Browse categories and answer follow-up questions to refine your symptom profile.
History
HPI overview
Pancreatitis symptom context
Epigastric pain pattern
Pain radiation to back
Nausea
Vomiting
Oral intake intolerance
Prior similar episodes
Baseline function before illness
OPQRST
OPQRST for abdominal pain
Onset
Time of onset
Sudden onset
Gradual onset
Provocation and palliation
Worse with meals
Worse when supine
Relief leaning forward
Quality
Severe constant pain
Burning pain
Cramping pain
Region and radiation
Epigastric location
Right upper quadrant location
Radiation to back
Severity
Pain score reported
Function limiting pain
Timing
Constant pain
Intermittent pain
Progression over hours
Etiology focused history
Etiology clues
Alcohol exposure
Biliary colic history
Recent ERCP
Recent abdominal trauma
Viral illness prodrome
Hypertriglyceridemia history
Hypercalcemia history
Recent new medication
Scorpion sting exposure
Associated symptoms
Associated symptoms
Fever
Jaundice
Dark urine
Pale stools
Pruritus
Chest pain
Dyspnea
Syncope
Confusion
GI bleeding symptoms
Alarm Features
Immediate life threats
Immediate escalation triggers
Hypotension
Refractory tachycardia
Respiratory distress
Altered mental status
Oliguria
Persistent vomiting with dehydration
Vital sign danger thresholds
High risk vital signs
Systolic BP under 90 mmHg
MAP under 65 mmHg
HR 120 or higher
RR 22 or higher
SpO2 under 92 percent on room air
Temperature 38.5 C or higher
High risk history features
High risk history features
Severe pain out of proportion
Syncope
Immunocompromised state
Anticoagulation use
Pregnancy
Recent pancreatic surgery
High risk exam findings
High risk exam findings
Peritonitis
Grey Turner sign
Cullen sign
Jaundice with fever
Severe abdominal distension
Respiratory fatigue
Medications
Medication reconciliation
Current medications and recent changes
Alcohol use disorder pharmacotherapy
Diabetes medications
GLP 1 receptor agonists
Thiazide diuretics
Valproate
Azathioprine
6 mercaptopurine
Didanosine
Tetracyclines
Estrogens
High risk medication considerations
Therapy interaction and contraindication checks
NSAID risks
Opioid tolerance
QT prolonging antiemetics
Renal impairment dose adjustments
Hepatic impairment dose adjustments
Diet
Recent intake and exposures
Intake pattern
Poor oral intake duration
High fat meal trigger
Binge alcohol exposure
Energy drink exposure
Caffeine excess
Hydration status indicators
Volume status indicators
Reduced urine output
Dry mucous membranes
Orthostasis symptoms
Review of Systems
GI and hepatobiliary
GI and hepatobiliary symptoms
Abdominal pain
Nausea
Vomiting
Diarrhea
Constipation
Melena
Hematemesis
Jaundice
Cardiopulmonary
Cardiopulmonary symptoms
Chest pain
Dyspnea
Orthopnea
Palpitations
Cough
Infectious and inflammatory
Infectious and inflammatory symptoms
Fever
Chills
Myalgias
Sick contacts
Neuro and endocrine
Neuro and endocrine symptoms
Confusion
Syncope
Polyuria
Polydipsia
Collateral History and Family History
Collateral and reliability
Collateral sources
Family report
EMS report
Prior records
Medication list accuracy
Family history
Familial risk
Gallstone disease
Hypertriglyceridemia
Cystic fibrosis
Pancreatic cancer
Hereditary pancreatitis
Household and social support
Support and supervision
Ability to maintain hydration
Ability to obtain medications
Reliable return precautions adherence
Risk Factors
Etiology risk factors
Pancreatitis risk factors
Alcohol use
Gallstones
Hypertriglyceridemia
Hypercalcemia
Recent ERCP
Abdominal trauma
Autoimmune disease
Severity risk factors
Severe course risk factors
Age 60 years or older
Significant comorbidity burden
Obesity
Chronic kidney disease
Chronic liver disease
Immunosuppression
Thrombosis and bleeding
Hemostasis risks
Anticoagulant therapy
