Acute Pancreatitis: CT Severity Index, Fluid-Resuscitation Nursing Algorithms, and Lipase/CRP as Outcome Markers
Abstract
Background: Acute pancreatitis (AP) is a common, potentially life-threatening inflammatory condition with heterogeneous etiologies and trajectories. Early risk stratification and coordinated supportive care are pivotal to reduce necrosis, organ failure, and resource use.
Aim: To synthesize evidence on three practical pillars of inpatient AP care—radiologic grading by CT Severity Index (CTSI), fluid-resuscitation nursing algorithms, and biochemical markers (lipase and C-reactive protein, CRP)—and to propose an integrated, bedside-ready framework.
Methods: Narrative review of contemporary diagnostic and management domains summarized in this article, emphasizing: (1) imaging roles (ultrasound/CECT/MRI) and CTSI for local complications; (2) nurse-led fluid protocols (targets, choice of crystalloid, ROSE phases); and (3) serial lipase/CRP as outcome markers alongside clinical severity classifications.
Results: CTSI reliably stages local pancreatic/peripancreatic complications and complements clinical systems (e.g., RAC/DBC) for prognostication and timing of interventions. Nurse-delivered resuscitation algorithms with early lactated Ringer’s at 5–10 mL/kg/h, dynamic endpoints (heart rate <120 beats/min, urine output >0.5 mL/kg/h), and avoidance of overload reduce SIRS, organ failure, and length of stay. Early enteral nutrition embedded in nursing pathways improves tolerance and pain trajectories. Lipase confirms diagnosis but trends add limited prognostic value; CRP trajectories (e.g., 48–72 h) better correlate with severity and necrosis, especially when interpreted with imaging and physiology. Multidisciplinary coordination among radiology, laboratory, and nursing closes operational gaps and accelerates definitive etiologic care.
Conclusion: An integrated pathway combining CTSI-guided imaging, protocolized nurse-led fluid resuscitation, and judicious use of lipase/CRP improves risk recognition, streamlines decisions, and may reduce complications and costs in AP.
Full text article
References
Petrov, M.S.; Yadav, D. Global epidemiology and holistic prevention of pancreatitis. Nat. Rev. Gastroenterol. Hepatol. 2019, 16, 175–184.
Della Corte, C.; Faraci, S.; Majo, F.; Lucidi, V.; Fishman, D.S.; Nobili, V. Pancreatic disorders in children: New clues on the horizon. Dig. Liver Dis. 2018, 50, 886–893.
Andersson, B.; Appelgren, B.; Sjödin, V.; Ansari, D.; Nilsson, J.; Persson, U.; Tingstedt, B.; Andersson, R. Acute pancreatitis–costs for healthcare and loss of production. Scand. J. Gastroenterol. 2013, 48, 1459–1465.
Banks, P.A.; Bollen, T.L.; Dervenis, C.; Gooszen, H.G.; Johnson, C.D.; Sarr, M.G.; Tsiotos, G.G.; Vege, S.S. Classification of acute pancreatitis—2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013, 62, 102–111.
Rompianesi, G.; Hann, A.; Komolafe, O.; Pereira, S.P.; Davidson, B.R.; Gurusamy, K.S. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis. Cochrane Database Syst. Rev. 2017, CD012010.
Busireddy, K.K.; AlObaidy, M.; Ramalho, M.; Kalubowila, J.; Baodong, L.; Santagostino, I.; Semelka, R.C. Pancreatitis-imaging approach. World J. Gastrointest. Pathophysiol. 2014, 5, 252–270.
Kiriyama, S.; Gabata, T.; Takada, T.; Hirata, K.; Yoshida, M.; Mayumi, T.; Hirota, M.; Kadoya, M.; Yamanouchi, E.; Hattori, T.; et al. New diagnostic criteria of acute pancreatitis. J. Hepato-Biliary-Pancreat. Sci. 2010, 17, 24–36.
Matta, B.; Gougol, A.; Gao, X.; Reddy, N.; Talukdar, R.; Kochhar, R.; Goenka, M.K.; Gulla, A.; Gonzalez, J.A.; Singh, V.K.; et al. Worldwide variations in demographics, management, and outcomes of acute pancreatitis. Clin. Gastroenterol. Hepatol. 2020, 18, 1567–1575.
