Fig. 4.

Generalised treatment strategy for acute pancreatitis at the admitting hospital, after referral to specialist, tertiary services for complex pancreatic disease, and subsequently to prevent recurrence as well as address the aftermath of the disease. a Initial treatment at the admitting hospital, scaled to the severity of disease. A low index of suspicion is recommended for 3D abdominal imaging, otherwise complications are likely to be missed and patients readmitted in a more compromised state, with delay in referral for specialist opinion and/or transfer. Specific treatments include insulin and/or plasmapheresis for hypertriglyceridaemia and antivenom for scorpion or snake bites in endemic areas throughout the world. b There are many options required for the specialist management of complex acute pancreatitis, many of which are itemised. Necrosectomy is better delayed for some 4 weeks but may have to be brought forward if there is uncontrollable sepsis or other organ injury. Embolisation is required for pseudoaneurysms; contrarily, anticoagulation is indicated for recent thrombosis at or near the portal venous confluence. Pancreatic ductal stenting together with glyceryl trinitrate (GTN, to relax the smooth muscle of the sphincter of Oddi) and octreotide (to reduce secretion) may assist healing of pancreatic ductal rupture. c Measures to prevent recurrent acute pancreatitis are displayed as these save lives, reduce morbidity, reduce healthcare costs, and halt or slow progression of disease. Local complications of complex acute pancreatitis include recurrent pseudocyst formation, recollection of abscesses, ductal strictures, progression to chronic pancreatitis—all of which can be causes of recurrent pain and/or sepsis, and for which patients should be kept under review. Appropriately thorough investigation of acute pancreatitis may have identified benign or malignant neoplasms, for which surgical resection +/– chemotherapy may be most appropriate