How is pancreatitis diagnosed and treated?

Diagnosis and Treatment of Pancreatitis

Diagnosis of Pancreatitis

The diagnosis of acute pancreatitis should be made within 48 hours of admission and requires a combination of clinical assessment, laboratory testing, and imaging studies to ensure accurate diagnosis and prevent missing other life-threatening conditions. 1

Clinical Presentation

• Upper abdominal pain and vomiting with epigastric or diffuse abdominal tenderness are common clinical findings 1
• Body wall ecchymoses (Cullen's sign at umbilicus, Grey-Turner's sign in flanks) may be present in severe cases 1
• Clinical presentation alone is unreliable and will misclassify approximately 50% of patients 2

Laboratory Diagnosis

• Serum amylase activity ≥4 times above normal or lipase activity ≥2 times the upper limit of normal is diagnostic in the appropriate clinical setting 1
• Lipase is preferred over amylase due to:
  • Higher specificity (no other sources of lipase reach the serum) 1
  • Longer elevation period (8-14 days vs. 3-7 days for amylase) 2
  • Higher sensitivity (79% vs 72% for amylase) 2
• Other helpful laboratory markers include:
  • C-reactive protein (CRP) 1
  • Procalcitonin (PCT) - most sensitive test for detecting pancreatic infection 1
  • White blood cell count 1

Imaging Studies

• Ultrasound examination should be performed initially in all patients with suspected acute pancreatitis 1
  • Helpful for detecting gallstones, free peritoneal fluid, and bile duct dilation 1
  • Limited by poor visualization of pancreas in 25-50% of cases 1
• CT scan with IV contrast is indicated when:
  • Clinical and biochemical findings are inconclusive 1
  • Severe disease is predicted (APACHE II score >8) 2
  • Should be performed after 72 hours of illness onset to avoid underestimating pancreatic necrosis 2
• Other imaging modalities include:
  • MRI 1
  • Endoscopic ultrasound (EUS) 1

Additional Diagnostic Procedures

• If peritoneal fluid is detected, sampling under radiological guidance may be helpful 1
• CT or EUS-guided fine-needle aspiration (FNA) for Gram stain and culture when infection is suspected 1
• Rarely, laparotomy may be warranted when clinical suspicion of peritonitis is high and all other tests are inconclusive 1

Treatment of Pancreatitis

Treatment approach should be based on severity classification (mild, moderately severe, or severe) 1:

Mild Acute Pancreatitis

• Regular diet with advancement as tolerated 1
• Oral pain medications 1
• Routine vital signs monitoring 1

Moderately Severe Acute Pancreatitis

• Enteral nutrition (oral, nasogastric, or nasojejunal) with parenteral nutrition as backup if not tolerated 1
• IV pain medications 1
• IV fluids to maintain hydration 1
• Monitoring of hematocrit, blood urea nitrogen, and creatinine 1
• Continuous vital signs monitoring 1

Severe Acute Pancreatitis

• Enteral nutrition (oral, nasogastric, or nasojejunal) with parenteral nutrition if not tolerated 1
• IV pain medications 1
• Early fluid resuscitation 1
• Mechanical ventilation if needed 1
• Organ support as required 1

Antibiotic Therapy

• Routine prophylactic antibiotics are not recommended for all patients with acute pancreatitis 1
• Antibiotics should be administered only to treat infected acute pancreatitis 1
• For infected pancreatitis without multidrug-resistant (MDR) organisms, options include:
  • Meropenem 1g q6h by extended infusion or continuous infusion 1
  • Doripenem 500mg q8h by extended infusion or continuous infusion 1
  • Imipenem/cilastatin 500mg q6h by extended infusion or continuous infusion 1

Biliary Pancreatitis Management

• Endoscopic retrograde cholangiopancreatography (ERCP) should be performed as soon as possible in patients with acute biliary pancreatitis and common bile duct obstruction 1

Important Considerations and Pitfalls

• The severity of acute pancreatitis is independent of the degree of enzyme elevation 2
• Early CT scans (within 72 hours) might underestimate the extent of pancreatic necrosis 2
• Patients with ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1
• Persistently elevated serum amylase after 10 days should be monitored closely due to increased risk of pseudocyst formation 2
• Overall mortality should be lower than 10%, and less than 30% in those diagnosed with severe disease 1