INDEX

    Acute Pancreatitis – Diagnosis

    Gastrointestinal

    Last Updated Dec 05, 2020
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    By Julian Marsden, Ellie Bay

    Context

    • Acute pancreatitis (AP) commonly leads to hospital admission.
    • 75% of cases are due to alcohol or gallstones/biliary tract disease in the developed world.
    • Multiple other causes of pancreatitis include:
      • Trauma, including ERCP;
      • Metabolic abnormalities (e.g., hypercalcemia and hypertriglyceridemia);
      • Viral infections (e.g., mumps, mononucleosis, hepatitis, coxsackie virus);
      • Pregnancy;
      • Lupus;
      • Other conditions that block duct (e.g., tumour, congenital);
      • Drugs, including antiretrovirals, chemotherapy, thiazide diuretics, sulfonamides, and azathioprine;
      • Scorpion sting;
      • Idiopathic
    • Pancreatic necrosis occurs in 5-10% of patients and may progress to infected necrosis which is associated with mortality rates of up to 30%.

    Diagnostic Process

    Diagnostic Criteria

    2/3 of the following criteria:

    • Abdominal pain (acute, severe, persistent, epigastric, +/- radiation to back)
      • 3 fold elevation from upper limit of normal of serum lipase (preferred) or amylase (various sources of amylase)
      • Risk of false negatives in early disease due to delayed elevation in levels (4-8h from inflammation onset).
    • Findings characteristic of AP on imaging (US/CT)

    Laboratory investigations

    • Serum lipase
    • CBC
    • Electrolytes
    • Glucose level
    • Calcium
    • Renal function
    • Liver function
    • C Reactive Protein (peaks at 36-72 hours)

    A diagnosis of AP is often made based on history, physical exam and serum lipase level. Imaging may be less urgent, occurring later in the work-up to determine the etiology. If no access to the necessary imaging modalities, patient transfer may be required.

    Imaging

    • All patients should undergo an ultrasound to look for stones in the biliary tract.
    • CT has limited utility initially:
      • Local complications may not be appreciable until 48-72 hours after onset.
      • Uses:
        • Diagnosis uncertain and/or to narrow a broad differential.
        • Assessment of potential local complications – cyst, necrosis, infarction – and pleural effusion.
        • Contrast is recommended unless contraindications.
      • Magnetic resonance cholangiopancreatography (MRCP) – elevated liver enzymes and an inconclusive or normal ultrasound of the common bile duct.
      • Chest X-ray for potential pleural effusions and infiltrates if symptomatic.

    Complications

    • Due to release of pancreatic enzymes locally and systemically.
      • Necrotizing pancreatitis – may become infected.
      • Systemic inflammatory response
        • Pulmonary complications
        • Metabolic complications (Ca++, increased BS)
        • Coagulopathy
        • Multi-organ failure
        • Sepsis, shock
    • Pancreatic pseudocyst or walled-off necrosis occur weeks after initial onset.

     

    Evaluation of disease severity

    • Presence of systemic inflammatory response syndrome (SIRS) or qSOFA
    • Scoring systems serve to support the clinical assessment.
    • Patients often present soon after symptom onset and prior to the development of complications making it challenging to gauge disease severity on initial assessment.
    • BISAP Score – parameters used to calculate score can be obtained in ED unlike older Ranson’s Criteria which requires parameters obtained at 48 h from time of admission:
      • BUN > 8.92 mmol/L
      • Impaired Mental Status
      • > 2 SIRS Criteria
      • Age > 60 years
      • Pleural effusion present
      • Score < 2 = mortality of 1.9%
    • Harmless Acute Pancreatitis Score (HAPS):
      • NB: Developed primarily by chart review (retrospective) studies.
      • Peritonitis (rebound tenderness/guarding)
      • Cr > 177 mmol/L
      • Hematocrit > 43% (male) or 39.6% (female)

    Other Resources

    Quality Of Evidence?

    Justification

    Clinical practice guideline: evidence-based recommendations that reflect findings from RCTs, systematic reviews and meta-analyses (see guidelines for grading of individual recommendations).

    High

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