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).
Treatment includes early 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
- Peptic ulcer disease
- Perforated viscus
- Esophageal spasm
- ACR appropriateness criteria: acute pancreatitis
- 2019 WSES guidelines for the management of severe acute pancreatitis
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