Lankisch, P.G.; Assmus, C.; Lehnick, D.; Maisonneuve, P.; Lowenfels, A.B. Acute pancreatitis: Does gender matter? Dig. Dis. Sci. 2001, 46, 2470–2474.
Lammert, F.; Gurusamy, K.; Ko, C.W.; Miquel, J.F.; Méndez-Sánchez, N.; Portincasa, P.; Van Erpecum, K.J.; Van Laarhoven, C.J.; Wang, D.Q. Gallstones. Nat. Rev. Dis. Primers 2016, 2, 16024.
Hodgson, R.J.; John, B.; Abbasi, T.; Hodgson, R.C.; Waller, S.; Thom, B.; Newcombe, R.G. Fast screening for alcohol misuse. Addict. Behav. 2003, 28, 1453–1463.
Yadav, D.; Lowenfels, A.B. Trends in the epidemiology of the first attack of acute pancreatitis: A systematic review. Pancreas 2006, 33, 323–330.
Yadav, D.; Lowenfels, A.B. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology 2013, 144, 1252–1261.
Roberts, S.E.; Akbari, A.; Thorne, K.; Atkinson, M.; Evans, P.A. The incidence of acute pancreatitis: Impact of social deprivation, alcohol consumption, seasonal and demographic factors. Aliment. Pharmacol. Ther. 2013, 38, 539–548.
Wu, D.; Tang, M.; Zhao, Y.; Zhou, S.; Xu, X.; Wang, F.; Liu, H.; Wu, M. Impact of seasons and festivals on the onset of acute pancreatitis in Shanghai, China. Pancreas 2017, 46, 496–503.
Nielsen, J.K.; Olafsson, S.; Bergmann, O.M.; Runarsdottir, V.; Hansdottir, I.; Sigurdardottir, R.; Björnsson, E.S. Lifetime drinking history in patients with alcoholic liver disease and patients with alcohol use disorder without liver disease. Scand. J. Gastroenterol. 2017, 52, 762–767.
Yadav, D.; Hawes, R.H.; Brand, R.E.; Anderson, M.A.; Money, M.E.; Banks, P.A.; Bishop, M.D.; Baillie, J.; Sherman, S.; DiSario, J.; et al. Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis. Arch. Intern. Med. 2009, 169, 1035–1045.
Yadav, D.; O’connell, M.; Papachristou, G.I. Natural history following the first attack of acute pancreatitis. Off. J. Am. Coll. Gastroenterol.|ACG 2012, 107, 1096–1103.
Maléth, J.; Balázs, A.; Pallagi, P.; Balla, Z.; Kui, B.; Katona, M.; Judák, L.; Németh, I.; Kemény, L.V.; Rakonczay, Z., Jr.; et al. Alcohol disrupts levels and function of the cystic fibrosis transmembrane conductance regulator to promote development of pancreatitis. Gastroenterology 2015, 148, 427–439.
Carr, R.A.; Rejowski, B.J.; Cote, G.A.; Pitt, H.A.; Zyromski, N.J. Systematic review of hypertriglyceridemia-induced acute pancreatitis: A more virulent etiology? Pancreatology 2016, 16, 469–476.
Zhang, R.; Deng, L.; Jin, T.; Zhu, P.; Shi, N.; Jiang, K.; Li, L.; Yang, X.; Guo, J.; Yang, X.; et al. Hypertriglyceridaemia-associated acute pancreatitis: Diagnosis and impact on severity. HPB 2019, 21, 1240–1249.
Berglund, L.; Brunzell, J.D.; Goldberg, A.C.; Goldberg, I.J.; Sacks, F.; Murad, M.H.; Stalenhoef, A.F. Evaluation and treatment of hypertriglyceridemia: An Endocrine Society clinical practice guideline. J. Clin. Endocrinol. Metab. 2012, 97, 2969–2989.
Murphy, M.J.; Sheng, X.; MacDonald, T.M.; Wei, L. Hypertriglyceridemia and acute pancreatitis. JAMA Intern. Med. 2013, 173, 162–164.
