APPROACH TO THE PATIENT Abdominal Pain
Abdominal pain is the major symptom of acute pancreatitis. Pain may vary from a mild discomfort to severe, constant, and incapacitating distress. Characteristically, the pain, which is steady and boring in character, is located in the epigastrium and periumbilical region, and may radiate to the back, chest, flanks, and lower abdomen. Nausea, vomiting, and abdominal distention due to gastric and intestinal hypomotility and chemical peritonitis are also frequent complaints.
Physical examination frequently reveals a distressed and anxious patient. Low-grade fever, tachycardia, and hypotension are fairly common. Shock is not unusual and may result from (1) hypovolemia secondary to exudation of blood and plasma proteins into the retroperitoneal space; (2) increased formation and release of kinin peptides, which cause vasodilation and increased vascular permeability; and (3) systemic effects of proteolytic and lipolytic enzymes released into the circulation. Jaundice occurs infrequently; when present, it usually is due to edema of the head of the pancreas with compression of the intrapancreatic portion of the common bile duct or passage of a biliary stone or sludge. Erythematous skin nodules due to subcutaneous fat necrosis may rarely occur. In 10–20% of patients, there are pulmonary findings, including basilar rales, atelectasis, and pleural effusion, the latter most frequently left sided. Abdominal tenderness and muscle rigidity are present to a variable degree, but compared with the intense pain, these signs may be less impressive. Bowel sounds are usually diminished or absent. An enlarged pancreas from acute fluid collection, walled off necrosis, or a pseudocyst may be palpable in the upper abdomen later in the course of the disease (i.e., 4–6 weeks). A faint blue discoloration around the umbilicus (Cullen’s sign) may occur as the result of hemoperitoneum, and a blue-red-purple or green-brown discoloration of the flanks (Turner’s sign) reflects tissue catabolism of hemoglobin from severe necrotizing pancreatitis with hemorrhage.