II. Clinical Types

II. Clinical Types

1. Edematous Type: This is the most common type, accounting for about 90% of cases. Patients experience severe, persistent upper abdominal pain, nausea, vomiting, mild fever, and tenderness in the upper abdomen, but without significant abdominal muscle tension. Serum

114 Integrated Traditional Chinese and Western Medicine Treatment for Epigastric Pain

amylase and urine amylase rise markedly in the short term. This type generally has a good prognosis.

2. Hemorrhagic-Necrotic Type: Clinical symptoms are more severe, with persistent fever, declining serum amylase levels, and even shock, peritonitis, hypocalcemia, hyperglycemia, hypochloremia, hypoalbuminemia, and azotemia, resulting in a poor prognosis.

III. Complications

Edematous acute pancreatitis rarely leads to complications; the course of the disease usually resolves within 1–2 weeks, though recurrent attacks are common. Hemorrhagic-necrotic acute pancreatitis, however, is a severe condition that easily develops complications, such as intra-abdominal and retroperitoneal abscesses, pancreatic pseudocysts, and pancreatogenic diabetes.

IV. Differential Diagnosis

1. Acute Gastroenteritis: Often occurs suddenly after overeating or improper diet, requiring differentiation from acute pancreatitis. However, in addition to nausea, vomiting, and abdominal pain, acute gastroenteritis may also involve diarrhea and hyperactive bowel sounds; the most important distinguishing feature is that repeated blood and urine amylase tests remain normal.

2. Acute Perforated Peptic Ulcer: This condition also has a sudden onset and severe upper abdominal pain, but with rigid abdominal muscles, which distinguishes it from acute pancreatitis. Patients with acute perforated peptic ulcers usually have a history of ulcer disease, the liver dullness border disappears, X-ray fluoroscopy reveals free gas under the diaphragm, and blood amylase tests generally do not exceed 500 units (Sue method), while urine amylase rarely exceeds 250 units (Sue method).

3. Acute Attack of Gallstone Disease: Similar to acute pancreatitis in terms of sudden onset and accompanying nausea and vomiting. However, the upper abdominal pain in gallstone attacks tends to be localized in the right upper quadrant and radiates to the right shoulder and back; the right upper abdominal muscles are tense with mild tenderness, Murphy's sign is positive, and ultrasound examination can reveal stone obstruction, all of which aid in differentiation. It should be noted that during acute cholecystitis or acute gallstone attacks, both urine and blood amylase may slightly increase; if pancreatitis occurs concurrently, blood and urine amylase levels will be very high. Since acute pancreatitis is often a complication of acute cholecystitis or gallstone disease, clinicians must clearly distinguish between the two while remaining vigilant for the possibility of simultaneous occurrence, with repeated blood and urine amylase tests serving as reliable monitoring indicators.

4. Acute Intestinal Obstruction: This condition shares similar symptoms with acute pancreatitis, such as paroxysmal abdominal cramping and distension; however, the location of abdominal pain in acute intestinal obstruction is usually around the navel or throughout the entire abdomen, accompanied by bloating, hyperactive bowel sounds resembling the sound of air meeting water, cessation of defecation and flatus, and abdominal X-ray plain films showing an intestinal fluid umbrella (commonly referred to as a parachute). Some patients also have a history of surgery or intestinal disease. It should also be noted that in acute intestinal obstruction, blood and urine amylase only slightly increase or do not increase at all.

5. Myocardial Infarction: Some atypical cases of myocardial infarction, particularly inferior wall infarctions, present with low-positioned pain and sudden onset, requiring differentiation from acute pancreatitis. Patients with myocardial infarction usually have a history of coronary heart disease, experience chest oppression, shortness of breath, and tightness in the chest during attacks, with pain radiating to the inner side of the left arm; electrocardiograms show signs of myocardial infarction. Serum AST and LDH levels are elevated, and the disease is more common in middle-aged and older individuals. Therefore, when elderly patients present with upper abdominal pain, caution must be exercised.

Section 3 Integrated Traditional Chinese and Western Medicine Treatment

For edematous acute pancreatitis, good results can be achieved with traditional Chinese medicine alone; however, severe cases require integrated treatment combining traditional Chinese and Western medicine. As for hemorrhagic-necrotic acute pancreatitis, if medical therapy fails, surgical drainage may be considered.