Besselink, M.; van Santvoort, H.; Freeman, M.; Gardner, T.; Mayerle, J.; Vege, S.S.; Werner, J.; Banks, P.; McKay, C.; Fernandez-del Castillo, C.; et al. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013, 13 (Suppl. S2), E1–E5.
Vinklerová, I.; Procházka, M.; Procházka, V.; Urbánek, K. Incidence, severity, and etiology of drug-induced acute pancreatitis. Dig. Dis. Sci. 2010, 55, 2977–2981.
Szatmary, P.; Grammatikopoulos, T.; Cai, W.; Huang, W.; Mukherjee, R.; Halloran, C.; Beyer, G.; Sutton, R. Acute pancreatitis: Diagnosis and treatment. Drugs 2022, 82, 1251–1276.
Jones, M.R.; Hall, O.M.; Kaye, A.M.; Kaye, A.D. Drug-induced acute pancreatitis: A review. Ochsner J. 2015, 15, 45–51.
Tenenbein, M.S.; Tenenbein, M. Acute pancreatitis due to erythromycin overdose. Pediatr. Emerg. Care 2005, 21, 675–676.
Kochar, B.; Akshintala, V.S.; Afghani, E.; Elmunzer, B.J.; Kim, K.J.; Lennon, A.M.; Khashab, M.A.; Kalloo, A.N.; Singh, V.K. Incidence, severity, and mortality of post-ERCP pancreatitis: A systematic review by using randomized, controlled trials. Gastrointest. Endosc. 2015, 81, 143–149.
Funatsu, E.; Masuda, A.; Takenaka, M.; Nakagawa, T.; Shiomi, H.; Yoshinaka, H.; Kobayashi, T.; Sakai, A.; Yagi, Y.; Yoshida, M.; et al. History of post-endoscopic retrograde cholangiopancreatography pancreatitis and acute pancreatitis as risk factors for post-ERCP pancreatitis. Kobe J. Med. Sci. 2017, 63, E1.
Kamisawa, T. Clinical significance of the minor duodenal papilla and accessory pancreatic duct. J. Gastroenterol. 2004, 39, 605–615.
Mukherjee, R.; Smith, A.; Sutton, R. Covid-19-related pancreatic injury. J. Br. Surg. 2020, 107, e190.
Fernández-del Castillo, C.; Harringer, W.; Warshaw, A.L.; Vlahakes, G.J.; Koski, G.; Zaslavsky, A.M.; Rattner, D.W. Risk factors for pancreatic cellular injury after cardiopulmonary bypass. N. Engl. J. Med. 1991, 325, 382–387.
Barreto, S.G.; Habtezion, A.; Gukovskaya, A.; Lugea, A.; Jeon, C.; Yadav, D.; Hegyi, P.; Venglovecz, V.; Sutton, R.; Pandol, S.J. Critical thresholds: Key to unlocking the door to the prevention and specific treatments for acute pancreatitis. Gut 2021, 70, 194–203.
Petersen, O.H.; Gerasimenko, J.V.; Gerasimenko, O.V.; Gryshchenko, O.; Peng, S. The roles of calcium and ATP in the physiology and pathology of the exocrine pancreas. Physiol. Rev. 2021, 101, 1691–1744.
Biczo, G.; Vegh, E.T.; Shalbueva, N.; Mareninova, O.A.; Elperin, J.; Lotshaw, E.; Gretler, S.; Lugea, A.; Malla, S.R.; Dawson, D.; et al. Mitochondrial dysfunction, through impaired autophagy, leads to endoplasmic reticulum stress, deregulated lipid metabolism, and pancreatitis in animal models. Gastroenterology 2018, 154, 689–703.
Sendler, M.; Dummer, A.; Weiss, F.U.; Krüger, B.; Wartmann, T.; Scharffetter-Kochanek, K.; van Rooijen, N.; Malla, S.R.; Aghdassi, A.; Halangk, W.; et al. Tumour necrosis factor α secretion induces protease activation and acinar cell necrosis in acute experimental pancreatitis in mice. Gut 2013, 62, 430–439.
Gukovskaya, A.S.; Gukovsky, I.; Algül, H.; Habtezion, A. Autophagy, inflammation, and immune dysfunction in the pathogenesis of pancreatitis. Gastroenterology 2017, 153, 1212–1226.
