The patient with slightly elevated pancreatic enzymes and abdominal complaints.

Abdominal complaints in combination with slightly elevated serum pancreatic enzymes represent a classical clinical challenge. These symptoms may be due to coincidental unrelated harmless disorders, benign pancreatic alterations which are fairly easily treatable such as mild acute pancreatitis or uncomplicated chronic pancreatitis. However, serious, often insidious diseases such as pancreatic tumours may also present with this constellation as their first signs. Diagnostic procedures need to be stratified according to acuteness and severity of symptoms. While patients with acute onset of symptoms and severe complaints need immediate and combined laboratory and imaging investigations to allow adequate therapy, chronic and mild complaints usually justify a stepwise diagnostic approach consecutively using abdominal ultrasound, CT/MRI and endoscopic ultrasound as imaging procedures and reserving ERCP for cases which remain unclear or in which interventional therapy is needed. Diagnosis and follow-up are often particularly demanding in patients with cystic tumours of the pancreas. In chronic pancreatitis patients pain therapy and adequate control of pancreatic exocrine insufficiency may pose major problems. Patients with refractory pain may ultimately require surgical intervention. Another important indication for surgery in chronic pancreatitis is suspicion of cancer that cannot be ruled out by dedicated diagnostic procedures. This also applies to cystic tumours of the pancreas, which have a high risk of malignant transformation or may even already represent pancreatic cancer at the time of diagnosis.