Pancreatitis Pain: Causes, Symptoms, Diagnosis, Treatment
Pancreatitis review of causes, symptoms, pain location, diagnosis, treatment, diet, and pathophysiology. Great for nursing, students, medical learners, USMLE, and NCLEX!
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Pancreatitis
Pancreatitis can lead to severe abdominal pain and is a cause for many hospital admissions annually.
But what exactly is pancreatitis? What causes it? What are the symptoms? How is it diagnosed and treated? Can diet modifications help?
Read on to find out!
In this post, we will walk through the features of pancreatitis including the definition, types, causes, symptoms, diagnosis, and treatment.
Without wasting any more time, let’s get right into it!
High-Yield Main Learning Points!
Make sure to check out the main learning points at the end of this post!
It’s a great high-yield summary of the important information and features to know for pancreatitis!
Pancreatitis: Review of pancreatitis including the definition, causes, symptoms, diagnosis, and treatment.
What is Pancreatitis?
In order to define pancreatitis, let’s break down the word.
We learned in the medical terminology lecture on suffixes that “itis” means inflammation.
Therefore, pancreatitis is inflammation of the pancreas.
But what exactly is the pancreas and what does it do?
Pancreatitis Definition: Inflammation of the pancreas
About the Pancreas
The pancreas is an organ located in the upper abdomen behind the stomach, and it extends into the left upper quadrant (LUQ).
You can see the normal position of the pancreas in the image above.
The image below shows the pancreas highlighted in red and moved to the front of the stomach for better visualization.
The pancreas produces enzymes (exocrine function) and hormones (endocrine function) that help with digestion and glucose control.
Pancreatic digestive enzymes include lipase, amylase, and proteases (such as trypsin and chymotrypsin).
The pancreatic digestive enzymes are released into the duodenum, the first part of the small intestine, to aid in the digestion of fats (lipase), carbohydrates/starches (amylase), and proteins (proteases).
Pancreatic hormones include insulin, glucagon, somatostatin, amylin, and gastrin.
Note: Gastrin is primarily produced in the stomach, but can also be produced in the duodenum and pancreas.
Pancreatic hormones are released into the bloodstream to aid in glucose control (insulin, glucagon, somatostatin, and amylin) and digestion (gastrin).
Pancreatitis: The pancreas (star) is located in the upper abdomen behind the stomach (moved to the front of the stomach for visualization), and extends into the LUQ.
Pancreatitis Pathophysiology
Pancreatitis occurs when the digestive enzymes mentioned above are prematurely activated in the pancreas rather than the small intestine.
The premature activation of these enzymes results in inflammation of the pancreas.
There are several different causes to the premature activation of pancreatic enzymes including obstruction, gallstones, alcohol, etc. - more on this soon!
But first, there are 2 main types of pancreatitis - Acute vs Chronic.
Let’s look at the difference between acute and chronic pancreatitis next.
Pancreatitis: The pancreas (star) is located in the upper abdomen and extends into the LUQ. Premature activation of pancreatic digestive enzymes in the pancreas causes inflammation. There are 2 main types of pancreatitis - Acute vs Chronic.
Acute vs Chronic Pancreatitis
There are 2 main types of pancreatitis - Acute and Chronic.
Acute Pancreatitis
Acute pancreatitis is an acute response to injury of the pancreas.
It is an isolated episode in which there is active inflammation of the pancreas.
While the onset of acute pancreatitis is often sudden and severe, it is short term with a duration of days to weeks before resolving.
Pancreatic enzymes are usually elevated since active inflammation is present, and this can be measured using a blood test - more on that soon!
Alcohol and gallstones are common causes of acute pancreatitis - more on that soon too!
In most cases of acute pancreatitis there is no long term damage to the pancreas, especially if the episode is mild and uncomplicated.
However, acute pancreatitis may lead to chronic pancreatitis, particularly if recurrent acute episodes occur.
Let’s take a look at chronic pancreatitis now.
Acute vs Chronic Pancreatitis: Features, symptoms, duration, diagnosis, and causes of acute and chronic pancreatitis.
Chronic Pancreatitis
Unlike acute pancreatitis which is an isolated episode, chronic pancreatitis is ongoing disease of the pancreas.
There is recurrent or continued inflammation, which may result in chronic irreversible damage to the pancreas.
Chronic pancreatitis may lead to fibrosis or calcification of the pancreas, and this can negatively affect its function in digestion and glucose control.
Whereas the symptoms of acute pancreatitis are often sudden and severe, the presence and severity of symptoms in chronic pancreatitis can fluctuate.
Some individuals with chronic pancreatitis can still have flare ups or episodes of acute pancreatitis as well.
