Acute pancreatitis: a case-based approach

The presentation

"David", a 52-year-old man in this illustrative example, arrives at A&E with severe pain in the upper part of his tummy that came on over a few hours after a large meal. The pain is constant, bores through to his back, and eases slightly when he leans forward. He has vomited several times but feels no better for it. He looks pale and sweaty, his heart is racing, and he is reluctant to move. He mentions episodes of similar milder pain after fatty food in recent months. The combination of severe, persistent upper abdominal pain radiating to the back, with vomiting, immediately raises the possibility of acute pancreatitis, and the team begins assessment straight away.

Why the pancreas becomes inflamed

The pancreas makes powerful enzymes that break down food in the gut. In acute pancreatitis, these enzymes become active too early — inside the gland itself — and begin to digest the pancreas, triggering intense inflammation. The two commonest triggers in the UK are gallstones, which can block the duct where pancreatic juices drain, and heavy alcohol use. Less common causes include a very high level of blood fats, certain medicines, and, occasionally, a procedure on the bile ducts. Sometimes no cause is found. Understanding the trigger matters because it guides treatment: a gallstone cause often leads to gallbladder surgery once recovered, while an alcohol cause needs support to stop drinking.

Making the diagnosis

Doctors diagnose acute pancreatitis using a combination of the story, examination and tests. A blood test measuring pancreatic enzymes — amylase or lipase — is central; a markedly raised level alongside typical pain strongly supports the diagnosis. Blood tests also check kidney function, blood count, calcium, glucose and markers of inflammation, which help judge severity. An ultrasound scan looks for gallstones as a cause. A CT scan is not always needed early but may be used later to look for complications if someone is not improving. Clinicians also use scoring systems to grade how severe the attack is likely to be, because this shapes how closely the person is monitored and where they are cared for.

Treatment and monitoring

There is no single medicine that switches off pancreatitis; treatment is about supporting the body while the inflammation settles. The mainstays are generous fluids given into a vein to protect the circulation and kidneys, effective pain relief, and anti-sickness treatment. People are monitored closely — pulse, blood pressure, oxygen, urine output and blood tests — because severe cases can affect the lungs, kidneys and circulation. Eating is reintroduced as soon as it is tolerated rather than starving the person for long periods. If gallstones are the cause, a procedure to clear a blocked duct may be needed urgently, and gallbladder removal is usually planned to prevent it happening again. Severe cases may need high-dependency or intensive care.

Recovery, complications and prevention

Most people with mild acute pancreatitis recover within about a week, but severe cases can be prolonged and dangerous. Complications include collections of fluid around the pancreas, infection of damaged tissue, and effects on other organs. Because the pancreas also controls blood sugar and digestion, repeated or severe attacks can occasionally lead to diabetes or difficulty absorbing food. Prevention depends on the cause: dealing with gallstones, stopping alcohol with support where that is the trigger, and reviewing any contributing medicines or high blood fats. Anyone who has had pancreatitis should seek prompt help if severe upper tummy pain returns, and follow the specific follow-up plan their hospital team arranges.