Signs and Symptoms of Pancreatitis
The classic presentation of acute pancreatitis includes severe upper abdominal pain radiating to the back, nausea, vomiting, and abdominal tenderness, with diagnosis requiring at least two of three criteria: characteristic abdominal pain, elevated pancreatic enzymes (preferably lipase >3 times normal), and imaging findings consistent with pancreatitis. 1, 2
Clinical Presentation
Cardinal Symptoms
Physical Examination Findings
- Epigastric or diffuse abdominal tenderness 4, 1
- Abdominal distension 4
- Prolonged ileus 4
- Fever (low to moderate grade is common in necrotizing pancreatitis) 4
- Tachycardia 3
- Rarely, body wall ecchymoses:
- Cullen's sign (periumbilical bruising)
- Grey-Turner's sign (flank bruising) 4
Advanced/Severe Disease Signs
- Epigastric mass (suggests acute fluid collection or pseudocyst) 4
- Persistent vomiting 4
- High fever (may indicate infection) 4
- Signs of systemic inflammatory response syndrome (SIRS) 1, 2
- Cardiorespiratory or renal failure (signs of septic complications) 4
- Pleural effusion (visible on chest X-ray) 4
- "Failure to thrive" - hypermetabolism and catabolic state requiring continued system support 4
- Weight loss (more common in chronic pancreatitis) 3
- Steatorrhea (in chronic pancreatitis) 3
Laboratory Findings
Diagnostic Markers
- Serum lipase: Elevation >3 times upper limit of normal (preferred test) 1, 2
- Serum amylase: Elevation >4 times upper limit of normal 4
- Urinary amylase: May be diagnostic when serum amylase is equivocal 4
Associated Laboratory Abnormalities
- Increasing leucocyte and platelet counts (suggest possible sepsis) 4
- Deranged clotting 4
- Elevated C-reactive protein (>150 mg/L at 48 hours suggests severe disease) 1
- Elevated liver function tests (ALT >3 times normal suggests gallstone pancreatitis) 1
- Elevated triglycerides (potential cause of pancreatitis) 1
- Abnormal calcium levels (hypercalcemia can cause pancreatitis) 1
- Elevated BUN and creatinine (in severe cases) 1
Imaging Findings
Common Radiological Signs
- CT findings: Pancreatic enlargement, peripancreatic inflammation, fluid collections, necrosis 1
- Ultrasound findings: Swollen pancreas (though pancreas is poorly visualized in 25-50% of cases) 4, 1
- Chest X-ray: May show pleural effusions or ARDS in severe cases 4
- Plain abdominal X-ray: May show generalized or local ileus (sentinel loop), colon cut-off sign, or rarely retroperitoneal gas (indicating infection) 4
Pitfalls and Caveats
- Clinical diagnosis alone is often unreliable and should be supported by laboratory or imaging findings 4
- Presentation may be atypical or obscured in certain circumstances (e.g., postoperative period) 4, 5
- Mild fever alone does not necessarily indicate deterioration in necrotizing pancreatitis 4
- Early CT (within first 72 hours) may underestimate disease severity and necrosis 1
- Severity must be reassessed 24-48 hours after onset as mild cases can rapidly progress to severe 6
- Unusual presentations can occur, including anterior abdominal wall abscess or epididymo-orchitis due to tracking of pancreatic fluid 5
Distinguishing Acute vs. Chronic Pancreatitis
Acute Pancreatitis
- Sudden onset of symptoms 2, 3
- Often follows gallstone disease or alcohol binge 2, 3
- Typically resolves with appropriate treatment 2
Chronic Pancreatitis
- Insidious progression of chronic, severe pain 3
- Often follows continued or repetitive pancreatic injury 3
- Associated with weight loss, steatorrhea, and eventually diabetes 3, 7
- May present with recurrent episodes mimicking acute pancreatitis 3
- Irreversible morphological alterations of pancreatic ducts and parenchyma 7
Remember that approximately 20% of patients with acute pancreatitis will have recurrent episodes, with alcohol use and smoking being major risk factors 2.