← Interactive tools
Gastroenterology · Calculator

Acute pancreatitis

Revised Atlanta diagnosis, SIRS, BISAP and modified Marshall organ-failure scoring with the severity grade, a WATERFALL-style moderate fluid plan, and a hypertriglyceridemia mode. Nothing is scored from a blank field.

Revised Atlanta 2012WATERFALL moderate fluidsIAP 2025 · ACG 2024Reviewed Oct 2026

What do you need?

1Revised Atlanta: two of three

How it works

Diagnosis and severity grade

Diagnosis (Revised Atlanta 2012): any two of typical pain, lipase or amylase at least 3 times the upper limit of normal, and characteristic imaging. ACG 2024 and IAP 2025 word the enzyme criterion as "more than 3 times"; this tool uses the Atlanta wording, compares the unrounded ratio and shows it truncated to two decimals. Pain plus enzyme is enough: imaging is not needed for the diagnosis. CT for severity is most informative at least 72–96 h after onset (IAP 2025).

Grade: mild, no organ failure and no local or systemic complication; moderately severe, organ failure that resolves within 48 h, or a local or systemic complication; severe, organ failure lasting more than 48 h. Organ failure is a modified Marshall score of 2 or more in any system.

Modified Marshall bands
ScorePaO₂/FiO₂Creatinine mg/dL (µmol/L)Systolic BP
0above 400under 1.4 (134 or less)above 90
1301–4001.4–1.8 (134–169)under 90, fluid responsive
2201–3001.9–3.6 (170–310)under 90, not fluid responsive
3101–2003.6–4.9 (311–439)under 90, pH under 7.3
4101 or lessabove 4.9 (above 439)under 90, pH under 7.2

The source's µmol/L bands overlap at 134 (score 0 is 134 or less, score 1 is 134–169); the tool scores 134 as 1, the safer side. The published mg/dL and µmol/L creatinine bands are not exact conversions of each other, so the tool scores the value on both and uses the higher score (it says so when they differ); the result does not change with the unit toggle. Pre-existing kidney disease: no formal correction for a baseline of 134 µmol/L or 1.4 mg/dL or more (Banks 2013 as reproduced; MSD gives 1.5 mg/dL). Non-ventilated FiO₂ estimates (Banks 2013, as reproduced by MSD): room air 21%, 2 L/min 25%, 4 L/min 30%, 6–8 L/min 40%, 9–10 L/min 50%. SBP of exactly 90 scores 0. The cardiovascular row applies off inotropes.

SIRS and BISAP

SIRS (2 or more): temperature above 38 or below 36 °C; heart rate above 90; respiratory rate above 20 or PaCO₂ below 32 mm Hg; WBC above 12 or below 4 ×10³/µL, or bands above 10%. A criterion left blank is not counted as normal: the count is reported as incomplete unless two are already met.

BISAP, one point each within 24 h: BUN above 25 mg/dL (urea above 8.9 mmol/L), impaired mental status (GCS under 15), SIRS, age above 60, pleural effusion. In the derivation cohort mortality ran from under 1% at the lowest scores to over 20% at the highest. BISAP is a mortality tool; no score predicts severe disease well (ACG 2024).

Urea mmol/L = BUN mg/dL ÷ 2.8.

Moderate fluid plan

WATERFALL moderate arm: lactated Ringer's 1.5 mL/kg/h; a 10 mL/kg bolus over 2 h first only if a hypovolemia criterion is present. Overload check at 3 h; reassess at 12, 24, 48 and 72 h. Repeat 10 mL/kg for hypovolemia; extra boluses before 24 h only for urine under 0.5 mL/kg/h or SBP under 90. Slow or stop for overload. Stop after 8 h of tolerated oral intake. Aggressive fluids (20 mL/kg then 3 mL/kg/h) caused more overload (20.5% vs 6.3%) without better outcomes.

The 24-hour projection assumes the bolus runs for 2 h and the infusion for the remaining hours. ACG 2024 notes most patients need 3–4 L in the first 24 h, depending on body size; projections above 4 L are flagged.

Triglyceride mode

mmol/L × 88.57 = mg/dL. ACG 2024 attributes pancreatitis to triglycerides above 1,000 mg/dL when gallstones and alcohol are absent. The insulin protocol shown is the Bi-TPAI design (regular insulin 0.1 units/kg/h, up to 0.3 units/kg/h, until TG is under 500 mg/dL; dextrose to keep glucose 120–200 mg/dL), as used by Le 2025 (5% dextrose once glucose reached 150–200 mg/dL; potassium adjusted every 4 h). It is a published research protocol, not a guideline dose. IAP 2025 recommends insulin in diabetics and says it may be considered in non-diabetics; IV insulin was no faster than fasting and fluids in one cohort (Dhindsa 2019).

The potassium gate (insulin only when K⁺ is above 3.5 mmol/L) is borrowed from the 2024 DKA consensus; no triglyceride-specific threshold has been published. No rate is shown while glucose is under 120 mg/dL or K⁺ is 3.5 or less (both holds are shown when both apply) (dextrose first; under 70 means hold insulin and treat hypoglycemia), or until the DKA question is answered when there is diabetes or glucose above 250 mg/dL (asked as DKA or HHS; glucose 600 or more is called out). No agreed ceiling exists; published protocols capped at 10–15 units/h, and rates above 10 units/h are flagged.

