Antibiotic prophylaxis is another area of acute pancreatitis that is under scrutiny. Most experts agree that in mild pancreatitis, there is no indication for antibiotics.^4,7 Severe acute pancreatitis offers more of a challenge. In the emergency department, it is often impossible to distinguish SIRS secondary to acute pancreatitis from that caused by bacterial sepsis.

In patients with acute abdominal pain, fever, and systemic toxicity, it is reasonable to initiate broad-spectrum antibiotics pending a complete infectious work-up, which may include eventual fine-needle aspiration of areas of pancreatic necrosis to distinguish sterile from infected necrosis.^1,3 Once infectious etiologies including pancreatic abscess and pseudocyst are ruled out, antibiotics should be discontinued.¹ Recommended antibiotics include carbapenems,² which have high pancreatic tissue penetration, or the combination of ciprofloxacin and metronidazole.^1,7

Emergency physicians should be familiar with the optimal timing of ERCP in the evaluation of acute pancreatitis. In patients with presumed biliary pancreatitis, the presence of choledocholithiasis or cholangitis mandates an urgent ERCP (within 24 hours of admission).^1,7 Unrelieved obstruction can lead to worsening pancreatitis.^2,4

Conclusion

Acute pancreatitis remains a disease with significant morbidity and mortal­ity. The emergency physician’s role in prompt recognition, assessment of severity, and initiation of supportive care is central to the treatment of this disease.

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