History
The cardinal symptom of acute pancreatitis is abdominal pain, which is characteristically dull, boring, and steady. Usually, the pain is sudden in onset and gradually intensifies in severity until reaching a constant ache. Most often, it is located in the upper abdomen, usually in the epigastric region, but it may be perceived more on the left or right side, depending on which portion of the pancreas is involved. The pain radiates directly through the abdomen to the back in approximately one half of cases.
Nausea and vomiting are often present, along with accompanying anorexia. Diarrhea can also occur. Positioning can be important, because the discomfort frequently improves with the patient sitting up and bending forward. However, this improvement is usually temporary. The duration of pain varies but typically lasts more than a day. It is the intensity and persistence of the pain that usually causes patients to seek medical attention.
Ask the patient about recent operative or other invasive procedures (eg, endoscopic retrograde cholangiopancreatography [ERCP]) or family history of hypertriglyceridemia. Patients frequently have a history of previous biliary colic and binge alcohol consumption, the major causes of acute pancreatitis.
Physical Examination
The following physical examination findings may be noted, varying with the severity of the disease:
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Fever (76%) and tachycardia (65%) are common abnormal vital signs; hypotension may be noted
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Abdominal tenderness, muscular guarding (68%), and distention (65%) are observed in most patients; bowel sounds are often diminished or absent because of gastric and transverse colonic ileus; guarding tends to be more pronounced in the upper abdomen
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A minority of patients exhibit jaundice (28%)
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Some patients experience dyspnea (10%), which may be caused by irritation of the diaphragm (resulting from inflammation), pleural effusion, or a more serious condition, such as acute respiratory distress syndrome (ARDS); tachypnea may occur; lung auscultation may reveal basilar rales, especially in the left lung
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In severe cases, hemodynamic instability is evident (10%) and hematemesis or melena sometimes develops (5%); in addition, patients with severe acute pancreatitis are often pale, diaphoretic, and listless
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Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia
A few uncommon physical findings are associated with severe necrotizing pancreatitis:
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The Cullen sign is a bluish discoloration around the umbilicus resulting from hemoperitoneum
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The Grey-Turner sign is a reddish-brown discoloration along the flanks resulting from retroperitoneal blood dissecting along tissue planes; more commonly, patients may have a ruddy erythema in the flanks secondary to extravasated pancreatic exudate
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Erythematous skin nodules may result from focal subcutaneous fat necrosis; these are usually not more than 1 cm in size and are typically located on extensor skin surfaces; in addition, polyarthritis is occasionally seen
Rarely, abnormalities on funduscopic examination may be seen in severe pancreatitis. Termed Purtscher retinopathy, this ischemic injury to the retina appears to be caused by activation of complement and agglutination of blood cells within the retinal vessels. It may cause temporary or permanent blindness.
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Acute pancreatitis. Suspected acute pancreatitis. Etiologic factors and forms of acute pancreatitis. Ranson criteria.
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Acute pancreatitis. Mild pancreatitis. Favorable prognostic signs for acute pancreatitis. Medical management and studies used for acute pancreatitis.
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Acute pancreatitis. Prognostic indicators for severe pancreatitis and intensive care unit management.
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Acute pancreatitis. Diagnosis and treatment of necrotizing pancreatitis.
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Acute pancreatitis. Treatment of and studies used for pancreatic pseudocysts.
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Acute pancreatitis. Idiopathic recurrent pancreatitis. Etiologies for acute pancreatitis.
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Acute pancreatitis. Pancreatic abscess. Definition of an abscess.
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Acute pancreatitis. A patient with acute gallstone pancreatitis underwent endoscopic retrograde cholangiopancreatography. The cholangiogram showed no stones in the common bile duct and multiple small stones in the gallbladder. The pancreatogram shows narrowing of the pancreatic duct in the area of genu, resulting from extrinsic compression of the ductal system by inflammatory changes in the pancreas.
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Acute pancreatitis. This image was obtained from a patient with pancreas divisum associated with minor papilla stenosis causing recurrent pancreatitis. Because pancreas divisum is relatively common in the general population, it is best regarded as a variant of normal anatomy and not necessarily as a cause of pancreatitis. In this case, note the bulbous contour of the duct adjacent to the cannula. This appearance has been termed Santorinicele. Dorsal duct outflow obstruction is a probable cause of pancreatitis when Santorinicele is present, and it is associated with a minor papilla that accommodates only a guide wire.
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Acute pancreatitis. A normal-appearing ventral pancreas is seen in a patient with recurrent acute pancreatitis. Dorsal pancreas (not pictured) showed evidence of chronic pancreatitis.
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Acute pancreatitis. Endoscopic retrograde cholangiopancreatography excluded suppurative cholangitis and established the presence of anular pancreas divisum. The dorsal pancreatogram showed extravasation into the retroperitoneum, and sphincterotomy was performed on the minor papilla. A pigtail nasopancreatic tube was then inserted into the dorsal duct and out into the retroperitoneal fluid collection. The other end of the tube was attached to bulb suction and monitored every shift.
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Acute pancreatitis. Although percutaneous drains remove loculated fluid collections elsewhere in the abdomen, a nasopancreatic tube drains the retroperitoneal fluid collection. One week later, the retroperitoneal fluid collection was much smaller (the image is reversed in a horizontal direction). By this time, the patient was off pressors and was ready to be extubated.
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Acute pancreatitis. Recurrent pancreatitis was associated with pancreas divisum in an elderly man. The pancreatogram of the dorsal duct shows distal stenosis with upstream chronic pancreatitis. After the stenosis was dilated and stented, his pain resolved and the patient improved clinically during 1 year of quarterly stent exchanges. Follow-up computed tomography (CT) scans showed resolution of the inflammatory mass. Although ductal biopsies and cytology were repeatedly negative, the patient's pain and pancreatitis returned when the stents were removed. He developed duodenal outflow obstruction and was sent to surgery; during the Whipple procedure, periampullary adenocarcinoma (of minor papilla) was revealed.
Tables
| Acute pancreatitis (any) or a history of post-ERCP pancreatitis |
| Younger age |
| Female sex |
| Absence of bile duct stones |
| More than 10 attempts to cannulate the papilla of Vater |
| Pancreatic duct cannulation |
| Contrast medium injection of the pancreatic system |
| Pancreatic sphincterotomy |
| Sphincter of Oddi dysfunction |
