From the Guidelines
Pancreatitis is diagnosed based on the presence of at least two of three key criteria: characteristic abdominal pain, elevated pancreatic enzymes, and supportive imaging findings, as stated in the 2019 WSES guidelines for the management of severe acute pancreatitis 1. The abdominal pain typically presents as severe epigastric pain that may radiate to the back.
- Serum lipase and amylase levels should be at least three times the upper limit of normal to support the diagnosis, with lipase being more specific and preferred over amylase, as indicated by a Cochrane revision that showed a sensitivity and specificity of 72% and 93% for serum amylase, and 79% and 89% for serum lipase, respectively 1.
- Imaging findings on CT scan, MRI, or ultrasound showing pancreatic inflammation, edema, or necrosis provide the third diagnostic criterion. Additional laboratory findings that may support the diagnosis include:
- Elevated inflammatory markers (CRP, WBC count)
- Abnormal liver function tests
- Elevated triglycerides, which should be measured and considered as the etiology if the value is > 11.3 mmol/l (> 1000 mg/dl) in the absence of gallstones or significant history of alcohol use 1. For acute pancreatitis, these symptoms typically develop rapidly, while chronic pancreatitis may present with persistent or recurrent episodes of pain with evidence of pancreatic damage on imaging. The diagnosis should be made promptly to guide appropriate management, which varies based on severity and etiology, and is supported by guidelines from the AGA Institute medical position statement on acute pancreatitis 1. These criteria help differentiate pancreatitis from other causes of acute abdominal pain such as peptic ulcer disease, cholecystitis, or intestinal obstruction. It is essential to note that the 2019 WSES guidelines provide the most recent and comprehensive approach to diagnosing pancreatitis, and should be prioritized in clinical practice 1.
From the Research
Diagnostic Criteria for Pancreatitis
The diagnostic criteria for pancreatitis are based on the presence of at least two of three criteria, which include:
- Upper abdominal pain
- Serum amylase or lipase level greater than three times the upper limit of normal
- Characteristic findings on imaging studies, such as computed tomography (CT) or magnetic resonance imaging (MRI) 2, 3, 4
Imaging Studies
Imaging studies, such as CT and MRI, can be useful in assessing the severity of pancreatitis and confirming the diagnosis, but they are not required for diagnosis 2, 5. Postmortem imaging examinations, including postmortem CT and postmortem MRI, can also be used to diagnose pancreatitis in rare cases 3.
Laboratory Investigations
Laboratory investigations, such as serum amylase and lipase analysis, are also important in diagnosing pancreatitis 4, 6. The assessment of pancreatic enzymes is the cornerstone of laboratory diagnosis, and lipase is preferred over total and pancreatic amylase 6. A definitive diagnostic threshold for lipase cannot be identified, but cut-offs between ≥2 and ≥4 times the upper limit of the reference interval are preferable 6.
Scoring Systems
Several scoring systems have comparable effectiveness in predicting disease severity, and the presence of systemic inflammatory response syndrome on day 1 of hospital admission is highly sensitive in predicting severe disease 2.
Diagnosis and Management
The diagnosis and management of acute pancreatitis involve a combination of clinical signs and symptoms, imaging techniques, and laboratory investigations 4. The initial investigation includes serum amylase and lipase analysis, and the initial therapy includes oxygen supplementation, intravenous fluids, pain control, and a nutrition regime 4.