An acute pancreatitis attack causes steady, boring upper abdominal pain, typically severe enough

to require parenteral opioids. The pain radiates through to the back in about 50% of patients. Pain usually develops suddenly in gallstone pancreatitis; in alcoholic pancreatitis, pain develops over a few days. The pain usually persists for several days. Sitting up and leaning forward may reduce pain, but coughing, vigorous movement, and deep breathing may accentuate it. Nausea and vomiting are common.

The patient tends to appear acutely ill and sweaty. Pulse rate is usually elevated (eg, 100 to 140 beats/minute). Respiration is shallow and rapid. Blood pressure may be transiently high or low, with significant postural hypotension. Temperature may be normal or even subnormal at first but may increase to 37.7 to 38.3° C within a few hours. Sensorium may be blunted to the point of obtundation. Scleral icterus is occasionally present because of obstruction of the bile duct by a gallstone or inflammation and swelling of the pancreatic head. The lungs may have limited diaphragmatic excursion and evidence of atelectasis.

Patients may have an ileus resulting in decreased bowel sounds and abdominal distention. Marked abdominal tenderness occurs, most often in the upper abdomen. Rarely, severe peritoneal irritation results in a rigid and boardlike abdomen. Pancreatic duct disruption may cause ascites (pancreatic ascites). The Grey Turner sign (ecchymoses of the flanks) and the Cullen sign (ecchymoses of the umbilical region) indicate extravasation of hemorrhagic exudate, occur in < 1% of cases, and portend a poor prognosis.

Infection in the pancreas or in an adjacent fluid collection should be suspected if the patient has a generally toxic appearance with fever and an elevated white blood cell count or if deterioration follows an initial period of stabilization. Patients with severe disease can develop multiorgan failure (cardiovascular, renal, and respiratory).