What are the characteristics of pain in a patient with gallstone pancreatitis using the PQRST (Pain, Quality, Region, Severity, Timing) assessment?

PQRST Assessment of Gallstone Pancreatitis Pain

Gallstone pancreatitis presents with sudden-onset, severe, steady epigastric and/or right upper quadrant pain that radiates to the back, typically lasting hours to a full day, often triggered by a fatty meal, and is severe enough to prompt urgent medical attention. 1, 2

P - Provocation/Palliation

• Pain onset is frequently related to a recent fatty meal or rich food intake, which triggers gallstone migration and subsequent pancreatic duct obstruction 1
• The pain is not relieved by bowel movements, postural changes, or antacids, distinguishing it from other gastrointestinal causes 3
• Pain is severe enough to interrupt daily activities and consistently leads patients to seek urgent medical care 3, 1
• The pain typically awakens patients from sleep due to its intensity 3, 4

Q - Quality

• The pain is characteristically steady and cramping in nature (61% of acute pancreatitis patients describe cramping pain) 5
• Sharp pain is particularly concerning, as it is associated with 2.5 times higher odds of severe acute pancreatitis (OR = 2.481,95% CI: 1.550-3.969) and 2.3 times higher mortality (OR = 2.263,95% CI: 1.199-4.059) compared to dull pain 5
• The pain builds to a steady level rather than being intermittent or colicky, which helps differentiate it from simple biliary colic 3

R - Region/Radiation

• Primary location is the epigastrium and/or right upper quadrant 1, 4
• Pain characteristically radiates to the upper back or right infrascapular area 3, 1
• Importantly, 50.9% of patients present with atypical pain locations (not epigastric or belt-like upper abdominal), so absence of classic location does not exclude the diagnosis 5

S - Severity

• Pain is intense in 70% of cases (511/727 patients in prospective cohort) 5
• The severity is sufficient to cause exquisite tenderness on examination and patients typically appear unwell and tachycardic 1
• Intense pain is associated with higher rates of peripancreatic fluid collections (19.5% vs. 11.0%; p = 0.009) and edematous pancreas (8.4% vs. 3.1%; p = 0.016) 5
• Patients with intense and sharp pain require closer monitoring as they have higher odds of severe disease and complications 5

T - Timing/Temporal Pattern

• Onset is relatively abrupt and sudden, distinguishing it from chronic conditions 1, 4
• In 56.7% of cases, pain begins less than 24 hours prior to hospital admission 5
• Episodes last for hours up to a full day (not minutes like typical biliary colic) 3, 4
• Pain duration greater than 72 hours before admission does not correlate with worse outcomes, so prolonged pain should not delay diagnosis or treatment 5

Associated Features Critical for Diagnosis

• Nausea and vomiting are commonly associated with the pain 3, 1
• The diagnosis requires any two of three criteria: (1) abdominal pain consistent with acute pancreatitis; (2) serum amylase/lipase >3 times upper limit of normal; (3) characteristic findings on cross-sectional imaging 2
• Approximately 80% of acute pancreatitis cases are caused by gallstones or alcohol, making gallstone pancreatitis the most common etiology in the Western world 1, 6