What are the signs of pancreatitis?

Signs of Pancreatitis

The three main signs of pancreatitis are abdominal pain (typically in the upper abdomen radiating to the back), elevated serum amylase or lipase (greater than 3 times the upper limit of normal), and characteristic imaging findings on CT or ultrasound. 1

Clinical Presentation

Primary Signs

• Pain characteristics:

  • Upper abdominal pain radiating to the back
  • Pain worsened by eating
  • Persistent back pain (suggests retroperitoneal infiltration in pancreatic cancer) 2

• Gastrointestinal symptoms:

  • Nausea and vomiting
  • Anorexia
  • Abdominal distension
  • Ileus 2

• Systemic manifestations:

  • Fever (low to moderate grade is common in necrotizing pancreatitis)
  • Sudden high fever may indicate infection 2
  • Jaundice (more common in ampullary tumors or biliary pancreatitis) 2
  • Severe and rapid weight loss 2

Physical Examination Findings

• Epigastric tenderness
• Abdominal distension
• Decreased bowel sounds
• Epigastric mass (suggests acute fluid collection or pseudocyst) 2
• Jaundice with palpable gallbladder (Courvoisier's sign) in pancreatic cancer 2
• Signs of severe disease:
  • Cullen's sign (periumbilical bruising)
  • Grey Turner's sign (flank bruising)
  • Ascites
  • Pleural effusions 1

Diagnostic Criteria

According to current guidelines, diagnosis of acute pancreatitis requires meeting two of the following three criteria 1, 3:

1. Characteristic abdominal pain
2. Serum amylase or lipase elevated to greater than 3 times the upper limit of normal
3. Imaging findings consistent with pancreatitis

Laboratory Findings

• Serum lipase: Preferred over amylase due to higher sensitivity (100%) and specificity (99%) when elevated more than three times the upper limit of normal 1
• Serum amylase: Acceptable alternative but less sensitive, especially after the first 24 hours 1
• Other laboratory abnormalities:
  • Increasing leucocyte and platelet counts
  • Deranged clotting
  • Elevated C-reactive protein (CRP >150 mg/L after 48 hours suggests severe pancreatitis) 2, 1
  • Abnormal liver function tests (in biliary pancreatitis)
  • Elevated blood glucose (may indicate pancreatic damage)
  • Hypocalcemia (in severe cases) 1

Imaging Findings

• Ultrasound: First-line imaging to detect gallstones; may show pancreatic edema or fluid collections 1
• CT scan with contrast: Shows pancreatic inflammation, necrosis, and peripancreatic fluid collections; not routinely needed for all patients but indicated for:
  • Unexplained pancreatitis
  • Clinical deterioration
  • Suspected complications
  • Failure to improve within 72-96 hours 1
• MRI/MRCP: Considered when biliary etiology is suspected but ultrasound is inconclusive 1

Signs of Severity

• Organ failure: Respiratory, cardiovascular, or renal failure persisting beyond 48 hours indicates severe pancreatitis 2, 1
• Local complications:
  • Acute fluid collections
  • Pancreatic necrosis
  • Walled-off necrosis
  • Pseudocyst formation 2
• Systemic complications:
  • SIRS (Systemic Inflammatory Response Syndrome)
  • Sepsis
  • Shock 1

Special Considerations

• Recent onset diabetes mellitus in older patients without predisposing factors may be an early warning sign of pancreatic cancer 2
• Unexplained episodes of acute pancreatitis should prompt investigation for underlying pancreatic cancer 2
• Migratory thrombophlebitis is rarely the first symptom of pancreatic disease 2

Common Pitfalls in Diagnosis

• Relying solely on amylase levels, which may normalize within 24 hours despite ongoing pancreatitis
• Failing to consider pancreatitis in patients with unexplained abdominal pain after delivery 4
• Overlooking pancreatitis as a cause of unexplained fever or leukocytosis in hospitalized patients
• Not recognizing that severe abdominal pain out of proportion to physical findings is characteristic of early pancreatitis 1

Early recognition of these signs is crucial for prompt management, as severe acute pancreatitis is a life-threatening condition with mortality rates of about 15% 2.