Compared to acute pancreatitis (days-weeks), chronic pancreatitis is long term and can persist for several months to years.
Unlike acute pancreatitis, pancreatic enzymes may be normal or only slightly elevated in chronic pancreatitis.
The reason the enzymes are normal is due to the loss of pancreatic function and fibrosis.
Chronic pancreatitis can be caused by recurrent episodes of acute pancreatitis, ongoing alcohol abuse, and hereditary conditions and diseases such as cystic fibrosis.
Let’s take a closer look at some of these causes now.
Acute vs Chronic Pancreatitis: Features, symptoms, duration, and causes of acute vs chronic pancreatitis.
What Causes Pancreatitis?
There are 3 main causes of pancreatitis to know.
3 Main Causes
Gallstones
Alcohol
Hypertriglyceridemia
Gallstones, alcohol, and high triglyceride levels make up the majority of pancreatitis causes.
If you are a medical learner, these 3 causes are commonly tested on medical board and licensure exams.
Questions pertaining to pancreatitis will often have a patient with a history of gallstones, alcohol abuse, or high triglyceride levels.
Other Causes
Autoimmune Pancreatitis
Pancreatic Duct Injury
Post ERCP
Biliary Sludge
Biliary Obstruction
Trauma
Hypercalcemia
Genetic Disorders (hereditary pancreatitis, cystic fibrosis, etc)
Medications (valproic acid, ACE inhibitors, etc)
Infections (mumps, hepatitis B, cytomegalovirus, etc)
Idiopathic (cause is unknown)
Smoking is also a risk factor for pancreatitis.
Pancreatitis Causes: Common causes of pancreatitis include gallstones, alcohol, and high triglyceride levels, among others.
Symptoms of Pancreatitis
Let’s review the symptoms of pancreatitis, particularly acute pancreatitis.
Abdominal Pain
Abdominal pain is the hallmark symptom of pancreatitis and is present in the majority of cases.
It is often described as epigastric or left upper quadrant abdominal pain that radiates to the back.
The abdominal pain is typically severe and sharp, especially with acute pancreatitis.
(Remember the presence and severity of symptoms can fluctuate with chronic pancreatitis).
Eating and lying supine may worsen the pain, and leaning forward may improve the pain.
Other Symptoms
In addition to abdominal pain, many individuals will experience nausea and vomiting.
Decreased appetite, weight loss, and changes to stool may also be present, especially with chronic pancreatitis.
What to Know for Exams
If you are a medical learner, the description “epigastric or left upper quadrant abdominal pain radiating to the back” is a buzzword phrase for pancreatitis on exams.
Question stems for pancreatitis will often have a patient with a history of gallstones, alcohol use, or hypertriglyceridemia presenting with epigastric abdominal pain radiating to the back.
Pancreatitis Symptoms: Abdominal pain is usually located in the epigastric/LUQ region, radiates to the back, is worse after eating and lying supine, and may improve with leaning forward. Nausea, vomiting, and decreased appetite may be present as well.
Signs of Pancreatitis
Now that we know the symptoms of pancreatitis, what are some of the signs?
Abdominal Tenderness/Guarding
Decreased Bowel Sounds
Jaundice
Grey-Turner Sign
Cullen’s Sign
Abnormal Vital Signs
Abdominal tenderness or guarding is often present on physical exam, especially to the epigastric or left upper quadrant regions.
There may be decreased bowel sounds as well.
Jaundice, a yellowing of the skin and sclera of the eyes, may indicate the presence of a biliary obstruction.
Grey-Turner sign (ecchymosis/bruising in the flank) and Cullen’s sign (periumbilical ecchymosis/bruising around navel) may be present.
These signs could indicate pancreatic necrosis and pancreatic hemorrhage or bleeding.
Vital signs may also be abnormal including elevated temperature, tachycardia or fast heart rate, and hypotension or low blood pressure.
Abnormal vitals could be a result of pain, dehydration, systemic illness, or a combination of the above.
Pancreatitis Signs: Warning signs of pancreatitis include abdominal tenderness, jaundice, Grey-Turner sign, Cullen’s sign, and abnormal vitals.
How is Pancreatitis Diagnosed?
We now know the signs and symptoms of pancreatitis, but how do we officially diagnose it?
At least 2 of the following 3 criteria should be present in order to diagnose pancreatitis:
Elevated serum lipase
Abdominal pain consistent with pancreatitis
Abdominal imaging with findings consistent with pancreatitis
Lipase
Lipase is an enzyme produced by the pancreas to help break down fats during digestion.
Inflammation of the pancreas can cause lipase levels in the blood to increase, which can be measured on blood tests.
Lipase has largely replaced amylase as the blood test of choice, especially with acute pancreatitis.
