8/8/2019 Case 25 algorithm handout
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Case 25: A 37 year old man with a PMH significant for alcoholism
presentswith severe mid-epigastric pain and a low-grade fever. His
laboratory testsreveal an elevated amylase, lipase, and white blood
cell count.
Differential Dx: Mesenteric ischemia, perforated ulcer,
intestinal obstruction,biliary colic, MI, acute pancreatitis
Acute Pancreatitis: Acute pancreatitis is a clinical diagnosis
that can beconfirmed by history and laboratory findings.
Specifically, this conditionrepresents inflammation of the pancreas
from prematurely activateddigestive enzymes which leads to
autodigestion of pancreatic tissue. Alcoholand gallstones typically
are the two most common causes of this condition,though there are
many other scenarios that could lead to this condition.Serum
amylase and/or lipase levels are usually diagnostic when
reportedvalues are greater than 3 times normal; lipase levels are
more specific;serum enzyme levels do not correlate with severity of
dx1; elevated enzymelevels are not always present in acute
pancreatitis. Therefore, acutepancreatitis may present with any of
the above associated laboratory
measurements.
Imaging algorithm: This case most closely corresponds to Variant
4 AcutePancreatitis (criteria: severe abdominal pain, elevated
amylase/lipase, fever,and elevated WBC count) on the American
College of Radiology guidelines.Given this variant, the guidelines
suggest first obtaining a CT abdomen withor without contrast (ACR
9). An additional way to work up acute pancreatitisinvolves first
assessing the presence of fever. If present, the first test is a
CTwith or without contrast. If a fever is not present, the first
test is an U/S of theabdomen and gallbladder to rule out gallstone
pancreatitis.
Regarding U/S, CT, and MRI, each of these has advantages
anddisadvantages with respect to diagnosing and managing acute
pancreatitis.
The advantages of using CT for the initial test of choice for
acute pancreatitisis that it provides clear images of the pancreas
and adjacent structures, itallows for the differentiation of acute
pancreatitis from other abdominaldxes, and it has no x-ray
exposure. The disadvantages include that it is aninsensitive
detector of biliary calculi, and it involves being exposed to
x-rays.Acute pancreatitis CT findings include: pancreatic
enlargement,peripancreatic inflammatory changes, fluid collections,
and uneven density ofpancreatic parenchyma.
Take home points: To diagnose acute pancreatitis, it is largely
based onclinical presentation (laboratory studies are supportive
and CT scan isconfirmatory). If you suspect acute pancreatitis with
fever, the first test to dois a CT with or without contrast.
Without fever, the first test is an U/S of theabdomen/gallbladder
to ruloe out gallstone pancreatitis. Ransons criteria areused to
determine the prognosis and mortality rates in pts with
acutepancreatitis. Pts with more than three or four Ransons
criteria should bemonitored in an ICU setting. Complications can be
many, including pancreaticnecrosis or pseudocyst, hemorrhagic
pancreatitis, ARDS, pancreaticascites/pleural effusion, ascending
cholangitis, or abscess. Tx: bowel rest(NPO), IV fluids, pain
control, and an NG tube may be necessary.
