Diagnosis of Acute Pancreatitis

of clinical, lab and imaging

1. DIAGNOSIS OF ACUTE PANCREATITIS Compiled and edited by AJ

2. HISTORY 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

3. 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

4. EXAMINATION General examination Pale Diaphoretic Listless Jaundice (minority of patients) Vital signs Fever T achycardia Hypotension Tachypnea

5. Abdominal examination Abdominal tenderness M uscular guarding (guarding tends to be more pronounced in the upper abdomen) and distention . B owel sounds are often diminished or absent because of gastric and transverse colonic ileus.

6. 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) P olyarthritis

7. INVESTIGATIONS LABORATORY CBC A nemia( hgic ), leukocytosis (inflammation, infection) Liver enzymes ALT if increases more that 150 U/L probably dto gallstones Serum electrolytes, BUN, creatinine Low Ca 2+ Blood glucose, cholesterol, triglycerides Blood glucose high dto B-cell injury ABG r espiratory distress

8. 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

9. Serum C-Reactive Protein: best marker for severity Trypsinogen and elastase have no significant advantage over amylase or lipase

10. IMAGING IN ACUTE PANCREATITIS Role: To clarify the diagnosis when the clinical picture is confusing H elp in determine the possible causes Assess severity (Balthazar score) Determine prognosis Detecting complications

11. 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

12. 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

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

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

15. 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.

16. CTSI

17. 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

18. SUMMARY