DIAGNOSIS

OF ACUTE PANCREATITIS

Compiled and edited by AJ

①HISTORY

• Abdominal pain– Site: upper abdomen– Acute onset– Gradually intensifies in severity – Duration: varies– Radiates to the back– Worsening when drinking alcohol or eating heavy meal– Relieve sometimes by sitting upright or leaning forward– Associated with nausea, vomiting, anorexia, fever

Don’t forget to ask..

• History of previous biliary colic• History of alcohol consumption• Any recent operative or other invasive

procedures (e.g. ERCP)• Any intake of certain medications • Any viral infection• Family history of hypertriglyceridemia

② EXAMINATIONGeneral examination• Pale• Diaphoretic • Listless• Jaundice (minority of

patients)Vital signs • Fever • Tachycardia • Hypotension• Tachypnea

Abdominal examination• Abdominal tenderness• Muscular guarding

(guarding tends to be more pronounced in the upper abdomen) and distention.

• Bowel sounds are often diminished or absent because of gastric and transverse colonic ileus.

Uncommon physical findings• Cullen’s sign: bluish

discoloration around the umbilicus resulting from hemoperitoneum

• Grey-Turner’s sign : reddish-brown discoloration along the flanks resulting from retroperitoneal blood dissecting along tissue planes.

• Erythematous skin nodules : focal subcutaneous fat necrosis(size not more than 1 cm, and the site is on extensor skin surfaces)

• Polyarthritis

③ INVESTIGATIONSLABORATORY• CBC– Anemia(hgic), leukocytosis (inflammation, infection)

• Liver enzymes– ALT if increases more that 150 U/L probably dto

gallstones• Serum electrolytes, BUN, creatinine – Low Ca2+

• Blood glucose, cholesterol, triglycerides– Blood glucose high dto B-cell injury

• ABG– respiratory distress

Laboratory studies

Serum amylas

e

Serum lipase

C-reactive protein

Other markers

• Pancreatic enzymes (serum amylase and lipase)– Serum amylase sensitivity of 81-95% but not

specific for pancreatitis– Serum lipase more preferred dto its improved

sensitivity esp in alcohol-induced pancreatitis, and its prolonged elevation

– Rise 2-4 times the upper limit of normal is recommended for dx

– Neither is useful in monitoring or predicting the severity the episode of acute pancreatitis

• Serum C-Reactive Protein: best marker for severity

• Trypsinogen and elastase have no significant advantage over amylase or lipase

IMAGING IN ACUTE PANCREATITIS

Role:• To clarify the diagnosis when the clinical picture is

confusing• Help in determine the possible causes• Assess severity (Balthazar score)• Determine prognosis• Detecting complications

1. Abdominal Ultrasound

• Indicated early in acute pancreatitis– Pros

• Inexpensive• Excellent for identifying gallbladder pathology• Technique of choice of detecting gallstones (Most common cause of

pancreatitis!)• Evaluate bile duct dilation‐• May visualize masses and follow up of pseudocyst

– Cons• Not optimal for pancreas; retroperitoneal location easily obscured by

bowel gas distension• Less sensitive for stones in distal CBD• Limited in early assessment of pancreatitis

2. Abdominal X-ray• Limited role in acute pancreatitis• Poor visualization of the pancreas and retroperitoneum• Most common radiologic signs associated with acute

pancreatitis include:

– Free air in the abdomen, indicating a perforated viscus– The colon cut-off sign, and sentinel loop sign, both

indicating inflammatory process damaging peripancreatic structures

COLON CUT-OFF SIGN•Markedly distended transverse colon with air•Absence of gas distal to splenic flexure

SENTINEL LOOP SIGN Mildly dilated, gas-filled segment of small bowel with or without air fluid level

3. Contrast-Enhanced CT

• Standard imaging of choice– Pros

• Aid in diagnosis and staging of pancreatitis• Evaluate complications• Evaluate common bile duct for stones or other obstructions• Assess severity of acute pancreatitis (CT Severity Index)

– Cons• limited in patients who are allergic to intravenous (IV)

contrast or have renal insufficiency.

CTSI

3. MRI

• Increasingly used in diagnosis and management of acute pancreatitis– Pros

• alternative in situations in which CECT is contraindicated• Non invasive and no use of IV contrast‐• Ability to delineate pancreatic and bile ducts (detect

choledocholithiasis missed on U/S )• Greater sensitivity than CT in detecting mild pancreatitis

– Cons• Expensive• Less readily available in non tertiary medical centers‐

SUMMARY