Acute pancreatitis most commonly presents as severe mid-epigastric or left upper quadrant pain that radiates to the back. Epigastric tenderness is typical.
Symptoms often include nausea and vomiting. A history of cholelithiasis or alcohol intake may be present.
Signs of hypovolemia (including decreased skin turgor, dry mucous membranes, hypotension, and sweating) are common. In more severe cases, the patient may be tachycardic and/or tachypneic.
In most patients who present with typical clinical signs, the diagnosis is confirmed by elevated serum lipase or amylase (>3 times upper limit of normal).
Initial treatment includes aggressive hydration with intravenous fluids, analgesia, and nutritional support, with early oral feeding favored if tolerated.
Treatment of severe acute pancreatitis includes support of end organ failure, most commonly of respiratory, renal, and circulatory systems. Local complications that may develop later include sterile or infected pancreatic necrosis and pseudocysts.
The presence of cholangitis in a patient with acute pancreatitis, characterized by an elevated bilirubin, warrants early endoscopic retrograde cholangiopancreatography (ERCP), typically within 24 hours from diagnosis.
Acute pancreatitis is an acute disorder of the exocrine pancreas associated with acinar cell injury and local and systemic inflammatory responses. The severity of the disease varies: most patients will have mild disease with minimal pancreatic edema, and will recuperate fully within a few days; a minority of patients will have severe disease, characterized by a persistent systemic inflammatory response and/or multi-organ failure, with or without pancreatic/peripancreatic necrosis.
History and exam
Key diagnostic factors
- abdominal pain
- nausea and vomiting
- signs of hypovolemia
Other diagnostic factors
- signs of organ dysfunction
- Grey-Turner sign
- Cullen sign
- Fox sign
- Chvostek sign
- abdominal distention
- middle-aged women
- young- to middle-aged men
- use of causative drugs
- Mycoplasma pneumoniae
- endoscopic retrograde cholangiopancreatography (ERCP)
- pancreas divisum
- pancreatic cancer
- sphincter of Oddi dysfunction
- family history of pancreatitis
1st investigations to order
- serum lipase or amylase
- liver function tests
- CBC and differential
- BUN and serum electrolytes
- arterial blood gas
- transabdominal ultrasound
- chest x-ray
- ratio of serum lipase:amylase
Investigations to consider
- abdominal CT scan
- magnetic imaging/magnetic resonance cholangiopancreatography (MRI/MRCP)
- endoscopic ultrasound (EUS)
deteriorating or failing to improve
Scott Tenner, MD, MPH, JD, FACG
Clinical Professor of Medicine
Director, The Greater New York Endoscopy Surgical Center
Director, Brooklyn Gastroenterology and Endoscopy
State University of New York
ST is an author of references cited in this topic. He declares that he has no other competing interests.
Craig T. Tenner, MD, FACP
New York University School of Medicine
CTT declares that he has no competing interests.
Dr Scott Tenner and Dr Craig T. Tenner would like to gratefully acknowledge Dr Nicholas J. Zyromski, Dr Brian Daley, Dr Catherine Lindsay McKnight, and Dr Fernando Aycinena, previous contributors to this topic. They would also like to thank Dr Camille Blackledge for her contribution to this topic.
NJZ is an author of a reference cited in this topic. BD, CLM, FA, and CB declare that they have no competing interests.
Tamas A. Gonda, MD
Assistant Professor of Medicine
Attending Physician and Director of Research
Columbia University Medical Center
TAG declares that he has no competing interests.
Alan Moss, MD
Harvard Medical Faculty Physician
Division of Gastroenterology
Beth Israel Deaconess Medical Center
AM declares that he has no competing interests.
Derek O'Reilly, MD
Consultant Hepatobiliary & Pancreatic Surgeon
Department of Surgery
North Manchester General Hospital
DOR is an author of a reference cited in this topic. He declares that he has no other competing interests.
Eric Frykberg, MD
Department of Surgery
Division General Surgery
Shands Jacksonville Medical Center
At the time of the peer review, Dr E. Frykberg declared no competing interests. We were made aware that Dr Frykberg is now deceased.
- Peptic ulcer disease
- Perforated viscus
- Esophageal spasm
- ACR appropriateness criteria: acute pancreatitis
- 2019 WSES guidelines for the management of severe acute pancreatitis
Pancreatic cancerMore Patient leaflets
Venepuncture and phlebotomy: animated demonstration
Radial artery puncture animated demonstrationMore videos
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer