• Suspect acute pancreatitis in any patient with epigastric pain and in patients with impaired general condition of unknown aetiology and a history of alcohol consumption.
• Identify acute pancreatitis at an early stage on the basis of the clinical presentation and determination of plasma amylase.
• The severity of the pancreatitis and the line of treatment are assessed as an emergency case in specialized care.

• There is substantial variation in the annual incidence across populations, ranging from a few to more than a hundred cases per 100,000 person-years https://www.gastrojournal.org/article/S0016-5085(21)03546-0/fulltext. The incidence has been on the increase in Europe and North America during the past decades, while being stable in Asia.
• Alcohol and gallstones are the most common causes, and their ratio varies across countries https://www.sciencedirect.com/science/article/abs/pii/S1424390317300170.

• Ask about alcohol consumption, biliary diseases and earlier episodes of pancreatitis.
  • Investigate alcohol consumption (Recognition of alcohol and drug abuse) in detail by type of drink and, when possible, an AUDIT survey .
• Girdle-like epigastric pain radiating to the back is typical, starting after abundant alcohol consumption.
• The general condition is most important.
• Shock, respiratory distress, anuria and mental confusion may indicate severe pancreatitis.
• Record epigastric tenderness and palpable masses.
• Examine the skin of the flanks and navel for haematomas (Grey-Turner's or Cullen's sign).
• Observe symptoms and clinical findings of peritonitis or intestinal paralysis.

• An increase in plasma amylase concentration (amylase or pancreatic amylase) is suggestive of pancreatitis. An increase of more than three times the upper limit of the reference value is considered diagnostic.
• Plasma CRP is a good test in the assessment of the severity of pancreatitis, although the concentration is not necessarily increased in the very initial stage of the disease. A concentration above 100 mg/l suggests severe pancreatitis.
• High ALT concentration suggests gallstone pancreatitis .
• If the aetiology is unclear it is advisable to determine plasma ionized calcium and plasma triglyceride concentrations in the initial stage of the disease already.

• If the patient has both typical abdominal pain and clearly increased (more than 3 times the upper limit of the reference value) plasma amylasis concentration, making a pancreatitis diagnosis does not require imaging.
• Contrast-enhanced computed tomography (CT) is the most accurate imaging method for diagnosing and assessing the severity of pancreatitis. Before administering the contrast medium, the patient’s renal function should be checked.
• Ultrasonography may give clues about gallstones as the possible aetiology of the pancreatitis, and, when needed, magnetic resonance cholangiopancreatography (MRCP) shows or excludes choledocholithiasis.

Mild pancreatitis

• Even mild pancreatitis should be followed up in a hospital because of the risk of complications.
• Sufficient early fluid resuscitation is the basis of conservative treatment. Even mild pancreatitis causes dehydration, and the minimum requirement for fluids during the first 24 hours is 3–4 l. Fluid resuscitation is continued according to the clinical condition and urine output. Ringer’s solution is well suited for intravenous fluid therapy.
• Adequate analgesia and follow-up are an essential part of the treatment.
• Antimicrobial drugs, other medications and nasogastric suction have not been proven to have an impact on the healing of the disease. A nasogastric tube can be used if the patient vomits profusely because of intestinal paralysis.
• Plasma CRP and glucose, basic blood count with platelets, sodium, and potassium should be determined daily.
• Sufficient rehydration is ensured by intravenous infusions with concurrent monitoring of diuresis, and peroral nutrition is started as soon as possible .

Biliary pancreatitis

• Urgent, performed as soon as possible (within 1–2 days), sphincterotomy and removal of gallstones from the common bile duct on ERCP improves the prognosis in severe pancreatitis, if there are signs of biliary obstruction or cholangitis.
• In mild biliary pancreatitis, operative removal of the gall bladder during the same hospital stay is aimed for.

Necrotizing pancreatitis

• The treatment of necrotizing pancreatitis should be concentrated to units with experience on it and intensive care readiness because of the risk of complications and significant mortality.
• The symptoms of severe pancreatitis, due to organ damages, include peritonitis shock, respiratory distress, anuria, and mental confusion.
• The severity of acute pancreatitis is based on the Atlanta classification. It assesses the presence of organ dysfunction/damage and response to intensive care. A significantly elevated CRP concentration suggests severe pancreatitis. Radiologically, pancreatic necrosis is detectable by contrast-enhanced CT.
• Recently, the treatment of necrotizing pancreatitis has been changed in favour of conservative approach, where initial stage fluid resuscitation and measures maintaining cardiovascular and respiratory function in the intensive care setting are essential. However, surgery may still be indicated. The primary indication for surgery is the infection of pancreatic necrosis. In the modern "step-up approach", the treatment methods progress from radiological drainage procedures to, according to need, mini-invasive or open surgery.
• As a complication of severe pancreatitis, the intra-abdominal pressure may increase impairing respiratory function and diuresis. According to recent experience in the treatment of this so called abdominal compartment syndrome, when the intra-abdominal pressure is elevated to 25–35 mmHg, it is beneficial to perform laparotomy and leave the abdominal cavity unsutured to start the so-called "open abdomen" treatment.

• Prevention of recurrence of acute pancreatitis
  • Lifestyle changes (avoidance of alcohol)
  • Adequate treatment of cholelithiasis (Cholelithiasis)