About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Commonest causes: gallstones (~40%) and alcohol (~30%) — mnemonic GET SMASHED for rarer causes
- Diagnosis: acute epigastric pain + serum lipase (or amylase) >3× upper limit of normal (lipase preferred)
- Severity assessment: modified Glasgow score (≥3 = severe), CRP >150 mg/L at 48h predicts severe disease
- Management: aggressive IV fluid resuscitation, analgesia, nil by mouth initially then early oral feeding when tolerated
- Gallstone pancreatitis: cholecystectomy during same admission (or within 2 weeks) to prevent recurrence
Overview
Acute pancreatitis is an inflammatory condition of the pancreas characterised by acute-onset upper abdominal pain, elevated pancreatic enzymes, and characteristic imaging findings. Severity ranges from mild self-limiting oedematous pancreatitis (~80%) to severe necrotising pancreatitis (~20%) with multiorgan failure and significant mortality. The two predominant causes are gallstones (biliary) and alcohol. Rarer causes include hypertriglyceridaemia, post-ERCP, drugs (azathioprine, valproate, steroids), autoimmune pancreatitis, trauma, and idiopathic.
Epidemiology
The UK incidence is approximately 30–56 per 100,000 per year and rising. It accounts for approximately 25,000 hospital admissions per year in England. Gallstone pancreatitis is more common in females and older age groups, while alcohol-related pancreatitis is more common in males aged 30–50. Overall mortality is ~5% but rises to 20–30% in severe necrotising pancreatitis. Approximately 25% of patients develop moderate or severe disease.
Clinical Features
Symptoms
Severe epigastric pain radiating straight through to the back (classic)
Pain relieved by sitting forward and worsened by lying flat
Nausea and vomiting (often persistent)
Anorexia
History of gallstones, alcohol binge, or recent ERCP
Fever and rigors (suggests infected necrosis or cholangitis)
Dyspnoea (pleural effusion or ARDS in severe disease)
Signs
Epigastric tenderness with guarding
Abdominal distension (paralytic ileus)
Tachycardia and hypotension (third-space fluid loss, SIRS)
Jaundice (if gallstone impacted at ampulla)
Grey-Turner sign (flank bruising) — haemorrhagic pancreatitis (rare, late sign)
Cullen sign (periumbilical bruising) — haemorrhagic pancreatitis (rare, late sign)
Reduced breath sounds at left base (sympathetic pleural effusion)
Investigations
First-line
Serum lipase (preferred) or amylase>3× upper limit of normal supports diagnosis. Lipase is more sensitive and specific than amylase. Note: amylase may be normal in late presentation or chronic pancreatitis
FBC, CRP, U&Es, LFTs, calcium, glucose, ABG/VBGCRP >150 mg/L at 48h predicts severe disease. LFTs to assess biliary cause. Calcium may fall (prognostic marker)
Abdominal ultrasoundFirst-line imaging — look for gallstones (biliary cause), dilated CBD, pancreatic swelling, free fluid
Second-line
CT abdomen with contrastNot routinely indicated at presentation. Perform at 72–96 hours if severe/not improving — to identify pancreatic necrosis, collections, or complications
Modified Glasgow (Imrie) scoreAssess at 48h: PaO₂ <8, Age >55, Neutrophils (WCC >15), Calcium <2, Renal (urea >16), Enzymes (LDH >600, AST >200), Albumin <32, Sugar (glucose >10). Score ≥3 = severe
MRCPIf biliary cause suspected but USS inconclusive — identifies CBD stones without ERCP risk
Specialist
ERCPWithin 72 hours if cholangitis or obstructed CBD (dilated duct + jaundice + raised bilirubin). Not for pancreatitis alone without biliary obstruction
CT-guided aspirationOf pancreatic necrosis if infected necrosis suspected (gas bubbles on CT, persistent sepsis) — for MC&S
Management
NICE NG104 (Pancreatitis), 20181
Supportive care
- Aggressive IV fluid resuscitation: crystalloid (Hartmann's preferred), 250–500 mL/h initially, guided by urine output (>0.5 mL/kg/h)
- Analgesia: IV paracetamol + opioid (morphine or tramadol) — no evidence that opioids worsen pancreatitis
- Nil by mouth initially, then early oral feeding (within 24–72 h) when pain improving and tolerated — enteral nutrition preferred over TPN
- Antiemetics, urinary catheter, and VTE prophylaxis
2
Biliary pancreatitis
- Cholecystectomy during the SAME admission (or within 2 weeks) to prevent recurrence — NICE NG104 recommendation
- ERCP within 72 hours ONLY if concurrent cholangitis or persistent biliary obstruction
- Do NOT perform ERCP routinely for gallstone pancreatitis without obstruction
3
Severe/necrotising pancreatitis
- HDU/ICU admission for organ support
- Do NOT give prophylactic antibiotics (no mortality benefit)
- Infected necrosis: antibiotics (e.g. meropenem) + delayed intervention (endoscopic/surgical necrosectomy) — step-up approach preferred over primary open surgery
- Drainage of symptomatic pseudocysts or walled-off necrosis (endoscopic or percutaneous)
4
Alcohol-related pancreatitis
- Alcohol cessation counselling and referral to alcohol services
- Advise complete alcohol abstinence to reduce recurrence risk
- Brief intervention and assess for alcohol dependence
Complications
- Pancreatic necrosis: Sterile or infected — infected necrosis carries 30% mortality. Suspect if persistent fever/SIRS >7–10 days, gas on CT
- Pseudocyst: Encapsulated collection of pancreatic fluid, typically 4+ weeks post-acute episode. Drain if symptomatic or >6 cm
- Pancreatic abscess: Infected collection — requires drainage
- Organ failure: ARDS, AKI, shock — defines severe pancreatitis (revised Atlanta classification)
- Splanchnic vein thrombosis: Portal/splenic vein thrombosis
- Pancreatic duct disruption: May cause pancreatic fistula or disconnected duct syndrome
UKMLA Exam Tips
- 1GET SMASHED: Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion sting, Hypertriglyceridaemia/Hypercalcaemia/Hypothermia, ERCP, Drugs
- 2Lipase is more specific than amylase for pancreatitis. Amylase also raised in perforated viscus, ectopic pregnancy, DKA, parotitis
- 3Grey-Turner (flanks) and Cullen (periumbilical) signs = retroperitoneal haemorrhage in severe haemorrhagic pancreatitis — poor prognosis
- 4Modified Glasgow score ≥3 at 48h = severe pancreatitis → consider HDU/ICU
- 5ERCP only if cholangitis or persistent biliary obstruction — NOT routinely for gallstone pancreatitis
- 6Cholecystectomy during SAME admission for gallstone pancreatitis (or within 2 weeks) — this is commonly examined
- 7Do NOT give prophylactic antibiotics in acute pancreatitis — no mortality benefit (NICE NG104)
practicetest your knowledge on acute pancreatitisApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
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