From the Guidelines
The workup for ongoing low-grade pancreatitis should start with a comprehensive approach including laboratory tests, imaging studies, and clinical assessment, with endoscopic ultrasound being the preferred diagnostic test for unexplained acute and recurrent pancreatitis, as recommended by the most recent guidelines 1. The initial evaluation should include serum amylase and lipase levels, which are typically elevated during acute episodes but may be normal in chronic or low-grade inflammation. Complete blood count, comprehensive metabolic panel, triglyceride levels, and calcium levels should be obtained to identify potential causes. Imaging is crucial, starting with abdominal ultrasound to evaluate for gallstones, followed by contrast-enhanced CT scan which provides detailed pancreatic visualization. Magnetic resonance cholangiopancreatography (MRCP) is particularly valuable for detecting subtle ductal abnormalities and early chronic changes. Some key points to consider in the workup include:
- Determination of etiology, with a focus on history of gallstones, alcohol use, hypertriglyceridemia, hypercalcemia, family history of pancreatic disease, and medication history 1
- Use of endoscopic ultrasound as the preferred diagnostic test for unexplained acute and recurrent pancreatitis, with magnetic resonance imaging with contrast and cholangiopancreatography as a reasonable complementary or alternative test 1
- Assessment of exocrine pancreatic function using tests such as fecal elastase-1
- Consideration of genetic testing in younger patients or those with a family history of pancreatic disease The goal of the workup is to identify the underlying cause of the pancreatitis, which is essential for targeted treatment and prevention of progression to chronic pancreatitis with irreversible damage to pancreatic tissue 1.
From the Research
Workup for Ongoing Low-Grade Pancreatitis
The workup for ongoing low-grade pancreatitis involves a comprehensive approach to diagnose and manage the condition.
- Diagnosis is based on pancreatic calcifications, ductal dilatation, and atrophy visualized by imaging with computed tomography, magnetic resonance imaging, or both 2.
- Endoscopic ultrasound can assist in making the diagnosis in patients with a high index of suspicion such as recurrent episodes of acute pancreatitis when imaging is normal or equivocal 2.
- The first line of therapy consists of advice to discontinue use of alcohol and smoking and taking analgesic agents (nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol) 2.
- A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients 2.
Identifying the Cause
It is essential to identify the cause of pancreatitis, as it can be caused by various factors, including:
- Genetic mutations, such as mutations of the trypsin inhibitor gene (SPINK1) or the cystic fibrosis transmembrane conductance regulator (CFTR) gene 2.
- Environmental factors, such as alcohol abuse and smoking 2.
- Certain medications, which can cause drug-induced pancreatitis 3, 4.
- Hypertriglyceridemia, which can cause acute pancreatitis 5.
Management
Management of ongoing low-grade pancreatitis involves:
- Withdrawal of the offending agent, if the cause is identified as a medication 3, 4.
- Supportive care, including fluid resuscitation, pain control, and nutritional support 6.
- Pharmacological management of hypertriglyceridemia, if the cause is identified as hypertriglyceridemia 5.
- Endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures, if there is pancreatic ductal obstruction due to stones, stricture, or both 2.