What are the signs and symptoms, causes, treatments, laboratory tests or imaging studies, and supportive care for pancreatitis (inflammation of the pancreas)?

From the Guidelines

Pancreatitis is a life-threatening condition that requires prompt diagnosis and treatment, and the management of severe acute pancreatitis involves supportive care, including fluid resuscitation, pain management, and nutritional support, as recommended by the 2019 WSES guidelines 1. The signs and symptoms of pancreatitis include severe upper abdominal pain that may radiate to the back, nausea, vomiting, fever, and abdominal tenderness. In severe cases, patients may develop hypotension, tachycardia, and respiratory distress. Common causes of pancreatitis include:

• Gallstones
• Alcohol abuse
• Certain medications
• Hypertriglyceridemia
• Hypercalcemia
• Genetic factors

Diagnosis of pancreatitis requires laboratory tests such as:

• Serum amylase and lipase (typically elevated at least three times the upper limit of normal) 1
• Complete blood count
• Metabolic panel
• Triglyceride levels

Imaging studies like abdominal ultrasound, CT scan, or MRI help confirm diagnosis and identify underlying causes like gallstones. The 2019 WSES guidelines recommend:

• Ultrasound (US) on admission to determine the etiology of acute pancreatitis (biliary) 1
• Computed tomography (CT) to provide good evidence of the presence or absence of pancreatitis
• Contrast-enhanced computed tomography (CE-CT) or magnetic resonance imaging (MRI) to assess patients with severe acute pancreatitis

Treatment of pancreatitis primarily involves supportive care, including:

• Nothing by mouth (NPO) status and intravenous fluids (typically crystalloids at 250-500 mL/hour initially, then adjusted based on response) 1
• Pain management with opioid analgesics like morphine 2-4 mg IV every 4 hours as needed
• Antiemetics such as ondansetron 4 mg IV every 8 hours Severe cases may require intensive care monitoring, nutritional support via enteral feeding within 48-72 hours if possible, and antibiotics only if infection is suspected. For gallstone pancreatitis, cholecystectomy is typically recommended after resolution of acute symptoms. Chronic pancreatitis management includes pain control, pancreatic enzyme replacement therapy, and lifestyle modifications including strict alcohol abstinence and low-fat diet.

From the FDA Drug Label

Pancreatitis was also observed (see WARNINGS and PRECAUTIONS) Gastrointestinal side effects may resemble acute intestinal obstruction, with progressive abdominal distension, severe epigastric pain, abdominal tenderness, and guarding Hepatobiliary: cholelithiasis, cholecystitis, cholangitis and pancreatitis, which have sometimes required cholecystectomy

The signs and symptoms of pancreatitis may include severe epigastric pain, abdominal tenderness, and guarding. The cause of pancreatitis is not directly stated in the label, but it is listed as an adverse event. The treatment for pancreatitis is not directly stated in the label, but cholecystectomy may be required in some cases. No laboratory tests or imaging studies are mentioned in the label as being used to diagnose or monitor pancreatitis. No supportive care is mentioned in the label for pancreatitis 2

From the Research

Signs and Symptoms

• Abdominal pain radiating to the back 3
• Serum lipase or amylase levels three or more times the upper limit of the normal level 3
• Findings indicating pancreatitis obtained via a computed tomography (CT) scan or magnetic resonance imaging (MRI) 3

Causes

• Gallstones 4, 5, 3, 6
• Autoimmune disorders 3
• Alcohol abuse 4, 5, 3, 6
• Smoking 3
• Hypertriglyceridemia 3
• Obesity 3
• Drugs 3
• Post-endoscope retrograde cholangiopancreatography (ERCP) 3

Treatments

• Aggressive hydration 4, 5, 6
• Early enteral nutrition 4, 5, 6
• Pain control 3
• Antibiotics in the setting of suspected superimposed infection 5
• Endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis or a strong suspicion of gallstones 4, 6
• Surgical, radiologic, and/or endoscopic drainage for infected necrosis 4, 5, 6

Laboratory Tests or Imaging Studies

• Serum amylase and lipase analysis 3
• Lipid panel including triglycerides 3
• Analysis of immunoglobulins 3
• Full blood count 3
• Electrolyte analysis 3
• Hemoglobin A1c test 3
• Complete metabolic panel 3
• Transabdominal ultrasound 3
• Computed tomography (CT) scan or magnetic resonance imaging (MRI) 4, 3

Supportive Care

• Oxygen supplementation 3, 6
• Provision of intravenous fluids 3
• Nutrition regime 3
• Early oral feeding if tolerated, or liquid supplement provision or enteral tube feeding within 48 h of admission 3
• Regular follow-ups and abstention from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis 3