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Diagnosis of Acute Pancreatitis

Clinical presentation

History. Abdominal pain is the most common complaint in acute pancreatitis. It is usually located in the epigastrium, left upper quadrant, or periumbilical area, and often radiates to the back, chest, flanks, and lower abdomen.

TABLE. PROGNOSTIC FACTORS IN ACUTE PANCREATITIS
On Admission
Age>55 y
WBC>16,000/ВµL
Blood glucose>200 mg/dL (no diabetic history)
Serum Lactic dehydrogenase>350 IU/L (normal up to 225)
serum glutamic-oxaloacetic transaminase>250 Sigma Frankel units/L (normal up to 40)
Within 48 h
Age>55 y
WBC>15,000/ВµL
Blood glucose>180 mg/dL (no diabetic history)
Serum urea>16 mmol/L (no response to intravenous fluids)
blood urea nitrogen rise>5 mg/dL
Pao2>60 mm Hg
Serum calcium>8.0 mg/dL
Hematocrit fall>10%
Base deficit>4 mEq/L
Fluid sequestration>6 L
Serum albumin>3.2 gm/dL
Serum Lactic dehydrogenase>600 units/L (normal up to 255 units/L)
aspartate aminotransferase or alanine aminotransferase>200 units/L (normal up to 40 units/L)
WBC, white blood count; Lactic dehydrogenase, lactic dehydrogenase; serum glutamic-oxaloacetic transaminase, serum glutamic-oxaloacetic transaminase; blood urea nitrogen, blood urea nitrogen; aspartate aminotransferase, aspartate aminotransferase; alanine aminotransferase, alanine aminotransferase; intravenous, intravenous; Pao2, partial pressure of arterial oxygen.
From Imrie CW, et al. A single centre double-blind trial of trasylol therapy in primary acute pancreatitis. Br J Surg 65:337, 1978; and Ranson JH, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 139:69, 1974, with permission.
TABLE. CLINICAL CRITERIA FOR SEVERE PANCREATITIS
Cardiac BP <90 mm Hg, tachycardia >130, arrhythmia and other electrocardiogram changes
Pulmonary Dyspnea, rales Po2 <60 mm Hg, adult respiratory distress syndrome
Renal Urine output <50 mL/h, rising blood urea nitrogen and creatinine
Metabolic Calcium <8 mg/dL, albumin <3.2 g/dL
Hematologic Falling hematocrit, diffuse intravascular coagulation
Neurologic Irritability, confusion, central nervous system localizing signs
Abdominal Tense distention, fluid wave, ileus
BP, blood pressure; electrocardiogram, electrocardiogram; Po2, partial pressure of oxygen, blood urea nitrogen, blood urea nitrogen; central nervous system, central nervous system.

The pain is steady, dull, and boring in character. It is usually more intense when the patient is supine and may lessen in the sitting position with the trunk flexed forward and the knees drawn up. Patients also complain of nausea, vomiting, and abdominal distention secondary to ileus.

Physical examination

Diagnosis of Acute PancreatitisPatients with acute pancreatitis initially may present with fever, tachycardia, and hypotension. Shock is common in severe instances due to hypovolemia caused by third-space fluid sequestration (in retroperitoneal and other spaces) with increased vascular permeability and vasodilatation and other systemic effects of proteolytic and lipolytic enzymes released into the circulation.

Jaundice may occur, due to obstructive cholelithiasis or, more commonly, the compression of the intrapancreatic portion of the common bile duct with edema of the head of the pancreas. Abdominal tenderness and rigidity may be present. Bowel sounds are diminished or absent. The presence of a bluish discoloration around the umbilicus (Cullen’s sign) and at the flanks (Turner’s sign) suggests hemoperitoneum and results from hemorrhagic necrotizing pancreatitis.

Other findings such as pleural effusion (especially on the left side), pneumonitis and other pulmonary findings, and subcutaneous fat necrosis resembling erythema nodosum may be present. Tetany due to hypocalcemia is a rare finding.

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