What is the next best test for diagnosing acute pancreatitis in a patient with severe epigastric pain, vomiting, and significantly elevated lipase and glucose levels?

Contrast-Enhanced CT Scan is the Next Best Test for Diagnosing Acute Pancreatitis

The next best test for diagnosing acute pancreatitis in this patient with severe epigastric pain and elevated lipase is a contrast-enhanced CT scan (CECT). 1

Rationale for CT Imaging

This 37-year-old male presents with classic features of acute pancreatitis:

• Epigastric pain radiating to back
• Vomiting
• Significantly elevated lipase (6000)
• Pain with movement
• Markedly elevated glucose (500) and HbA1c (10.2)

The diagnosis of acute pancreatitis is already established based on:

1. Characteristic abdominal pain
2. Biochemical evidence (lipase >3x upper limit of normal)

However, CT imaging is now indicated because:

• It will confirm the diagnosis and rule out other potential causes of acute abdominal pain
• It allows staging of disease severity through the CT Severity Index (CTSI)
• It can detect complications such as necrosis, fluid collections, or hemorrhage
• It will help guide management decisions based on severity assessment 1, 2

CT Severity Index (CTSI)

The CTSI combines pancreatic inflammation grading with extent of necrosis:

CT Severity Index	Morbidity	Mortality
0-3	8%	3%
4-6	35%	6%
7-10	92%	17%

This patient is at high risk for severe disease given:

• Obesity (BMI 42)
• Significantly elevated glucose (likely undiagnosed diabetes)
• Acanthosis nigricans (suggesting insulin resistance)
• Markedly elevated lipase 2, 1

Timing of CT Imaging

CT imaging should be performed with intravenous contrast to:

• Assess for pancreatic necrosis
• Evaluate for local complications
• Determine the extent of inflammation
• Calculate the CTSI score

While CT can be performed early in the disease course, optimal timing for assessing severity is typically 72-96 hours after symptom onset, as premature imaging may underestimate the extent of necrosis. 1

Alternative Diagnostic Considerations

While CT is the preferred next test, other imaging modalities to consider include:

1. MRI/MRCP: Alternative when contrast CT is contraindicated; better for identifying non-liquefied material and evaluating pancreatic/biliary ducts 1

2. Ultrasound: Less useful for visualizing the pancreas but valuable for identifying gallstones as a potential cause; however, this patient's clinical presentation (elevated glucose, acanthosis nigricans) suggests metabolic etiology rather than biliary 1

Laboratory Tests Already Performed

The following diagnostic tests have already been completed:

• Lipase (6000) - significantly elevated, confirming pancreatic inflammation
• Glucose (500) and HbA1c (10.2) - indicating uncontrolled diabetes, a risk factor for pancreatitis

Pitfalls to Avoid

1. Delaying imaging in a patient with this presentation could miss complications requiring intervention
2. Relying solely on laboratory values without imaging assessment can lead to underestimation of disease severity
3. Using non-contrast CT would fail to evaluate for pancreatic necrosis, a critical determinant of prognosis
4. Performing ERCP without evidence of biliary obstruction would be inappropriate and potentially harmful 1

CT imaging will provide the most comprehensive assessment of this patient's condition and guide appropriate management based on disease severity.