Acute pancreatitis: presentation, signs and symptoms, and management

Typical presentation

The classic patient has sudden, severe epigastric pain that radiates to the back. Nausea and vomiting usually accompany it, and some patients have abdominal distention or signs of dehydration (Current Surgical Therapy 14e, p. 604). Pain is often worse supine and eased by leaning forward. This is common clinical teaching and wasn't in the passages I pulled.

Rosen's Emergency Medicine also notes that the pain can be out of proportion to the abdominal exam findings.

Common causes. Gallstones and alcohol together account for about two thirds of cases. Other causes include hypertriglyceridemia, hypercalcemia, post-ERCP injury, drugs, trauma, anatomic variants such as pancreas divisum, and autoimmune or idiopathic disease (Goldman-Cecil Medicine, Ch. 130; Current Surgical Therapy 14e).

Gallstone pancreatitis tends to come with biliary-type pain.
Alcoholic pancreatitis usually follows more than 5 years of heavy intake, averaging more than 5 to 8 drinks daily.

Signs and symptoms

Domain	Findings
Symptoms	Epigastric or upper abdominal pain radiating to the back, nausea, vomiting, early satiety
Vital signs	Tachycardia, low-grade fever, hypotension in severe disease
Abdomen	Epigastric tenderness, distention, reduced bowel sounds, guarding that may be mild relative to the pain
Severe or hemorrhagic disease	Grey-Turner sign (flank ecchymosis) and Cullen sign (periumbilical ecchymosis), both uncommon, from retroperitoneal bleeding
Systemic	Cool, cyanotic extremities from underperfusion, WBC 12,000 to 20,000/mm³ (Sleisenger and Fordtran's)
Complications	Hypoxemia or ARDS, renal failure, shock, hypocalcemia

Diagnosis

Diagnosis needs 2 of 3 criteria (Current Surgical Therapy 14e, p. 604):

Compatible abdominal pain.
Serum lipase or amylase more than 3 times the upper limit of normal.
Pancreatic inflammation on imaging.

Lipase vs amylase. Lipase is preferred. It is more specific, stays elevated longer, and is more sensitive in delayed presentations and in alcohol or hypertriglyceridemia-related disease. Adding amylase to a non-diagnostic lipase does not improve accuracy (Tintinalli's).
Other blood tests. Check renal and liver function, electrolytes, glucose, calcium, triglycerides, WBC, and hematocrit.
Gallstone clue. ALT above 150 U/L within 48 hours predicts gallstone pancreatitis with a positive predictive value above 85% (Tintinalli's).
Imaging. Right upper quadrant ultrasound is done in all patients to look for gallstones. Contrast CT is not needed at presentation if the diagnosis is clear. Use it later, usually after 72 hours, if there is concern for necrosis or complications.

Severity (2012 Revised Atlanta Classification) (Current Surgical Therapy 14e):

Mild: no organ failure and no local or systemic complications.
Moderately severe: transient organ failure lasting under 48 hours, or local or systemic complications. This is about 15% of patients.
Severe: persistent organ failure beyond 48 hours. This is about 5% of patients, with mortality up to 36 to 50%, and higher with infected necrosis.

Useful scores are BISAP, Ranson, APACHE II, and the CT severity index.

Management

Fluid resuscitation.
- Give crystalloid, preferably lactated Ringer's.
- Tintinalli's suggests a total of 2.5 to 4 L over the first 12 to 24 hours, or 5 to 10 mL/kg/h.
- Go slower in heart or renal failure to avoid overload, pulmonary edema, and abdominal compartment syndrome.
- Large volumes of normal saline can cause hyperchloremic acidosis, and one randomized study showed less SIRS with lactated Ringer's.
- Monitor heart rate below 120, MAP 65 to 85, urine output 0.5 to 1 mL/kg/h, and hematocrit and creatinine.
Analgesia and antiemetics. Use IV opioids and antiemetics. A nasogastric tube is not helpful unless there is ileus or persistent vomiting.
Nutrition.
- Avoid prolonged NPO status, which promotes gut atrophy and bacterial translocation.
- Restart oral feeding early, as soon as nausea and vomiting settle and pain improves. A low-fat solid diet is safe and gives more calories than clear liquids.
- If the patient cannot eat, give early enteral feeding (nasogastric or nasojejunal) rather than parenteral nutrition.
Supportive care.
- Give oxygen as needed.
- Replace calcium and magnesium.
- Control glucose.
- Monitor in a high-dependency or ICU setting for organ failure.
Antibiotics. Do not give them prophylactically. Pancreatitis alone is not an infection. Treat only a demonstrated source, such as cholangitis, pneumonia, or infected necrosis.
Treat the cause.
- Biliary: Do ERCP within 24 hours only if there is cholangitis or a persistent biliary obstruction. Routine early ERCP does not improve outcomes. Offer cholecystectomy during the same admission for mild gallstone pancreatitis. This last point is from guideline teaching, not the passages I pulled.
- Alcohol: Counsel on cessation and smoking cessation.
- Hypertriglyceridemia: Give insulin infusion and lipid-lowering therapy.
- Hypercalcemia or drugs: Correct the calcium and stop the offending drug.
Complications.
- Necrosis and collections. Suspect infected necrosis with fever, worsening pain, or sepsis. Manage with antibiotics and delay intervention, usually to about 4 weeks.
- Walled-off necrosis. Use a step-up approach: endoscopic or percutaneous drainage first, then minimally invasive necrosectomy if needed.
- Pseudocysts. These form after 4 weeks, and drainage is only needed if they are symptomatic.

Recent evidence flag

A PubMed search of the last 2 years found newer work that may update parts of the above:

The iLATAM-AP 2026 guideline (PMID 42216617).
A 2024 meta-analysis of aggressive vs non-aggressive IV fluids (PMID 38872377).
A 2025 overview of pharmacological interventions (PMID 40035297).

I only saw the titles, not the full abstracts. Recent trials and guidelines generally favor moderate, goal-directed fluid rates over very aggressive hydration, because of the overload risk. That is from my background knowledge, not from these papers. Check your local protocol for fluid volumes.

I couldn't find a suitable image of Grey-Turner or Cullen signs in the image library.

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