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For further information, see CMDT Part 16-26: Acute Pancreatitis

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


  • 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


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 ...

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