From the Guidelines
The workup of acute pancreatitis should begin with clinical assessment, laboratory tests, and imaging, prioritizing the identification of severity and etiology to guide management decisions, as recommended by the most recent guidelines 1. The diagnosis of acute pancreatitis requires at least two of three criteria: characteristic abdominal pain, serum lipase or amylase levels at least three times the upper limit of normal, and characteristic findings on imaging. Initial laboratory evaluation should include:
- Complete blood count
- Comprehensive metabolic panel
- Triglycerides
- Calcium levels Serum lipase is preferred over amylase due to its higher specificity and longer elevation, as stated in the 2019 WSES guidelines for the management of severe acute pancreatitis 1. Abdominal ultrasound should be performed in all patients to evaluate for gallstones, while contrast-enhanced CT scan is indicated for patients with diagnostic uncertainty, severe symptoms, or lack of improvement after 48-72 hours, as recommended by the 2019 WSES guidelines for the management of severe acute pancreatitis 1. Severity assessment tools like the Ranson criteria, APACHE II score, or BISAP score should be used to guide management decisions. Etiology workup should focus on identifying common causes such as gallstones (biliary pancreatitis) and alcohol use, as well as less common causes like hypertriglyceridemia, hypercalcemia, medications, and autoimmune conditions. For biliary pancreatitis, early ERCP (within 24 hours) is recommended if there is evidence of cholangitis or persistent biliary obstruction, as stated in the management of intra-abdominal infections: recommendations by the Italian Council for the Optimization of Antimicrobial Use 1. The workup guides treatment decisions, including:
- Fluid resuscitation
- Pain management
- Nutritional support
- Specific interventions based on the underlying cause and severity of the disease. Prophylactic antibiotics are not recommended for all patients with acute pancreatitis, but should be used to treat infected severe acute pancreatitis, as stated in the management of intra-abdominal infections: recommendations by the Italian Council for the Optimization of Antimicrobial Use 1. Enteral nutrition is preferred, but parenteral nutrition can be used if not tolerated, as recommended by the ESPEN guidelines on parenteral nutrition: pancreas 1.
From the Research
Diagnosis of Acute Pancreatitis
- The diagnosis of acute pancreatitis requires two of the following: upper abdominal pain, amylase/lipase ≥ 3 × upper limit of normal, and/or cross-sectional imaging findings 2
- Serum amylase and lipase levels are commonly used for diagnosis, with amylase having high sensitivity but low specificity, and lipase having increased sensitivity in acute alcoholic pancreatitis 3, 4
- Other enzymes such as pancreatic isoamylase, immunoreactive trypsin, and elastase are not widely used due to their complexity and cost 3
Laboratory Tests
- Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, and transabdominal ultrasound are indicated in the workup of acute pancreatitis 2
- C-reactive protein at 48 hours is a useful marker for predicting the severity of acute pancreatitis 3
- Urinary trypsinogen activation peptides within 12-24 hours of onset can also predict severity, but are not widely available 3
Imaging Studies
- Cross-sectional imaging is useful for assessing severity and detecting complications, but is not required for diagnosis 2, 5
- Computed tomography can be used to assess severity and detect complications such as necrotizing pancreatitis 5
Prediction of Severity
- The presence of systemic inflammatory response syndrome on day 1 of hospital admission is highly sensitive in predicting severe disease 5
- Scoring systems such as the revised Atlanta classification can be used to predict disease severity, but their effectiveness is comparable and limited by available studies 5