Acute Pancreatitis – Diagnosis
- 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);
- Other conditions that block duct (e.g., tumour, congenital);
- Drugs, including antiretrovirals, chemotherapy, thiazide diuretics, sulfonamides, and azathioprine;
- Scorpion sting;
- Pancreatic necrosis occurs in 5-10% of patients and may progress to infected necrosis which is associated with mortality rates of up to 30%.
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)
- Serum lipase
- Glucose level
- 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.
- 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.
- 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.
- Due to release of pancreatic enzymes locally and systemically.
- Necrotizing pancreatitis – may become infected.
- Systemic inflammatory response
- Pulmonary complications
- Metabolic complications (Ca++, increased BS)
- 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)
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Clinical practice guideline: evidence-based recommendations that reflect findings from RCTs, systematic reviews and meta-analyses (see guidelines for grading of individual recommendations).
Besinger B, Stehman CR. Pancreatitis and Cholecystitis. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020. Accessed November 23, 2020.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 05, 2020
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