Liu, J.; Huang, L.; Luo, M.; Xia, X. Bacterial translocation in acute pancreatitis. Crit. Rev. Microbiol. 2019, 45, 539–547.
Yu, S.; Xiong, Y.; Xu, J.; Liang, X.; Fu, Y.; Liu, D.; Yu, X.; Wu, D. Identification of dysfunctional gut microbiota through rectal swab in patients with different severity of acute pancreatitis. Dig. Dis. Sci. 2020, 65, 3223–3237.
Navina, S.; Acharya, C.; DeLany, J.P.; Orlichenko, L.S.; Baty, C.J.; Shiva, S.S.; Durgampudi, C.; Karlsson, J.M.; Lee, K.; Bae, K.T.; et al. Lipotoxicity causes multisystem organ failure and exacerbates acute pancreatitis in obesity. Sci. Transl. Med. 2011, 3, 107–110.
De Oliveira, C.; Khatua, B.; Noel, P.; Kostenko, S.; Bag, A.; Balakrishnan, B.; Patel, K.S.; Guerra, A.A.; Martinez, M.N.; Trivedi, S.; et al. Pancreatic triglyceride lipase mediates lipotoxic systemic inflammation. J. Clin. Investig. 2020, 130, 1931–1947.
Dellinger, E.P.; Forsmark, C.E.; Layer, P.; Lévy, P.; Maraví-Poma, E.; Petrov, M.S.; Shimosegawa, T.; Siriwardena, A.K.; Uomo, G.; Whitcomb, D.C.; et al. Determinant-based classification of acute pancreatitis severity: An international multidisciplinary consultation. Ann. Surg. 2012, 256, 875–880.
Petrov, M.S.; Shanbhag, S.; Chakraborty, M.; Phillips, A.R.; Windsor, J.A. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 2010, 139, 813–820.
Schepers, N.J.; Bakker, O.J.; Besselink, M.G.; Ali, U.A.; Bollen, T.L.; Gooszen, H.G.; van Santvoort, H.C.; Bruno, M.J. Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis. Gut 2019, 68, 1044–1051.
Komara, N.L.; Paragomi, P.; Greer, P.J.; Wilson, A.S.; Breze, C.; Papachristou, G.I.; Whitcomb, D.C. Severe acute pancreatitis: Capillary permeability model linking systemic inflammation to multiorgan failure. Am. J. Physiol. Gastrointest. Liver Physiol. 2020, 319, G573–G583.
Hong, W.; Lin, S.; Zippi, M.; Geng, W.; Stock, S.; Basharat, Z.; Cheng, B.; Pan, J.; Zhou, M. Serum Albumin Is Independently Associated with Persistent Organ Failure in Acute Pancreatitis. Can. J. Gastroenterol. Hepatol. 2017, 2017, 5297143
Robert, J.H.; Frossard, J.L.; Mermillod, B.; Soravia, C.; Mensi, N.; Roth, M.; Rohner, A.; Hadengue, A.; Morel, P. Early prediction of acute pancreatitis: Prospective study comparing computed tomography scans, Ranson, Glascow, Acute Physiology and Chronic Health Evaluation II scores, and various serum markers. World J. Surg. 2002, 26, 612–619.
van den Berg, F.F.; Kempeneers, M.A.; van Santvoort, H.C.; Zwinderman, A.H.; Issa, Y.; Boermeester, M.A. Meta-analysis and field synopsis of genetic variants associated with the risk and severity of acute pancreatitis. BJS Open 2020, 4, 3–15.
Shabanzadeh, D.M. Incidence of gallstone disease and complications. Curr. Opin. Gastroenterol. 2018, 34, 81–89.
Somasekar, K.; Foulkes, R.; Morris-Stiff, G.; Hassn, A. Acute pancreatitis in the elderly-Can we perform better? Surgeon 2011, 9, 305–308.
Baeza-Zapata, A.A.; García-Compeán, D.; Jaquez-Quintana, J.O.; Scharrer-Cabello, S.I.; Del Cueto-Aguilera, Á.N.; Maldonado-Garza, H.J. Acute pancreatitis in elderly patients. Gastroenterology 2021, 161, 1736–1740.
