Acute pancreatitis: Clinical sciences

Acute pancreatitis is an inflammation of the pancreas, most commonly caused by biliary stones, followed by alcohol use and hypertriglyceridemia, but can also be idiopathic. There are many other causes of acute pancreatitis, including trauma, iatrogenic post-endoscopic retrograde cholangiopancreatography or ERCP, autoimmune disorders, genetic diseases, infections, malignancies, toxic exposure, and medications like thiazides, antiretrovirals, and valproic acid. Depending on the severity of the disease, pancreatitis can range from mild to moderate or even severe, life-threatening pancreatitis.

The first step in assessing a patient with signs and symptoms suggestive of acute pancreatitis is to perform the ABCDE assessment to determine if the patient is stable or unstable. If the patient is unstable, start acute management and stabilize the airway, breathing, and circulation. Next, obtain IV access and initiate IV fluids for aggressive resuscitation. Make sure the patient is NPO, and provide supportive care including pain management and antiemetic medication.

Alright, now let's talk about stable patients. Start by taking a focused history and physical examination. Usually, patients with acute pancreatitis present with persistent, unremitting epigastric abdominal pain that radiates to the back, worsens after meals, and improves when leaning forward. The pain is often associated with nausea and vomiting, while some patients might report a fever as well. It is also possible for patients to present with jaundice as a sign of biliary obstruction. Additionally, some patients might develop tetany, or involuntary muscle spasms, as a result of hypocalcemia. Finally, don’t forget to ask about a history of similar previous episodes, cholelithiasis, or alcohol use.

Physical exam typically reveals epigastric abdominal tenderness, distention, or guarding. Some patients' physical examinations may show ecchymosis due to associated intra-abdominal or retroperitoneal bleeding. Examples include the Cullen sign, or periumbilical ecchymosis; the Grey-Turner sign, or flank ecchymosis; the Fox sign, or inguinal ecchymosis; and the Bryant sign, or scrotal ecchymosis. Lastly, in some cases, you might find signs of fluid sequestration like ascites or pleural effusion.