A 52-year-old with gallstones presents with severe epigastric pain, lipase 2400, lactate 4.2, SpO2 90% on air, oliguric. Walk us through your management.

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Severe acute pancreatitis with multi-organ failure. ABCDE in resus — high-flow O2, two large-bore cannulae, ABG, lactate, FBC, U&E, LFTs, calcium, glucose, CRP, amylase, lipase, group and save. I'd calculate the Glasgow score and confirm severity given the lactate, hypoxia and oliguria. Resuscitate with moderate-rate Hartmann's titrated to urine output and lactate, mindful of WATERFALL trial data against aggressive fluids. Early HDU referral for vasopressor and possible RRT. I'd arrange urgent USS for gallstones and dilated CBD, and if cholangitis or persistent obstruction is present I'd liaise with ERCP within 72 hours. Otherwise MRCP. I'd avoid prophylactic antibiotics, start NG/NJ enteral feeding within 72 hours, and book index-admission cholecystectomy once recovered. I'd keep the family fully informed given the high mortality of severe AP.

Severe acute pancreatitis with organ failure

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