Acute Pancreatitis: Symptoms, Diagnosis and Treatment
Acute pancreatitis is a rapidly developing inflammation of the pancreas. Most patients present with severe upper abdominal pain radiating to the back, nausea and vomiting. The majority of episodes are mild and settle within days, but a proportion progress to organ failure or tissue necrosis. For this reason any suspected case should be assessed in hospital. In Antalya, Dr. Gökhan ATEŞ provides patient information on identifying the cause, monitoring severity, and timing surgery in gallstone-related cases.
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Acute pancreatitis is sudden inflammation of the pancreas. The diagnosis usually requires at least two of three criteria: typical upper abdominal pain, often radiating to the back; a blood amylase or lipase level above roughly three times the upper limit of normal; and imaging findings (CT, MRI or ultrasound) consistent with pancreatitis. Gallstones and alcohol are the most frequent causes. Treatment takes place in hospital and centres on fluid support, pain control, resuming nutrition at the right time and removing the underlying cause. Severity and the risk of organ failure are monitored closely during the first days.
What are the symptoms?
Pain typically starts suddenly in the upper middle abdomen and often radiates to the back. It may ease slightly when leaning forward and worsen when lying flat. Nausea and vomiting are common, and vomiting usually does not relieve the pain.
- Constant, severe upper abdominal pain radiating to the back
- Nausea, vomiting, loss of appetite
- Abdominal distension and tenderness
- Fever, rapid pulse
- Yellowing of the eyes or skin in gallstone-related cases
- In severe disease: breathlessness, reduced urine output, confusion
Most common causes
- Gallstones and biliary sludge (among the most frequent causes)
- Alcohol use
- High triglyceride levels
- Certain medications
- Pancreatitis after ERCP
- High calcium levels, trauma, anatomical variants
- Cases with no identifiable cause (idiopathic)
How is it diagnosed?
Internationally accepted practice requires at least two of three criteria: typical abdominal pain; amylase or lipase above roughly three times the upper limit of normal; and imaging findings consistent with pancreatitis. Lipase stays elevated longer than amylase and is generally more informative.
The height of the enzyme value does not reflect disease severity. A value far above the threshold may accompany a mild course, while a borderline value may occur in severe disease. Enzyme levels alone therefore never drive the decision.
Ultrasound is requested in almost every patient — not primarily to visualise the pancreas but to look for gallstones and biliary dilatation. Contrast-enhanced CT is generally more informative after the first 48–72 hours, when the diagnosis is unclear or the clinical course is not improving as expected; necrosis may not yet be visible on a very early scan.
Diagnostic criteria and tests
| Criterion / test | What it shows | Note |
|---|---|---|
| Typical pain | Persistent upper abdominal pain radiating to the back | The clinical part of the diagnosis |
| Lipase / amylase | Elevation above ~3× the upper limit of normal | The degree of elevation does not indicate severity |
| Ultrasound | Gallstones, biliary dilatation | First step in looking for the cause |
| Contrast-enhanced CT | Necrosis, collections, complications | Usually more meaningful after 48–72 hours |
| MRI / MRCP | Bile duct stones, ductal anatomy | No radiation; preferred when a stone is suspected |
| CRP, blood gases, kidney and liver tests | Inflammatory response and organ function | Used to monitor severity |
Why severity is assessed in hospital
The course of acute pancreatitis can change within the first days. A picture that looks mild at presentation may progress within 24–48 hours to fluid loss and deterioration of respiratory, circulatory or kidney function. Severity classification is based on the presence and duration of organ failure together with local complications.
Monitoring therefore involves regular assessment of pulse, blood pressure, urine output, oxygenation and laboratory values. Patients with organ failure, or at high risk of it, are observed in an intensive care setting. Severe cases are managed jointly by general surgery, gastroenterology, radiology and intensive care.
Treatment approach
In most mild cases treatment is supportive: balanced intravenous fluids, adequate pain control, relief of nausea, and restarting oral intake as soon as the patient tolerates it. Prolonged fasting is no longer routinely recommended; early, stepwise feeding is well tolerated by most patients.
Antibiotics are used only when infection is proven or strongly suspected; routine prophylactic antibiotics are generally not advised. Where necrosis develops, the preferred strategy is to delay intervention where possible and, when needed, to start with the least invasive option (percutaneous or endoscopic drainage) in a step-up manner.
Treating the cause matters just as much: removing the gallbladder at the appropriate time in gallstone-related disease, or correcting high triglycerides or a causative medication, reduces the risk of recurrence.
When are surgery or intervention considered?
The decision is individual and combines clinical course, imaging findings and comorbidities. Sterile (non-infected) necrosis often requires no intervention at all.
- In mild gallstone pancreatitis, cholecystectomy is usually planned during the same admission once the episode has settled
- ERCP is considered when cholangitis or ongoing biliary obstruction is present
- Drainage or intervention may be needed for infected necrosis or large symptomatic collections
- Emergency surgery may be required for raised intra-abdominal pressure, bleeding or bowel ischaemia
After discharge
After discharge, nutrition is returned to normal gradually, alcohol should be avoided and the plan addressing the cause should be completed. Recurrent pain, fever, vomiting or jaundice call for reassessment. When no cause is found, MRCP or endoscopic ultrasound may be arranged for further evaluation.
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