acute pancreatitis has been shown to result in an absolute 8.5% reduction in mortality. It is also far more effective than normal saline in preventing or reversing SIRS. The lactated Ringer’s prevents pancreatic enzymes from going hematogenous and causing extrapancreatic tissue breakdown.
In addition to aggressive fluid resuscitation, other elements of "golden hours" management include monitoring of urine output, oxygen, pain control with careful monitoring of oxygen saturation, and monitoring for SIRS. Centers of Excellence where the golden hours approach has been adopted have a 25% reduction in the relative risk of mortality (Gastroenterology 2013;144:1272-81).
In 2013 there is no longer any role for prophylactic antibiotics in patients with acute pancreatitis. Nasogastric decompression, which was once routine, is now done only for symptomatic ileus. Nor is endoscopic cholangiopancreatography appropriate for biliary pancreatitis within the first 24 hours save when ascending cholangitis is present or in the setting of a deteriorating clinical course with worsening liver function tests. Otherwise, the time to perform ERCP, Dr. McNally stressed, is after resolution of acute pancreatitis.
He reported having no financial conflicts.