From the Guidelines
I would order an abdominal CT with pancreatic protocol for this patient. This imaging study is the most appropriate next step for a patient with recurrent pancreatitis who has eliminated alcohol consumption but continues to have persistent epigastric pain. The CT with pancreatic protocol provides detailed visualization of the pancreatic parenchyma and surrounding structures, allowing for assessment of chronic changes such as calcifications, ductal dilatation, or pseudocysts that may explain his ongoing symptoms. While the patient's previous ultrasound showed pancreatic edema without fluid collection, a CT scan offers superior sensitivity for detecting subtle pancreatic abnormalities, including early chronic pancreatitis changes that may have developed from his recurrent alcohol-induced episodes 1.
Additionally, CT can identify other potential causes of his symptoms such as pancreatic masses that might have been missed on ultrasound. Fecal elastase would primarily assess exocrine pancreatic insufficiency but wouldn't explain his pain; secretin-enhanced MRCP and endoscopic ultrasound are excellent but more specialized tests that would be reasonable second-line options if the CT findings are inconclusive or if specific ductal abnormalities need further characterization. According to the most recent guidelines, after an unrevealing initial evaluation, endoscopic ultrasound is the preferred diagnostic test for unexplained acute and recurrent pancreatitis, but MRI/MRCP is a reasonable complementary or alternative test to EUS, based on local expertise and availability 1. However, given the patient's history and symptoms, an abdominal CT with pancreatic protocol is the most appropriate initial test.
Some key points to consider in this patient's management include:
- The patient's history of recurrent pancreatitis and ongoing symptoms despite cessation of alcohol use
- The need for detailed imaging to assess for chronic changes in the pancreas
- The potential for other causes of his symptoms, such as pancreatic masses, to be identified on CT
- The role of more specialized tests, such as endoscopic ultrasound and secretin-enhanced MRCP, in further characterizing any abnormalities identified on CT 1.
From the Research
Diagnostic Approach
The patient presents with epigastric pain radiating to the back, worsened by meals and recumbent position, and a history of acute recurrent pancreatitis related to alcohol use. Given the patient's symptoms and history, the following diagnostic approaches are considered:
- Fecal elastase: This test is used to assess pancreatic exocrine function, but it may not be directly relevant to the patient's current symptoms and history of pancreatitis 2, 3.
- Abdominal CT with pancreatic protocol: This imaging modality is useful for evaluating the pancreas and detecting potential complications of pancreatitis, such as pseudocysts or necrosis 4, 5.
- Secretin-enhanced MRCP: This test is used to evaluate the pancreatic duct and diagnose conditions such as pancreas divisum, but it may not be the first-line diagnostic approach in this case 4.
- Endoscopic ultrasound: This modality is useful for evaluating the pancreas and detecting potential lesions or complications, but it may not be necessary as an initial diagnostic step 6.
Imaging Guidelines
According to the American College of Radiology Appropriateness Criteria, imaging studies such as CT or MRI are recommended for evaluating patients with acute pancreatitis, particularly in the late phase of the disease 4. The use of abdominal CT with pancreatic protocol may be appropriate in this case, given the patient's history of pancreatitis and current symptoms 5.
Considerations
The patient's history of alcohol use and recurrent pancreatitis suggests a possible underlying pancreatic pathology. The fact that the patient has quit consuming alcoholic beverages but continues to smoke cigarettes may also be relevant to their current symptoms and diagnostic approach 3.