Pancreatitis, Acute

Key Features

Essentials of Diagnosis

• Abrupt onset of deep epigastric pain, often with radiation to the back

• Nausea, vomiting, sweating, weakness, fever

• Abdominal tenderness and distention

• Leukocytosis, elevated serum lipase, elevated serum amylase

• History of previous episodes, often related to alcohol intake

General Considerations

• Most often due to passed gallstone, usually < 5 mm in diameter, or to heavy alcohol intake

• Rarely, may be the initial manifestation of a pancreatic or ampullary neoplasm

• The pathogenesis may include edema or obstruction of the ampulla of Vater, bile reflux into pancreatic ducts, or direct injury of the pancreatic acinar cells

• Annual incidence of acute pancreatitis ranges from 13 to 45 per 100,000 population and has increased since 1990

Clinical Findings

Symptoms and Signs

• There may be a history of alcohol intake or a heavy meal immediately preceding the attack, or a history of milder similar episodes or biliary pain in the past

• An international classification of the severity of acute pancreatitis has been proposed

  • Mild: absence of pancreatic or peripancreatic necrosis and organ failure

  • Moderate: presence of sterile (peri)pancreatic necrosis and/or transient (< 48 hours) organ failure using the sequential organ failure assessment (SOFA) score

  • Severe: presence of infected (peri)pancreatic necrosis or persistent (≥ 48 hours) organ failure

  • Critical: presence of infected (peri)pancreatic necrosis and persistent organ failure

Pain

• Severe, steady, boring epigastric pain, generally abrupt in onset; usually radiates into the back but may radiate to the right or left

• Often made worse by walking and lying and better by sitting and leaning forward

• The upper abdomen is tender, most often without guarding, rigidity, or rebound

• There may be distention and absent bowel sounds from paralytic ileus

• Nausea and vomiting

• Weakness, sweating, and anxiety in severe attacks

• Fever of 38.4–39.0°C, tachycardia, hypotension (even shock), pallor, and cool clammy skin are present in severe cases

• Mild jaundice may be seen

• Occasionally, an upper abdominal mass may be palpated

• Acute kidney injury (usually prerenal) may occur early in the course

Differential Diagnosis

• Acute cholecystitis

• Acutely perforated duodenal ulcer

• Acute intestinal obstruction

• Leaking aortic aneurysm

• Renal colic and acute mesenteric ischemia

Diagnosis

Laboratory Tests

• Serum lipase and amylase increase, usually > 3 times normal, within 24 h in 90% of cases; lipase remains elevated longer than amylase and is slightly more accurate for diagnosis

• Leukocytosis (10,000–30,000/mcL [10–30 × 10⁹/L]), proteinuria, granular casts, glycosuria (10–20% of cases), hyperglycemia, and hyperbilirubinemia may be present

• Blood urea nitrogen (BUN) and serum alkaline phosphatase may be elevated and coagulation tests abnormal

• An early rise in serum levels of neutrophil gelatinase-associated lipocalin has ...