Prior VTE
Active malignancy
Differential Diagnosis
Life threatening
Life threatening differentials
Acute coronary syndrome (I21.9)
Epigastric pain mimic
Diaphoresis
Aortic dissection (I71.00)
Tearing pain
Pulse deficit
Mesenteric ischemia (K55.9)
Pain out of proportion
Elevated lactate
Perforated viscus (K63.1)
Free air on imaging
Peritonitis
Cholangitis (K83.09)
Fever
Jaundice
RUQ pain
Bowel obstruction with ischemia (K56.609)
Peritonitis
Persistent tachycardia
Common
Common differentials
Acute pancreatitis (K85.9)
Epigastric pain radiating to back
Lipase elevation
Biliary colic (K80.20)
Postprandial RUQ pain
Transient episodes
Acute cholecystitis (K81.0)
RUQ tenderness
Fever
Peptic ulcer disease (K27.9)
Burning epigastric pain
NSAID exposure
Gastritis (K29.70)
Epigastric discomfort
Alcohol exposure
Less common
Less common differentials
Diabetic ketoacidosis (E10.10)
Kussmaul respirations
Ketones
Hepatitis (K75.9)
Marked transaminase elevation
Risk exposures
Pancreatic cancer with obstruction (C25.9)
Weight loss
Painless jaundice
Splenic infarct (D73.5)
LUQ pain
Embolic risk
Mimics and pitfalls
Mimics and diagnostic pitfalls
Lipase elevation from non pancreatitis causes
Renal failure
Bowel ischemia
Cholecystitis
Early imaging false reassurance
Necrosis may evolve after 48 to 72 hours
Mild cases may have normal CT
Past Medical History
Comorbidities
Relevant comorbidities
Gallstone disease
Alcohol use disorder (F10.20)
Hypertriglyceridemia (E78.1)
Diabetes mellitus (E11.9)
Chronic pancreatitis (K86.1)
CKD (N18.9)
Prior episodes and procedures
Prior episodes and interventions
Prior pancreatitis severity
Prior ICU admission
Prior ERCP
Prior cholecystectomy status
Baseline function
Baseline status
Baseline oral intake
Baseline mobility
Baseline cognition
Physical Exam
General and vitals
General assessment
Toxic appearance
Diaphoresis
Dehydration signs
Hemodynamic stability pattern
Abdominal exam
Abdominal findings
Epigastric tenderness
Guarding
Rebound
Distension
Bowel sounds reduction
RUQ tenderness
Murphy sign
Cardiopulmonary exam
Cardiopulmonary findings
Crackles
Pleural effusion signs
Increased work of breathing
New murmur
Skin and extremities
Skin and perfusion
Jaundice
Mottling
Capillary refill delay
Peripheral edema
Grey Turner sign
Cullen sign
Neuro exam
Neurologic status
Mental status change
Asterixis
Focal deficit
Lab Studies
Diagnostic criteria labs
Key diagnostic labs
Lipase
Supportive if 3 times or more above upper limit of normal
May be normal early
Amylase
Less specific than lipase
May support if lipase unavailable
Etiology and complications
Etiology and complication labs
CBC
Hemoconcentration marker
Leukocytosis marker
CMP
Creatinine for AKI
BUN trend for volume status and prognosis
Electrolytes for vomiting losses
AST
Elevated suggests biliary etiology when markedly high early
Trend with cholestasis markers
ALT
Elevated suggests biliary etiology when markedly high early
Trend with AST
ALP
Cholestasis marker
Biliary obstruction clue
Bilirubin
Biliary obstruction clue
Cholangitis risk marker
Triglycerides
Hypertriglyceridemia pancreatitis if markedly elevated
Consider repeat fasting level if uncertain
Calcium
Hypercalcemia trigger
Hypocalcemia in severe disease
Sepsis and organ failure
Severe disease evaluation
Lactate
Hypoperfusion marker
Sepsis marker
CRP
Inflammatory burden marker
Higher values after 48 hours correlate with severity
Blood gas
Hypoxemia assessment
Acid base assessment
Coagulation studies
DIC concern marker
Procedure readiness marker
Pregnancy and metabolic
Special population labs
Pregnancy test
All patients with pregnancy potential
Imaging selection impact
Glucose and ketones
DKA mimic or complication
Stress hyperglycemia
Imaging
Scoring Systems
Severity and risk tools
