So, let’s turn now away
from the pathophysiology
and look more practically
at how patients present.
Typically, they’ll have upper or diffuse
abdominal pain that may radiate to the back
and usually worsens with meals,
especially fatty meals as the
pancreas is more responsive
to the ingestion of fat than
for example clear liquids.
There may be a slight delay in the pain
because the pancreas is
going to wait to constrict
and shoot out its
when the stomach sends the signal that
it’s going to be releasing a fatty bolus.
These patients may have nausea,
they may have vomiting,
and they often have fever as well,
especially when an infection is involved.
On your exam of a patient with pancreatitis,
you will usually notice tachycardia.
That may be both from pain,
and also from dehydration
because these patients
typically don’t want to drink.
They may develop hypotension
either from primary dehydration
or from sepsis as a
result of infection.
Typically, we will see a small
degree of abdominal distention,
more maybe in the
And you may well notice
decreased bowel sounds.
What’s key is palpable abdominal
mass if there’s a pseudocyst.
So, if there’s a mass in that pancreas,
you may well be able to palpate it.
Patients may also have jaundice.
If you’re suspecting pancreatitis, the
key enzyme to obtain is the lipase.
We used to get amylase and lipase
but the amylase is less specific
because it also is produced
by the salivary glands.
We will typically see patients with an
elevated CRP, especially in severe disease.
Patients may have an elevated
alk phos, GGT, and ALT and AST,
especially if the whole system is
involved as opposed to just the pancreas.
They may have elevated bilirubin,
especially if these are gallstones,
and there’s a lot of backup and they’re
starting to get congested liver.
There are some findings that indicate
a poor prognosis with pancreatitis.
The first is hypocalcemia.
Patients with hyperglycemia may
have involvement of their endocrine
as opposed to just exocrine
function of the pancreas.
This implies a more severe illness.
Patients with coagulopathy
probably have liver involvement
and are in a bit of trouble.
And if a patient has a
they’re likely fairly sick and we
have to be more worried about them.
So, if we get some labs, we might want
to confirm exactly what’s going on.
Is there a pseudocyst?
Is there a mass?
What is the cause of
And the test of choice for imaging
is the abdominal ultrasound.
Again, in children, we’re trying
to move away from irradiation
as a method of imaging.
If the abdominal ultrasound
is not able to be obtained,
which might happen in a patient who’s more
overweight or has a thicker body habitus,
we will usually proceed to MRI,
or if we can’t get them to
hold still, a contrast, CT.
Here, you can see a very significant
involvement of the pancreas on this scan.
Alternatively, patients can get endoscopic
However, this modality
is very rarely used
because the ERCP itself can
in fact cause pancreatitis.
This is not a benign
Treatment of pancreatitis
really depends on severity.
For acute uncomplicated pancreatitis,
which is the vast majority in children,
pain control is key.
We often will give NSAIDS,
and we may give opiates as well.
IV hydration is critical for
maintaining their hydration
a metabolic acidosis.
Oftentimes, we may provide
PPIs for acid suppression,
and that will allow us to help
control some of that pain.
Mostly, we will have
them NPO while vomiting.
Maybe 20 years ago, we
would maintain NPO status
well past the stage at which they
were having pain and vomiting.
But now, we really limit the NPO
period during active vomiting,
and we’re a little bit more
aggressive in advancing the diet,
starting with clears and gradually
moving into a low-fat diet.
We like low-fat diet because it’s
less stressful on the pancreas,
which is responsible for making the
lipase that will digest the fat.
Patients can get complications of
pancreatitis, and this includes pseudocysts.
Patients can very rarely get
splenic vein thrombosis.
They may get sepsis.
They may get ARDS or develop a
systemic inflammatory response
as a result of the infection and the
autodigestion of the pancreas,
and they may eventually
develop multi-organ failure.
So this can be a very severe disease.
But as I said, majority of patients are
simple acute pancreatitis who get better,
and many of these complications
are mostly in older people.
The prognosis in children
is reasonably good.
Uncomplicated cases typically
resolve in three to seven days,
and patients can be
discharged from the hospital
when they’re able to maintain hydration
and their pain is under control.
There is a slightly
increased risk of carcinoma
in patients with
So we want to keep an eye
on those patients because
pancreatic carcinoma can
be very hard to detect
and has a high mortality rate
because of that problem.
Associated conditions may
affect your prognosis,
if a patient has systemic
disease or trauma.
Patients with systemic inflammatory response
syndrome have a much worse prognosis
than patients who have
Well, in most cases, this
is an idiosyncratic event.
It just happens and there’s not much
that you can do for prevention.
But certainly, if you have a patient
who’s abusing alcohol, for example,
addressing that is important.
A low-fat diet is
important for all of us,
but it’s especially important for people
with problems with their pancreas.
Remember, low-fat diet will result
in a shorter gastric transit time
and will be less stressful on the pancreas
and will prevent recurrent acute episodes.