What are the typical signs, symptoms, laboratory findings, and CT scan results in a patient presenting with pancreatitis?

Pancreatitis: Signs, Symptoms, Laboratory Findings, and CT Scan Results

Pancreatitis presents with characteristic abdominal pain, elevated pancreatic enzymes, and specific CT findings including pancreatic enlargement, peripancreatic inflammation, and potential necrosis that can be graded using the CT severity index to predict morbidity and mortality. 1

Clinical Presentation

Signs and Symptoms

• Abdominal pain: Typically severe, constant epigastric pain that often radiates to the back
• Nausea and vomiting: Present in most patients
• Fever: May indicate infection or severe inflammation
• Abdominal tenderness: Usually in the epigastrium
• Abdominal distension: Due to ileus or fluid collections
• Tachycardia and hypotension: In severe cases with fluid sequestration
• Jaundice: May be present if biliary obstruction occurs
• Cullen's sign (periumbilical bruising) and Grey Turner's sign (flank bruising): Rare findings in severe hemorrhagic pancreatitis

Laboratory Findings

Key Diagnostic Tests

• Serum amylase: Elevation >3 times upper limit of normal is diagnostic
• Serum lipase: More specific than amylase and remains elevated longer
• C-reactive protein (CRP): >150 mg/L at 48 hours suggests severe pancreatitis 1
• Complete blood count: Leukocytosis common
• Liver function tests: May be elevated in biliary pancreatitis
• Blood urea nitrogen (BUN): Rising BUN suggests inadequate fluid resuscitation
• Calcium: Hypocalcemia may occur in severe cases
• Glucose: Hyperglycemia is common

CT Scan Findings

CT Protocol

CT scanning should follow a specific protocol for optimal assessment:

• Initial non-contrast scan
• Oral contrast (approximately 500 ml)
• IV contrast (100 ml non-ionic contrast at 3 ml/s)
• Thin collimation (≤5 mm) through pancreatic bed 1

CT Severity Index (Balthazar Score)

The CT severity index combines pancreatic inflammation grade and extent of necrosis:

Pancreatic Inflammation Grade:

• Grade 0: Normal pancreas
• Grade 1: Pancreatic enlargement/edematous pancreatitis
• Grade 2: Grade 1 plus mild peripancreatic inflammation
• Grade 3: Grade 2 plus one fluid collection
• Grade 4: Grade 2 plus multiple/extensive fluid collections 1

Necrosis Score:

• None: 0 points
• <30% necrosis: 2 points
• 30-50% necrosis: 4 points

• 50% necrosis: 6 points 1

Total CT Severity Index (CTSI) = Inflammation Grade + Necrosis Score

• CTSI 0-3: 8% complication rate, 3% mortality
• CTSI 4-6: 35% complication rate, 6% mortality
• CTSI 7-10: 92% complication rate, 17% mortality 1

Other CT Findings

• Pancreatic edema: Diffuse or focal enlargement
• Peripancreatic fat stranding: Indicative of inflammation
• Free intraperitoneal fluid: Associated with worse outcomes
• Pseudocysts: Fluid collections that develop after 4 weeks
• Vascular complications: Pseudoaneurysms, venous thrombosis
• Non-opacification of pancreatic tissue indicates necrosis 1

Management Implications

Fluid Resuscitation

Adequate fluid resuscitation is crucial for preventing systemic complications. Recent evidence suggests that moderate rather than aggressive hydration may be optimal to avoid fluid overload while maintaining adequate perfusion 2, 3.

Follow-up CT Scanning

• Patients with mild pancreatitis (CTSI 0-2): Further CT only if clinical deterioration
• Patients with severe pancreatitis (CTSI 3-10): Additional scans if clinical deterioration or failure to improve
• Consider a follow-up scan before discharge to detect asymptomatic complications like pseudocysts 1

Common Pitfalls to Avoid

1. Inadequate CT technique: Non-contrast CT alone gives suboptimal information
2. Too early CT assessment: Necrosis may not be evident until at least 4 days after symptom onset
3. Over-reliance on amylase alone: Lipase is more specific and remains elevated longer
4. Inadequate fluid resuscitation: Monitor urine output (target >0.5 ml/kg/hr) and vital signs
5. Failure to identify the etiology: Always look for gallstones with ultrasound early in the course

By systematically evaluating clinical presentation, laboratory values, and CT findings, clinicians can accurately diagnose pancreatitis, assess its severity, and implement appropriate management strategies to reduce morbidity and mortality.