From the Guidelines
I would order an endoscopic ultrasound (EUS) for this patient. This diagnostic approach is supported by the American Gastroenterological Association (AGA) clinical practice update on the endoscopic approach to recurrent acute and chronic pancreatitis, which recommends EUS as the preferred diagnostic test for unexplained acute and recurrent pancreatitis after an unrevealing initial evaluation 1. The patient's history of recurrent pancreatitis, persistent epigastric pain, and previous hospital admissions suggest a complex pancreatic pathology that may not be fully evaluated by other imaging modalities. Some key points to consider in this patient's evaluation include:
- The patient has already undergone traditional ultrasound, which showed pancreatic edema but did not provide a clear explanation for his ongoing symptoms.
- Fecal elastase (option 1) would only assess exocrine function and may not provide insight into the patient's pain or underlying pancreatic pathology.
- Abdominal CT with pancreatic protocol (option 2) could provide detailed visualization of the pancreatic parenchyma and surrounding structures, but EUS is preferred for its high sensitivity in detecting subtle pancreatic abnormalities.
- Secretin-enhanced MRCP (option 3) offers excellent ductal visualization but is typically reserved after initial findings from other imaging modalities, such as EUS or CT.
- Given the patient's history and symptoms, EUS is the most appropriate next step in his evaluation, as it provides a comprehensive assessment of the pancreatic parenchyma and ductal system, and can help identify potential causes of his recurrent pancreatitis, such as pancreatic divisum, ductal strictures, or other structural abnormalities 1.
From the Research
Diagnostic Approach
To determine the best course of action for the 44-year-old gentleman with epigastric pain and a history of acute recurrent pancreatitis, the following diagnostic tests can be considered:
- Fecal elastase: This test can help assess pancreatic exocrine function, but it may not directly address the patient's current symptoms or the underlying cause of his pancreatitis 2.
- Abdominal CT with pancreatic protocol: This imaging study can help visualize the pancreas and detect any complications associated with pancreatic pseudocysts, such as fluid collections, organ involvement, or vascular complications 3, 4.
- Secretin-enhanced MRCP: This test can provide detailed images of the pancreatic ducts and help diagnose any ductal abnormalities or strictures, but it may not be necessary as an initial step given the patient's history and symptoms.
- Endoscopic ultrasound: This modality can be useful for evaluating pancreatic cysts or masses, and it can provide high-resolution images of the pancreas and surrounding tissues 2, 4.
Rationale for Test Selection
Given the patient's history of recurrent pancreatitis and the presence of pancreatic edema on ultrasound, an abdominal CT with pancreatic protocol may be the most appropriate initial test to evaluate for any complications associated with pancreatitis, such as pseudocysts or vascular involvement 3, 4. Endoscopic ultrasound may also be considered if the CT scan is inconclusive or if there is a suspicion of a pancreatic cyst or mass 2, 4. The choice of test will depend on the patient's specific clinical presentation and the availability of imaging modalities.