What are the signs and symptoms of pancreatitis?

From the Guidelines

Severe acute pancreatitis is associated with persistent organ failure, and high mortality, thus patients with organ failures should be admitted to an intensive care unit whenever possible. The management of severe acute pancreatitis involves several key components, including pain management, fluid resuscitation, and nutritional support. According to the 2019 WSES guidelines for the management of severe acute pancreatitis 1, patients who have persistent organ failure with infected necrosis have the highest risk of death.

Diagnosis and Severity Grading

The diagnosis of acute pancreatitis should be established within 48 hours of admission, based on compatible clinical features and elevations in amylase or lipase levels, as stated in the AGA institute medical position statement on acute pancreatitis 2. Elevations in amylase or lipase levels greater than 3 times the upper limit of normal are most consistent with acute pancreatitis.

Pain Management

Pain is the cardinal symptom of acute pancreatitis, and its relief is a clinical priority, as discussed in the 2019 WSES guidelines for the management of severe acute pancreatitis 3. All patients with acute pancreatitis must receive some form of analgesia in the first 24 hours of hospitalization. The best current recommendation is to adhere to the most current acute pain management guidelines in the perioperative setting.

Key Considerations

• Patients with severe acute pancreatitis should be admitted to an intensive care unit whenever possible 1.
• Pain control should be achieved with opioid analgesics, avoiding NSAIDs due to their potential to exacerbate pancreatitis.
• Nutritional support should begin early, preferably within 48 hours, with enteral feeding being preferred over parenteral nutrition when possible.
• The underlying cause, such as gallstones, alcohol, medications, or metabolic disorders, should be identified and addressed to prevent recurrence.
• Patients should abstain from alcohol completely and follow a low-fat diet during recovery.
• Early recognition and management of complications is essential for improving outcomes in acute pancreatitis.

From the Research

Definition and Diagnosis of Pancreatitis

• Pancreatitis is an inflammatory process within the pancreas, which can be mild but also have severe forms with a mortality rate of up to 30% 4.
• The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation 4, 5.
• The most common etiologies include gallbladder disease and alcohol use 4, 6.

Management of Acute Pancreatitis

• Initial management of acute pancreatitis should focus on fluid resuscitation, with some data to support Ringer's lactate over physiological saline 6.
• Early oral feeding should be encouraged, not avoided, and use of parenteral nutrition is discouraged 6.
• Nonopioid analgesics should be the first line of analgesia in patients with acute pancreatitis 7.
• Cholecystectomy during the same admission of biliary pancreatitis should be performed in order to prevent future acute pancreatitis episodes 6.

Prevention and Risk-Reduction Strategies

• Statin use is associated with lower incidence of acute pancreatitis in the general population and ongoing studies are evaluating its preventive role in acute pancreatitis recurrences 7.
• The preventive role of rectal indomethacin in post-endoscopic retrograde cholangiopancreatography pancreatitis is indisputable, with subject selection and timing of administration requiring further investigation 7.
• Risk-reduction strategies, such as cholecystectomy and alcohol cessation counseling, should be used during and after hospitalization for acute pancreatitis 8.

Complications and Prognosis

• Complications of acute pancreatitis can be severe, and patients with local complications should be referred to specialist tertiary centres to guide further management 5.
• Scoring systems, such as the Bedside Index of Severity in Acute Pancreatitis (BISAP) and the Acute Physiology and Chronic Health Evaluation (APACHE) II tools, have good predictive capabilities for disease severity and mortality 8.
• Early and aggressive fluid resuscitation and early enteral nutrition are associated with lower rates of mortality and infectious complications 8.