Lipase levels are typically at least 3x the upper limit of normal in acute pancreatitis.
However, the lipase and amylase levels may be normal in chronic pancreatitis because of the chronic damage and fibrosis to the pancreas.
Abdominal Pain Consistent with Pancreatitis
If the lipase is elevated and there is abdominal pain consistent with pancreatitis, then pancreatitis is a likely diagnosis.
Remember the pain is often sharp and severe, located in the epigastric or left upper quadrant region, and radiates to the back.
Abdominal Imaging
Abdominal imaging, such as a CT scan or MRI, may show findings consistent with pancreatitis.
It is important to note that abdominal imaging is not required to make the diagnosis of pancreatitis in most cases, especially in mild to moderate uncomplicated cases.
If the history, physical, and lipase levels suggest pancreatitis, then it can be treated as such.
Exceptions….
Imaging may be necessary when the symptoms fail to resolve or the diagnosis remains in question.
If there is concern for underlying pathology or complications that would require imaging, then imaging should be considered.
This may include a peripancreatic abscess, pancreatic pseudocyst, necrotizing pancreatitis, pancreatic mass, biliary obstruction, etc.
Imaging may also be necessary in severe presentations and/or any other indication that would require it.
Pancreatitis Diagnosis: At least 2 of the 3 is indicative of pancreatitis. 1. Elevated serum lipase. 2. Abdominal pain consistent with pancreatitis. 3. Abdominal imaging showing findings consistent with pancreatitis.
Adjunct Tests
Other considerations for work up include a liver function test (LFT).
An AST to ALT ratio > 2 is indicative of alcoholic liver disease, and could suggest alcohol abuse as an underlying cause to the pancreatitis.
An elevated alkaline phosphatase may suggest biliary obstruction from gallstones or a pancreatic mass.
AST, ALT, and bilirubin levels may be elevated in the case of biliary obstruction as well.
Consider working up the underlying cause to the pancreatitis as well.
This may include a right upper quadrant ultrasound for gallstones, asking about alcohol use, or obtaining a serum triglyceride or ethanol level.
Other labs may include a metabolic panel, lactate, complete blood count, CRP, and stool studies especially with chronic pancreatitis.
Pancreatitis Diagnosis: Other diagnostic considerations include liver function tests (LFTs), ultrasound, triglyceride levels, etc.
Pancreatitis Treatment
Now that we know how to diagnose pancreatitis, let’s review how it is treated.
IV Fluids
Aggressive fluid resuscitation is important in the management of acute pancreatitis.
Be mindful of any cardiovascular or renal comorbidities that may require close monitoring of fluids.
NPO/Oral Feeds
Patients with pancreatitis may not tolerate oral feeds initially due to pain, and they may need to be NPO (nothing by mouth).
However, oral feeds should be restarted as soon as the patient can tolerate them.
Diet usually starts as a clear liquid and bland diet with progression to a normal diet as the pancreatitis resolves.
A low-fat diet may be advised.
Pain and Symptom Control
Pain and symptoms should be controlled with analgesics and antiemetics.
Antibiotics
Antibiotics are usually not necessary unless concerned for sepsis or other underlying infectious complications.
Intervention
Gallstone pancreatitis may require intervention such as an ERCP (endoscopic retrograde cholangiopancreatography) to remove a gallstone obstructing the bile ducts.
If gallstones were the cause of the pancreatitis, then a cholecystectomy may be recommended (removal of the gallbladder).
Procedures on the pancreas may be necessary to remove fluid or diseased tissue.
Education
Education, treatment, and counseling may be necessary to assist with smoking and/or alcohol cessation, lifestyle modifications, changes to a low-fat diet, or changes to medications.
Pancreatitis Treatment: Management of pancreatitis includes IV fluids, diet modifications, pain/symptom control, possible surgery, and education.
Pancreatitis Learning Points
Here are the high-yield buzzwords and learning points to know about pancreatitis.
Definition: Inflammation of the pancreas
Types: Acute vs Chronic
Causes: Gallstones, Alcohol, Hypertriglyceridemia
Symptoms: Epigastric/LUQ abdominal pain radiating to the back
Signs: Abdominal tenderness; +/- jaundice, Grey-Turner sign, Cullen’s sign
Diagnosis: Lipase, +/- abdominal imaging
Treatment: IV fluids, oral feeds once tolerated, symptom control, +/- intervention
Remember a question about pancreatitis on medical exams will usually have a patient with a history of gallstones, alcohol use, or high triglyceride levels presenting with epigastric abdominal pain radiating to the back.
Pancreatitis Learning Points: Main buzzwords and learning points for pancreatitis including the definition, causes, symptoms, diagnosis, and treatment.
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