Episode one of the Acute Pancreatitis chapter follows a single mechanism from trypsin escaping its compartment to the cytokine cascade, third-spacing, and lost pancreatic perfusion. The organizing idea: every first-hours decision reaches back to that mechanism. The two-of-three rule diagnoses around the failure modes of pain, enzymes, and imaging alone; the cause is worked up on admission because the trigger reshapes management; severity stays provisional while organ failure declares; and fluids are moderate lactated Ringer's titrated to hematocrit and BUN. The trial that asked whether more fluid was better answered no and stopped early. Topics covered Mechanism: trypsin activation and the calcium convergence point Triggers: gallstones, alcohol, triglycerides, calcium Systemic inflammation, third-spacing, and necrosis Clinical presentation and lipase versus amylase Revised Atlanta two-of-three diagnosis Severity grading by organ failure Etiology workup during the index admission Severity scores and first-day hematocrit and BUN trends Moderate goal-directed lactated Ringer's resuscitation Key decisions Diagnose acute pancreatitis on the revised Atlanta two-of-three rule: characteristic upper abdominal pain, lipase or amylase over three times the upper limit of normal, or characteristic cross-sectional imaging. Order lipase rather than amylase because it rises within four to eight hours, stays up for eight to fourteen days, and is pancreas-specific, and remember the enzyme height does not track severity. Avoid routine early CT because necrosis takes seventy-two to ninety-six hours to demarcate; reserve imaging for diagnostic uncertainty, failure to improve at forty-eight to seventy-two hours, or suspected complications. Get a right-upper-quadrant ultrasound in everyone, since a positive study means same-admission cholecystectomy, and treat an ALT over three times normal (roughly above one hundred fifty) as a strong pointer to a gallstone cause. Define severe disease as persistent organ failure beyond forty-eight hours, a modified Marshall score of two or more in the renal, pulmonary, or cardiovascular system, and treat early severity as provisional. Escalate on rising hematocrit or BUN despite fluids, because hemoconcentration is a surrogate for the hypoperfusion driving necrosis, even before the Marshall score turns positive. Resuscitate with moderate goal-directed lactated Ringer's at about one and a half milliliters per kilogram per hour after a ten-milliliter-per-kilogram bolus in hypovolemic patients, titrating to urine output of half to one milliliter per kilogram per hour. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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