A 56-year-old with epigastric pain radiating to the back, lipase 5x ULN, T 38.5, HR 115, BP 95/55, lactate 3.5. USS: gallstones, dilated CBD 9 mm. How do you manage?

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This is **severe gallstone pancreatitis with cholangitis features** — tachycardia, hypotension, fever, raised lactate and a dilated CBD. Management follows **BSG / IAP** and **Atlanta 2012**.

**ABCDE and resuscitation.** Two large-bore IV, arterial line, urinary catheter, monitoring. **Goal-directed fluid resuscitation with Hartmann's** at 5–10 ml/kg/h titrated to urine output ≥0.5 ml/kg/h, MAP ≥65 and falling lactate — the **WATERFALL trial (NEJM 2022)** showed aggressive resuscitation increases fluid overload without benefit.

**Investigations.** FBC, U&E, LFTs, calcium, magnesium, glucose, triglycerides, ABG, lactate, CRP, coagulation, blood cultures. **Glasgow score at 48 h, APACHE II, CRP >150** all stratify severity. Urgent **abdominal USS** confirmed gallstones and CBD dilation; **MRCP** is the next imaging if cholangitis remains uncertain. **CECT pancreas is best at 72–96 hours** to assess necrosis — not in the first 24 hours unless diagnosis uncertain.

**Identify and treat cholangitis.** With fever, tachycardia, hypotension and dilated CBD, this is **acute cholangitis (Tokyo guidelines)** until proven otherwise. **IV piperacillin-tazobactam**, blood cultures, and **ERCP with sphincterotomy within 24 hours** is indicated (BSG / NICE NG104). Without cholangitis or persistent obstruction, routine early ERCP does **not** benefit gallstone pancreatitis.

**Supportive care.** Generous analgesia (IV opioid PCA), antiemetics, **early enteral feeding within 72 hours** (NG or NJ) — reduces infectious complications and mortality vs TPN. **No prophylactic antibiotics** for sterile necrosis.

**Escalation.** ITU/HDU for organ failure (Marshall score). Phone the **tertiary HPB centre** early for suspected necrosis or infected collections — endoscopic / percutaneous step-up approach is preferred over open necrosectomy (PANTER trial).

**Definitive treatment.** **Index-admission laparoscopic cholecystectomy** for mild gallstone pancreatitis (NICE NG104); delayed cholecystectomy at 6 weeks for severe disease once inflammation has settled.

**Communication.** Honest conversation about severe pancreatitis mortality (15–20%), ITU course, and the staged surgical plan. Document and Datix any avoidable delay to ERCP.

Severe acute gallstone pancreatitis with early sepsis

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