Clinical diagnostic of acute pancreatitis

The cardinal symptom of acute pancreatitis is abdominal pain, which is characteristically dull, boring, and steady. Usually, the pain is sudden in onset and gradually intensifies in severity until reaching a constant ache. Most often, it is located in the upper abdomen, usually in the epigastric region, but it may be perceived more on the left or right side, depending on which portion of the pancreas is involved. The pain radiates directly through the abdomen to the back in approximately one half of cases. The duration of pain varies but typically lasts more than a day.

Nausea and vomiting are often present.

Positioning can be important, because the discomfort frequently improves with the patient in the supine position.

Atypical acute pancreatitis may be misdiagnosed. In a study of patients with pancreatitis discovered at autopsy, 13% presented with abdominal pain, 19% had disease that occurred in the postoperative setting, and 68% presented with various cardiac, pulmonary, hepatic, renal, abdominal and metabolic disturbances.

The following physical examination findings vary with the severity of the disease.

Fever and tachycardia are common abnormal vital signs.

Abdominal tenderness, muscular guarding and distension are observed in most patients. Bowel sounds are often hypoactive due to gastric and transverse colonic ileus. Guarding tends to be more pronounced in the upper abdomen.

A minority of patients exhibit jaundice.

Some patients experience dyspnea, which may be caused by irritation of the diaphragm (resulting from inflammation), pleural effusion, or a more serious condition, such as acute respiratory distress syndrome.

In severe cases, haemodynamic instability is evident and haematemesis or melena sometimes develops (erosive haemorrhagic gastropathy). In addition, patients with severe acute pancreatitis are often pale, diaphoretic and listless.

Cullen’s sign – bluish discolouration around the umbilicus.

Grey-Turner’s sign – reddish-brown skin discolouration along the flanks resulting from retroperitoneal space blood dissecting.

Mondor’s sign – violet sports on the body and face.

Holsted’s sign – cyanosis of skin of abdominal wall.

Grunvald’s sign – petechial skin rash in the navel region.

Korte’s sign – regional tension of anterior abdominal wall in epigastria region, along the projection of pancreas.

Mayo–Robson's sign – palpation pain in the left costal-vertebral angle.

Gobye’s sign – abdominal distension in upper region.

Voskresensky’s sign – absence of pulsation of abdominal aorta in epigastria region (sign of parapancreatical infiltration).

Patients may have a ruddy erythema in the flanks secondary to extravasated pancreatic exudate.

Erythematous skin nodules may result from focal subcutaneous fat necrosis. These are usually not more than 1 cm in size and are typically located on extensor skin surfaces. In addition, polyarthritis is occasionally seen.