What are the signs and symptoms of pancreatitis?

Signs and Symptoms of Pancreatitis

The cardinal presentation of acute pancreatitis is severe epigastric pain radiating to the back, accompanied by nausea, vomiting, and abdominal tenderness—with diagnosis requiring at least two of three criteria: characteristic abdominal pain, elevated pancreatic enzymes (lipase ≥2-3 times normal), and imaging findings consistent with pancreatic inflammation. 1, 2, 3

Primary Clinical Features

Pain Characteristics

• Epigastric pain radiating to the back is the classic and most distinguishing feature, though approximately 50% of patients present with atypical pain patterns including diffuse abdominal, periumbilical, or flank pain 1, 4, 5
• Pain is typically severe and sudden in onset, worse with eating, and may be described as sharp (associated with higher severity and mortality), dull, or cramping 4, 2, 5
• Intense pain on admission correlates with higher rates of peripancreatic fluid collections and severe disease 5

Gastrointestinal Symptoms

• Nausea and vomiting are nearly universal presenting symptoms 1, 2
• Prolonged ileus and abdominal distension indicate more severe disease and potential complications 6, 1

Physical Examination Findings

• Epigastric or diffuse abdominal tenderness is the most common finding on examination 1
• Cullen's sign (periumbilical ecchymosis) and Grey-Turner's sign (flank ecchymosis) indicate severe hemorrhagic pancreatitis with significantly worse prognosis 1
• Epigastric mass with persistent vomiting suggests acute fluid collection or developing pseudocyst 6, 1

Severity Stratification by Clinical Presentation

Mild Acute Pancreatitis

• Minimal systemic disturbance with symptoms resolving within days 1
• Abdominal signs resolve easily and can be monitored clinically 6

Severe Acute Pancreatitis

• Persistent severe pain, prolonged ileus, and signs of systemic inflammatory response syndrome characterize severe disease 1
• Multi-organ dysfunction including cardiorespiratory or renal failure indicates life-threatening complications 6, 1
• Respiratory distress may develop in critical cases 1

Laboratory and Diagnostic Findings

Biochemical Markers

• Elevated serum lipase ≥2-3 times normal is more specific than amylase and remains elevated longer 1, 2, 3
• Elevated serum amylase ≥4 times normal is common but less specific 1
• Increasing leucocyte and platelet counts, deranged clotting, and elevated CRP indicate possible sepsis and need for urgent reassessment 6, 1

Imaging Findings

• Chest X-ray may reveal pleural effusions or ARDS in severe cases, which directly impacts mortality and management decisions 1, 7
• Ultrasound shows swollen pancreas though visualization is limited in 25-50% of cases 1
• CT scan reveals pancreatic inflammation, necrosis, or fluid collections, with dynamic CT recommended every two weeks in severe cases 6, 1

Warning Signs of Complications

Recognize these red flags that indicate deteriorating clinical status and potential septic complications:

• Sudden high fever (as opposed to unremitting low-grade fever which is common in necrotizing pancreatitis and doesn't necessarily indicate deterioration) suggests infection 6, 1
• Increasing abdominal distension beyond initial presentation 1
• Development of epigastric mass indicating pseudocyst formation 1
• Signs of cardiorespiratory or renal failure are ominous indicators of septic complications 6, 1
• "Failure to thrive"—patients requiring continued system support with hypermetabolism and catabolic state—suggests developing complications 6

Critical Pitfalls to Avoid

Do not rely on clinical presentation alone for diagnosis, as pancreatitis symptoms mimic other acute abdominal conditions including perforated viscus, intestinal obstruction, leaking abdominal aortic aneurysm, and mesenteric ischemia—all of which can be fatal if missed 1, 4, 7

Approximately 50% of patients will be misclassified by clinical assessment alone, necessitating both biochemical confirmation and imaging to exclude surgical emergencies 7

The clinical picture may be obscured in postoperative patients, making diagnosis more challenging 1

Do not assume typical pain patterns—over half of patients present with atypical pain locations, so maintain high clinical suspicion even without classic epigastric-to-back radiation 1, 5