Sources

  1. Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology guidelines: management of acute pancreatitis. Am J Gastroenterol 2024;119(3):419–437. doi:10.14309/ajg.0000000000002645 — diagnosis, CT timing, moderately aggressive fluids (no more than 1.5 mL/kg/h without hypovolemia; 10 mL/kg bolus if hypovolemic; 3–4 L in the first 24 h for most), triglycerides above 1,000 mg/dL, ERCP, feeding, antibiotics.
  2. International Association of Pancreatology revised guidelines on acute pancreatitis 2025 (endorsed by APA, EPC, Indian Pancreas Club, Japan Pancreas Society). Pancreatology 2025;25(6):770–814. doi:10.1016/j.pan.2025.04.020 — Q1 diagnosis, Q4 SIRS, Q11 1.5 mL/kg/h, Q12 targets, Q15 ICU at Marshall 2 or more, Q63 saline in marked hypercalcemia, Q64–Q67 hypertriglyceridemia.
  3. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification. Gut 2013;62:102–111. doi:10.1136/gutjnl-2012-302779 — diagnosis, severity grades, modified Marshall score (bands as tabulated in the MSD Manual Professional, which cites this source).
  4. de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis (WATERFALL). N Engl J Med 2022;387:989–1000. doi:10.1056/NEJMoa2202884. Protocol: Front Med 2020;7:440. doi:10.3389/fmed.2020.00440 — hypovolemia criteria, checkpoints, bolus rules, exclusions, stopping rule.
  5. Wu BU, Johannes RS, Sun X, et al. The early prediction of mortality in acute pancreatitis (BISAP). Gut 2008;57:1698–1703. doi:10.1136/gut.2008.152702. Impaired mental status as GCS under 15 and BUN 25 mg/dL = 8.9 mmol/L urea per the MSD Manual BISAP calculator.
  6. Bone RC, Balk RA, Cerra FB, et al. ACCP/SCCM consensus definitions (SIRS). Chest 1992;101:1644–1655. doi:10.1378/chest.101.6.1644
  7. Song X, Shi D, Cui Q, et al. Intensive insulin therapy versus plasmapheresis in hypertriglyceridemia-induced acute pancreatitis (Bi-TPAI): study protocol. Trials 2019;20:365. doi:10.1186/s13063-019-3498-x — regular insulin 0.1 up to 0.3 units/kg/h to TG under 500 mg/dL; dextrose to keep glucose 120–200 mg/dL.
  8. Le TQ, Le HTT, Tran NTT, et al. Continuous IV insulin in hypertriglyceridemia-induced acute pancreatitis. Medicine (Baltimore) 2025;104(22):e42674. doi:10.1097/MD.0000000000042674 — 5% dextrose once glucose reached 150–200 mg/dL; potassium adjusted every 4 h; TG at 12, 24, 48, 72 h; stop at TG under 5.6 mmol/L; hypoglycemia 16.7%, hypokalemia 18.5%.
  9. Dhindsa S, Sharma A, Al-Khazaali A, et al. Intravenous insulin versus conservative management in hypertriglyceridemia-associated acute pancreatitis. J Endocr Soc 2019;4(1):bvz019. doi:10.1210/jendso/bvz019
  10. Umpierrez GE, et al. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia 2024;67:1455–1479. doi:10.1007/s00125-024-06183-8 — insulin delayed until K⁺ above 3.5 mmol/L (applied to triglyceride insulin by analogy only).
  11. TRYNGOLZA (olezarsen) prescribing information, Ionis Pharmaceuticals, revised 06/2026 (DailyMed) — sHTG indication (TG 500 mg/dL or more) to reduce TG and acute pancreatitis risk, 50 mg monthly (80 mg if needed); FCS 80 mg monthly.
  12. Ibarra F Jr. Acute management of hypertriglyceridemia with a disease-specific IV insulin order set. Ann Pharmacother 2023;57(11):1248–1254. doi:10.1177/10600280231155921 — hypoglycemia defined as glucose under 70 mg/dL. Infusion cap of 10 units/h as summarized by the University of Illinois Chicago Drug Information Group, January 2026 FAQ (secondary).
  13. Perez V, Faust AC, Taburyanskaya M, et al. Effectiveness of an intravenous insulin-based treatment protocol for hypertriglyceridemia-associated acute pancreatitis. J Pharm Technol 2023;39(2):55–61. doi:10.1177/87551225231151570 (PMC10084412) — protocol maximum of 15 units/h.
  14. Connelly-Smith L, et al. ASFA guidelines, ninth special issue. J Clin Apher 2023;38(2):77–278. doi:10.1002/jca.22043 — hypertriglyceridemic pancreatitis category III (as reported by Gubensek J, BMC Gastroenterol 2023;23:341). Tenth special issue: Zantek ND, et al. J Clin Apher 2026;41(Suppl 2):e70141. doi:10.1002/jca.70141 (PMID 42747330) — confirm the current fact sheet.

Educational reference only — not a substitute for clinical judgment, institutional protocols, or specialist advice. Calculations run in your browser; nothing you enter is sent or stored.