Diagnosis of Acute Pancreatitis
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Transcript of Diagnosis of Acute Pancreatitis
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