BISAP score
BUN over 8.9 mmol/L
Impaired mental status
SIRS present
Age over 60 years
Pleural effusion
SIRS criteria
HR 90 or higher
RR 20 or higher
Temperature under 36 C
Temperature 38 C or higher
WBC over 12
WBC under 4
Revised Atlanta severity categories
Mild
Moderately severe
Severe
Ranson criteria
Admission variables
48 hour variables
MRI
MRI and MRCP
Indications
Suspected choledocholithiasis with unclear ultrasound
Contrast avoidance need
Limitations
Availability and timing constraints
Motion artifact in severe pain
CT
CT abdomen pancreas protocol
Indications
Diagnostic uncertainty
Deterioration after 48 to 72 hours
Suspected necrosis
Contrast considerations
AKI risk assessment
Contrast allergy history
Ultrasound
Ultrasound
RUQ ultrasound
Gallstones detection
CBD dilation detection
POCUS
Gallbladder and biliary tree screen
Pleural effusion screen
Special Tests
Biliary obstruction and cholangitis evaluation
Biliary pathway tests
ERCP timing logic
If cholangitis, urgent ERCP
If persistent biliary obstruction, early ERCP consideration
EUS
Microlithiasis evaluation
Indeterminate CBD stone evaluation
Metabolic and rare etiologies
Etiology clarification tests
IgG4
Autoimmune pancreatitis suspicion
Painless jaundice with pancreatic enlargement
Genetic testing
Recurrent idiopathic pancreatitis
Young onset pancreatitis
ECG
When ECG matters
ECG indications in abdominal pain
Epigastric pain mimic of ACS
Older age
Known CAD
Hemodynamic instability
High risk ECG findings
ECG red flags
STEMI patterns
New ischemic ST depression
New T wave inversion with symptoms
Malignant arrhythmia
Serial ECG logic
Serial ECG
If ongoing pain with initial nondiagnostic ECG, repeat within 15 to 30 minutes
If rising troponin or evolving symptoms, repeat with each status change
Assessment
Diagnostic criteria and confirmation
Acute pancreatitis working diagnosis (K85.9)
Typical abdominal pain pattern
Lipase 3 times or more above upper limit of normal
Imaging consistent with pancreatitis when labs equivocal
Etiology assessment
Likely etiology category
Biliary pancreatitis
Alcohol associated pancreatitis
Hypertriglyceridemia pancreatitis
Medication induced pancreatitis
Post ERCP pancreatitis
Idiopathic pancreatitis
Severity stratification
Severity tier
Mild
No organ failure
No local complications
Moderately severe
Transient organ failure under 48 hours
Local complications present
Severe
Persistent organ failure 48 hours or more
Shock or respiratory failure
Complications to rule out
Complication screen
Cholangitis
Pancreatic necrosis
Infected necrosis
Pseudocyst or walled off necrosis
Hypocalcemia
AKI
ARDS
Plan
Approach to critical patient
First 5 minutes workflow
If hypotension or altered mentation, resuscitation bay
Cardiac monitor and pulse oximetry
Two large bore IV access if severe illness
If SpO2 under 92 percent, oxygen to target 92 to 96 percent
If MAP under 65 mmHg after fluids, vasopressor and ICU consult
Fluids and hemodynamics
IV fluids
Balanced crystalloid preferred example lactated Ringer bolus 10 to 20 mL per kg for hypovolemia
Maintenance example 1.5 mL per kg per hour with frequent reassessment
Reassessment targets
HR improvement
MAP 65 mmHg or higher
Urine output 0.5 mL per kg per hour or higher
BUN and creatinine trend improvement
Analgesia and antiemetics
Symptom control
Opioid analgesia example hydromorphone IV 0.2 to 0.5 mg every 10 to 15 minutes as needed
Alternative opioid example fentanyl IV 25 to 50 mcg every 5 to 10 minutes as needed
Antiemetic example ondansetron IV 4 mg
If refractory vomiting, add metoclopramide IV 10 mg
Nutrition
Feeding strategy
If mild and improving, early oral feeding as tolerated
If unable to tolerate oral, enteral nutrition preferred over parenteral
