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Prompt specialist consultation should be sought for patients with AP. A routine gastroenterologist or pancreatologist consultation should be obtained for all patients presenting with AP. When gallstone etiology is suspected, a surgical consultation for possible early cholecystectomy during the same admission is recommended by American Gastroenterological Association (AGA) guidelines [28,29]. Some of the patients with gallstone pancreatitis may have concomitant acute cholangitis and/or choledocholithiasis from gallstones obstructing the common bile duct. Cholangitis, as in those patients without AP, is an indication for urgent ERCP [29]. If liver dysfunction and/or dilated bile ducts are noted on the ultrasound, consultation with an interventional endoscopist for possible ERCP is recommended.

Table 7.1 Clinical findings associated with a severe course for initial risk assessment.^a

Source: Tenner et al. [5]. Reproduced with permission of Wolters Kluwer Health, Inc.

Patient characteristics Age >55 years Obesity (BMI >30 kg/m2) Altered mental status Comorbid disease Systemic inflammatory response syndrome (SIRS) Presence of more than two of the following criteria: Pulse >90 bpm Respirations >20/min or PaCO 2 >32 mmHg Temperature >38°C or <36°C WBC count >12 × 109/l or <4 × 109/l or >10% immature neutrophils (bands) Laboratory findings Blood urea nitrogen (BUN) >20 mg/dl Rising BUN Hematocrit (HCT) >44% Rising HCT Elevated creatinine Radiology findings Pleural effusions Pulmonary infiltrates Multiple or extensive extrapancreatic collections

^a The presence of organ failure and/or pancreatic necrosis defines severe acute pancreatitis.

BMI, body mass index; WBC, white blood cell.