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Approach to a patient with acute pancreatitis: abdominal pain

General considerations
Pancreatic inflammatory disease may be classified as (1) acute pancreatitis or (2) chronic pancreatitis. The pathologic spectrum of acute pancreatitis varies from interstitial pancreatitis, which is usually a mild and self-limited disorder, to necrotizing pancreatitis, in which the extent of pancreatic necrosis may correlate with the severity of the attack and its systemic manifestations.

The incidence of pancreatitis varies in different countries and depends on cause [e.g., alcohol, gallstones, metabolic factors, and drugs ]. The estimated incidence in the United States is increasing and is now estimated to be 70 hospitalizations/100,000 persons annually, thus resulting in >200,000 new cases of acute pancreatitis per year.
Approach to the patient : Abdominal pain
Abdominal pain is the major symptom of acute pancreatitis. Pain may vary from a mild  and tolerable discomfort  and more commonly to severe, constant and incapacitating distress. Characteristically, the pain, which is steady and boring in character, is located in the epigastrium and periumbilical region often radiates to the back as well as  to the chest, flanks, and lower abdomen. The pain is frequently more intense when the patient is supine, and patient may obtain some relief by sitting with the truck flexed and knees drawn up. Nausea, vomiting and abdomial distention due to gastric and intestinal hypomotility and chemical perionitis are also frequent complaints
Physical examination frequently reveals a distressed and anxious patient. Lower grade fever, tachycardia, and  hypotension are failly common. Shock is’t unusual. Jaundice occurs infrequently, when present, it usually due to edema of the head of the pancreas with compression of the intrapancreatic portion of the comon bile duct. Erythematous skin nodules due to subcutaneous fat necrosis may occur. There are pulmonary  findings, pleural effusion, basilar rales and atelectasis. Abdominal tenterness and muscle rigidity are present to a variable degree. Bowel sounds are usually diminished or absent. A enlarged pancreas with wall of necrosis of pseudocyst may be palpable in the upper abdomen later in the disease course ( i.e: four to six weeks). A faint blue discorloration around the umbilicus ( Cullen’s sign) may occur as the result of hemoperitoneum, and a blue-red-purple or green-brown discorloration of the flans ( Tunner’s sign) reflects tissue catabolism of hemoglobin. The latter two findings, which are uncommon, indicate the presence of severe necrotizing pancreatitis.


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