A 56-year-old woman presents with a 10-year history of recurrent abdominal pain in her right upper quadrant with a cholecystectomy 5 years ago. Her previous workups revealed a mild transient transaminase elevation with a normal lipase and amylase. All subsequent imaging was unremarkable. During this presentation, AST and ALT were 304 and 280, respectively, and an ultrasound showed the common bile duct to be dilated at 10 mm. Patient history and clinical symptoms suggested a possible sphincter of Oddi dysfunction, so ERCP with sphincterotomy was scheduled for the next day. About 4 h post-procedure, the patient complained of continuous, severe epigastric pain radiating to the back along with intractable nausea and vomiting. Lipase at this time was 1500 and vital signs were stable. Diagnosis of post-ERCP acute pancreatitis was made, and the patient was admitted to an ICU step-down unit on intravenous lactated Ringer’s at 250 ml/h.

The risk of post-ERCP pancreatitis after diagnostic ERCP is thought to be 0.4–1.5%, while therapeutic ERCP is 1.6–5.4%. However, some risk can be as high as 10–20% in certain demographics, including those undergoing ERCP for the evaluation of sphincter of Oddi dysfunction and those with a past history of post-ERCP pancreatitis [1]. Etiology of acute pancreatitis in patients receiving ERCP is usually due to instrumentation with specific attention given to difficult cannulation of the biliary tree and needle-knife sphincterotomy [2].

Diagnosis of acute pancreatitis has been established by the presence of two of the following three criteria: (1) abdominal pain, (2) serum amylase or lipase greater than three times the upper limit of normal, and (3) suggestive findings on imaging [3]. However, imaging is not required for diagnosis if clinical suspicion is high, and a CT scan may not even show signs of acute pancreatitis if done within 3 h of symptom onset. Once a patient is diagnosed, resuscitation should begin immediately based on the patient’s hemodynamic status. Clinical evaluation should consider the need for admission to an ICU or step-down unit depending on the patient’s course of disease and presence of organ failure signs. Our patient was correctly managed after diagnosis with immediate fluid resuscitation and placement into an intermediate care unit to increase the staff’s ability for frequent reevaluation [3].

The revised Atlanta classification from 2013 divides acute pancreatitis into mild, moderately severe, and severe [4]. Mild pancreatitis, or interstitial edematous pancreatitis, features pancreatic inflammation without necrosis or organ failure and usually resolves within 1 week without any further sequelae. Moderately severe pancreatitis requires the presence of local complications or transient organ failure that resolves by the 48 h mark. Severe pancreatitis, however, may result in pancreatic necrosis, abscess formation, and pseudocysts and is characterized by persistent organ failure lasting longer than 48 h [4]. With acute pancreatitis, timing, evaluation, and prompt treatment of the patient in the first 48 h after diagnosis are critical.