If severe or prolonged intolerance, nasogastric or nasojejunal feed with dietitian support
Etiology specific management
Biliary pancreatitis pathway
If cholangitis, urgent ERCP and antibiotics
If gallstones without cholangitis, cholecystectomy during index admission when clinically stable
Hypertriglyceridemia pathway
If very high triglycerides with organ failure, ICU consult for insulin infusion protocol dependent
Fibrate initiation planning after acute phase
Alcohol associated pathway
Withdrawal risk monitoring
Thiamine replacement if malnutrition risk
Antibiotics and infection
Antibiotic strategy
If uncomplicated pancreatitis, no prophylactic antibiotics
If cholangitis, antibiotics per local protocol and source control
If suspected infected necrosis, antibiotics and early GI and surgery consult
Monitoring and reassessment loop
Reassessment loop
Vital signs and pain reassessment every 30 to 60 minutes early
Repeat labs within 6 to 12 hours if unstable or severe concern
Escalate level of care if rising oxygen requirement
Escalate level of care if worsening renal function
Consultations
Consultation triggers
GI consult for cholangitis concern
GI consult for persistent obstruction concern
Surgery consult for gallstone pancreatitis and timing of cholecystectomy
ICU consult for persistent organ failure
Disposition
ICU criteria
ICU level care criteria
Vasopressor requirement
Persistent organ failure 48 hours or more
Mechanical ventilation requirement
Lactate rising with shock concern
Severe metabolic acidosis
Inpatient admission criteria
Admission criteria
Uncontrolled pain needing IV opioids
Persistent vomiting with dehydration
AKI
Hypoxemia
Electrolyte derangements requiring IV replacement
Biliary obstruction concern
BISAP 2 or higher
Observation pathway criteria
Observation criteria
Mild pancreatitis with improving symptoms
Stable vitals after initial fluids
No cholangitis concern
Discharge criteria
Discharge criteria
Pain controlled on oral regimen
Tolerating oral fluids and food
Stable vitals
No rising creatinine
No biliary obstruction concern
Reliable follow up and return precautions
Transfer criteria
Transfer considerations
Need for ERCP not available locally
Need for ICU bed not available locally
Suspected necrosis needing advanced multidisciplinary care
Discharge Instructions
Copy discharge instructions
You were diagnosed with acute pancreatitis which is inflammation of the pancreas
Drink fluids frequently to avoid dehydration
Eat small low fat meals as tolerated
Avoid alcohol until cleared by your clinician
Take your prescribed pain medicine only as directed
Do not drive or drink alcohol when taking opioid pain medicine
Follow up with your primary care clinician within 2 to 3 days
If gallstones were suspected, follow up with surgery or GI as arranged
Return to the emergency department now for worsening abdominal pain
Return to the emergency department now for repeated vomiting or inability to keep fluids down
Return to the emergency department now for fever or shaking chills
Return to the emergency department now for yellowing of the eyes or skin
Return to the emergency department now for chest pain or trouble breathing
Return to the emergency department now for fainting or confusion
References
Guidelines and consensus sources
Key sources
American College of Gastroenterology guideline on management of acute pancreatitis 2024
American Gastroenterological Association Institute guideline on initial management of acute pancreatitis 2018
Revised Atlanta classification and definitions international consensus 2012 published 2013
IAP and APA evidence based guidelines for management of acute pancreatitis 2013
Review on practical management of severe acute pancreatitis 2025
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.