What are the signs and symptoms of acute and chronic pancreatitis?

Signs and Symptoms of Pancreatitis

The hallmark presentation of acute pancreatitis is sudden-onset severe upper abdominal pain radiating to the back, accompanied by nausea, vomiting, and epigastric tenderness on examination. 1, 2

Acute Pancreatitis: Core Clinical Features

Primary Symptoms

• Abdominal pain is the dominant symptom, present in 97.3% of patients, typically severe and sudden in onset 1, 3
• Pain characteristically radiates to the back, which helps distinguish pancreatitis from other acute abdominal conditions 1, 2, 4
• Pain is most commonly epigastric or diffuse upper abdominal, though 50.9% of patients present with atypical pain locations 1, 3
• Nausea and vomiting are nearly universal accompanying symptoms 1, 2, 5
• Pain onset may follow a recent alcohol binge or fatty meal 4

Physical Examination Findings

• Epigastric or diffuse abdominal tenderness is the most consistent examination finding 1, 2
• Patients may appear tachycardic and systemically unwell 4
• Abdominal distension occurs in more severe cases 1

Severity Indicators and Warning Signs

Markers of Severe Disease

Body wall ecchymoses indicate severe hemorrhagic pancreatitis and should immediately raise concern: 1, 2

• Cullen's sign: periumbilical bruising
• Grey-Turner's sign: flank bruising

Progressive Disease Features

• Prolonged ileus with persistent abdominal distension signals ongoing deterioration 2, 6
• Persistent severe pain beyond expected recovery time 1
• Development of an epigastric mass suggests pseudocyst formation or acute fluid collection 1, 2
• Low-to-moderate grade fever is common in necrotizing pancreatitis and does not necessarily indicate infection 2, 6
• Sudden high fever is a red-flag sign suggesting infected necrosis or abscess requiring urgent investigation 1, 2, 6

Systemic Complications

• Respiratory distress or pleural effusions visible on chest X-ray 1
• Multi-organ dysfunction including renal, cardiovascular, or respiratory failure 1, 2
• Fever particularly high-grade in cases of infection 1

Chronic Pancreatitis: Distinct Presentation

Primary Features

• Insidious progression of chronic, severe upper abdominal pain radiating to the back, caused by progressive pancreatic destruction, inflammation, and duct obstruction 4
• Weight loss and steatorrhea from exocrine insufficiency 4, 7
• Diabetes mellitus from endocrine insufficiency developing later in disease course 4, 7
• Patients may present with recurrent episodes mimicking acute pancreatitis both symptomatically and metabolically 4

Pain Characteristics with Prognostic Significance

Sharp pain on admission is associated with higher odds of severe disease (OR 2.48) and increased mortality (OR 2.26) compared to dull or cramping pain. 3

• Intense pain (reported by 70% of patients) correlates with higher rates of peripancreatic fluid collections (19.5% vs 11.0%) and edematous pancreas 3
• Cramping pain is the most common pain type (61% of patients) 3
• Pain duration prior to admission is typically less than 24 hours (56.7% of cases), though longstanding pain >72 hours shows no association with outcomes 3

Laboratory and Imaging Correlates

Biochemical Findings

• Elevated serum lipase (≥2 times normal) is more specific than amylase and remains elevated longer 1, 2
• Elevated serum amylase (≥4 times normal) is common but less specific 1
• Rising leukocyte and platelet counts suggest developing complications or sepsis 1, 6
• Elevated CRP and rising APACHE II scores indicate worsening severity 2, 6
• Deranged clotting profile warns of complications 1

Imaging Findings

• Ultrasound may show swollen pancreas, though visualization is limited in 25-50% of cases 1
• CT scan reveals pancreatic inflammation, necrosis, or fluid collections 1
• Chest X-ray may demonstrate pleural effusions or ARDS in severe cases 1

Critical Diagnostic Pitfalls to Avoid

Clinical findings alone should never be relied upon for diagnosis, as pancreatitis mimics many other acute abdominal conditions. 1, 2

• The clinical picture may be obscured in postoperative patients 1
• Atypical pain locations occur in over half of patients, so absence of classic epigastric/back radiation does not exclude pancreatitis 3
• Recent-onset diabetes in older patients without predisposing factors may be an early warning sign of underlying pancreatic disease 1
• Patients with intense and sharp pain require closer monitoring and tailored pain management due to higher complication rates 3

Mild vs. Severe Disease Distinction

Mild Acute Pancreatitis

• Minimal systemic disturbance with uneventful recovery 8, 1
• Resolution of symptoms within days 1
• Predominant pathology is interstitial edema of the gland 8

Severe Acute Pancreatitis

• Organ failure and/or local complications such as necrosis, pseudocyst, or abscess 8
• Persistent severe pain, prolonged ileus, and signs of systemic inflammatory response syndrome 1
• Associated with pancreatic necrosis, though patients with edematous pancreatitis may also manifest severe features 8