2002 to 2005. 4 Gallstone-related disorders may be the cause of this increase in the United States, because of increases in obesity and the aging population, although it also may be related to an increased frequency of testing (Figure 1). 4 This comes at a huge cost to the healthcare system, with more than $2.4 billion spent per year in the United States alone. 5 Management of acute pancreatitis has changed considerably in the past 10 years, including a multidisciplinary methodology, and tailored interventions with a minimally invasive endoscopic approach rather than open surgical intervention for complications. 6 To reduce patient morbidity and mortality, clinicians must be familiar with the presentation, diagnosis, and management of this disease.© MEDICALSTOCKS/SHUTTERSTOCK.COM I n most patients, acute pancreatitis is mild, self-limited, and follows an uncomplicated course. 1 However, 15% to 20% of all patients have severe acute pancreatitis, and 5% to 10% of them will develop necrosis of the pancreatic glands, peripancreatic tissue, or both. 2 In severe cases, if the necrotic collection becomes infected, patient mortality can reach 30%. 3 The incidence of acute pancreatitis requiring hospitalization in the United States continues to rise, with a 13.2% increase between 2009 and 2012 compared with ABSTRACT Acute pancreatitis is associated with signifi cant morbidity and mortality, and is one of the most common gastrointestinal disorders requiring hospitalization. This article describes current concepts in the diagnosis and management of severe acute and necrotizing pancreatitis. Management of this disease requires IV fl uids, pain control, and advanced medical and interventional care. Early identifi cation and intervention may help to prevent patient morbidity and mortality.

An 84-year-old woman arrived at the ED on recommendation from her primary care provider because of significant leakage and pain at her gastrostomy site.History The patient underwent percutaneous endoscopic gastrostomy (PEG) tube placement about 1 week ago (Figure 1 shows tube placement in a different patient). The next day, she was evaluated by the gastroenterology PEG clinic and was provided with care instructions. She used the tube for supplemental nutrition, although she was still able to take medications and most of her nutrition by mouth.The patient said that the pain and thick purulent drainage from the PEG site started 1 day ago. She reported no known trauma to the tube and denied fever, nausea, vomiting, dysuria, diarrhea, and constipation. She denied any history of tobacco, alcohol, or illicit drug use.Her past medical history was significant for heart failure and newly diagnosed squamous cell carcinoma of the hard palate. The PEG tube was placed in anticipation of a planned surgery for the cancer. She took amlodipine daily and recently had been started on carboplatin.Physical examination The patient's vital signs were oral temperature, 97.9° F (36.6° C); heart rate, 61 beats/ minute; respirations, 16 and unlabored; BP, 120/47 mm Hg; and SpO 2 , 100% on room air. Her BMI was 26. She was alert, in no acute distress, and appeared well nourished. She had tenderness to palpation near the gastrostomy site, with 1 cm of induration superiorly and purulent drainage noted. No erythema was noted. Her bowel sounds were normal. The patient's external bumper, the measurement marker on the tube where the bumper meets the skin, was found to be at 2 cm; previous documentation suggests it was at 3.5 cm. Gastric contents easily retracted and the tube was easily flushed; however, the tube could not be rotated nor traversed in or out of the abdominal wall. No abnormal lymph nodes or rashes were noted.