Park, J.; Fromkes, J.; Cooperman, M. Acute pancreatitis in elderly patients: Pathogenesis and outcome. Am. J. Surg. 1986, 152, 638–642.
Minato, Y.; Kamisawa, T.; Tabata, T.; Hara, S.; Kuruma, S.; Chiba, K.; Kuwata, G.; Fujiwara, T.; Egashira, H.; Koizumi, K.; et al. Pancreatic cancer causing acute pancreatitis: A comparative study with cancer patients without pancreatitis and pancreatitis patients without cancer. J. Hepato-Biliary-Pancreat. Sci. 2013, 20, 628–633.
Majumder, S.; Takahashi, N.; Chari, S.T. Autoimmune pancreatitis. Dig. Dis. Sci. 2017, 62, 1762–1769.
Morinville, V.D.; Lowe, M.E.; Ahuja, M.; Barth, B.; Bellin, M.D.; Davis, H.; Durie, P.R.; Finley, B.; Fishman, D.S.; Freedman, S.D.; et al. Design and implementation of INSPPIRE. J. Pediatr. Gastroenterol. Nutr. 2014, 59, 360–364.
Yang, Z.; Guo, G.; Li, H. Predicting fetal loss in severe acute pancreatitis during pregnancy: A 5-year single-tertiary-center retrospective analysis. Postgrad. Med. 2020, 132, 473–478.
Ducarme, G.; Maire, F.; Chatel, P.; Luton, D.; Hammel, P. Acute pancreatitis during pregnancy: A review. J. Perinatol. 2014, 34, 87–94.
Pitchumoni, C.S.; Yegneswaran, B. Acute pancreatitis in pregnancy. World J. Gastroenterol. 2009, 15, 5641–5646.
Tetsche, M.S.; Jacobsen, J.; Nørgaard, M.; Baron, J.A.; Sørensen, H.T. Postmenopausal hormone replacement therapy and risk of acute pancreatitis: A population-based case-control study. Off. J. Am. Coll. Gastroenterol.|ACG 2007, 102, 275–278.
Aljenedil, S.; Hegele, R.A.; Genest, J.; Awan, Z. Estrogen-associated severe hypertriglyceridemia with pancreatitis. J. Clin. Lipidol. 2017, 11, 297–300.
O’Driscoll, B.R.; Howard, L.S.; Earis, J.; Mak, V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017, 72 (Suppl. S1), ii1–ii90.
Machicado, J.D.; Papachristou, G.I. Intravenous fluid resuscitation in the management of acute pancreatitis. Curr. Opin. Gastroenterol. 2020, 36, 409–416.
Malbrain, M.L.; Langer, T.; Annane, D.; Gattinoni, L.; Elbers, P.; Hahn, R.G.; De Laet, I.; Minini, A.; Wong, A.; Ince, C.; et al. Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA). Ann. Intensive Care 2020, 10, 64.
Wu, B.U.; Hwang, J.Q.; Gardner, T.H.; Repas, K.; Delee, R.; Yu, S.; Smith, B.; Banks, P.A.; Conwell, D.L. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin. Gastroenterol. Hepatol. 2011, 9, 710–717.
Iqbal, U.; Anwar, H.; Scribani, M. Ringer’s lactate versus normal saline in acute pancreatitis: A systematic review and meta-analysis. J. Dig. Dis. 2018, 19, 335–341.
Ona, X.B.; Comas, D.R.; Urrútia, G. Opioids for acute pancreatitis pain. Cochrane Database Syst. Rev.
Authors
Copyright (c) 2025 Abdulmohsen Ateeq Alamari, Adel Garsan Seed Alzahrani, Fahad Mohmmed Saead Alqhtani, Fatimah Mousa Ibrahim Alsekiny, Adel Maqbul Mutlaq Alsharar, Hussain Homoud Habibi Namazi, Mohammed Ahmed Mohammed Muyidi , Ahmed Saud Alhejaili, Hosam Hasan Alzhrani , Wazan Maeid Al-Anzi
This work is licensed under a Creative Commons Attribution 4.0 International License.