What are the symptoms and treatment of pancreatitis?

Symptoms of Pancreatitis

The primary symptom of pancreatitis is upper abdominal pain that often radiates to the back, typically worsening after eating, accompanied by nausea and vomiting. 1

Clinical Presentation

Pain Characteristics

• Upper abdominal pain is the predominant symptom, present in 97.3% of patients with acute pancreatitis 2
• Pain is typically intense (70% of cases) and cramping in nature (61% of cases) 2
• Pain often radiates to the back and worsens after eating 1
• Interestingly, about 50.9% of patients may present with atypical pain patterns (not just epigastric or belt-like upper abdominal pain) 2
• Sharp pain is associated with increased disease severity and higher mortality compared to other pain types 2

Associated Symptoms

• Nausea and vomiting are common accompanying symptoms 1
• Fever, particularly moderate grade fever, is commonly seen in necrotizing acute pancreatitis 3
• A sudden high fever may indicate development of infection, although this can arise from sources other than the pancreatic area 3

Physical Examination Findings

• Epigastric or diffuse abdominal tenderness is commonly found 3
• Occasionally, body wall ecchymoses may be present (Cullen's sign at the umbilicus, Grey-Turner's sign in the flanks) 3
• Signs of cardio-respiratory or renal failure may indicate septic complications 3

Laboratory Findings

• Elevated serum lipase (greater than twice the upper limit of normal) or amylase (four times above normal) 3
• Increased white blood cell count 3
• Elevated C-reactive protein (CRP) 3
• Procalcitonin (PCT) is the most sensitive laboratory test for detection of pancreatic infection 3
• Other tests may show deranged clotting, increased APACHE II score, and biochemical features of multiple organ failure in severe cases 3

Imaging Findings

• Ultrasound may show a swollen pancreas, though the gland is poorly visualized in 25-50% of cases 3
• CT scan with IV contrast is the gold standard imaging modality 3
• MRI can also be used as an alternative to CT 3
• Chest x-ray may show pleural effusions or features of acute respiratory distress syndrome (ARDS) in severe cases 3

Classification of Severity

Mild Acute Pancreatitis

• Minimal organ dysfunction with uneventful recovery 3
• Predominant pathological feature is interstitial edema of the gland 3
• Usually resolves within the first week 3

Moderately Severe Acute Pancreatitis

• Transient (less than 48h) organ failure 3
• Local complications or exacerbation of co-morbid disease 3

Severe Acute Pancreatitis

• Persistent (more than 48h) organ failure 3
• Associated with organ failure and/or local complications such as necrosis (with infection), pseudocyst, or abscess 3
• Life-threatening with hospital mortality rates of about 15% 3

Treatment Approach

Initial Management

• Fluid resuscitation is the cornerstone of initial management 4
• Pain control, often requiring opioid analgesics 1
• Early oral feeding is now recommended, within the first 24 hours as tolerated 1
• If oral feeding is not tolerated, enteral nutrition via nasogastric or nasojejunal tubes should be initiated 1

Antibiotics

• Routine prophylactic antibiotics are not recommended for all patients with acute pancreatitis 3
• Antibiotics are indicated only for confirmed infections or when there are signs of systemic infection 1
• When indicated, imipenem has been recommended based on studies of antibiotic penetration into pancreatic tissue 3

Interventional Procedures

• Endoscopic retrograde cholangiopancreatography (ERCP) is indicated in gallstone pancreatitis with cholangitis or common bile duct obstruction 3
• Surgical or endoscopic interventions may be needed for biliary or obstructive pancreatitis 1
• Patients with local complications should be referred to specialist tertiary centers for further management 5

Monitoring and Supportive Care

• All cases of severe acute pancreatitis should be managed in a high-dependency unit (HDU) or intensive therapy unit (ITU) setting 3
• Regular monitoring of vital signs, including pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 3
• Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 3

Complications and Prognosis

• One in five patients will have recurrent episodes of pancreatitis 1
• Some patients develop chronic pancreatitis, associated with chronic pain and pancreatic dysfunction 1
• Complications include infected necrosis, pancreatic abscess, and acute fluid collections 3
• Mortality in patients with infected necrosis and organ failure can be as high as 35.2% 3