From the Guidelines
I would order an abdominal CT with pancreatic protocol for this patient. This imaging study is the most appropriate next step for a patient with recurrent pancreatitis who has eliminated alcohol consumption but continues to have persistent epigastric pain, as it provides detailed visualization of the pancreatic parenchyma and surrounding structures, allowing for assessment of chronic changes such as calcifications, ductal dilatation, or pseudocysts that may explain his ongoing symptoms 1. While the previous ultrasound showed pancreatic edema, it has limited sensitivity for detecting subtle pancreatic abnormalities. The patient's continued symptoms despite alcohol cessation suggest possible structural complications of chronic pancreatitis that require evaluation.
According to the guidelines, CT scanning has become the initial imaging of choice given the poor sensitivity of USS in this situation, and its sensitivity in detecting early pancreatic changes is unknown, but it is significantly less than EUS or magnetic resonance cholangiopancreatography (MRCP)/ERP 1. Endoscopic ultrasound would be a reasonable alternative if the CT is inconclusive, as it offers excellent visualization of the pancreas, but is more invasive and typically used after cross-sectional imaging, as recommended by the AGA clinical practice update on the endoscopic approach to recurrent acute and chronic pancreatitis 1. Secretin-enhanced MRCP is helpful for evaluating pancreatic ductal anatomy but is usually reserved for specific indications after initial cross-sectional imaging. Fecal elastase would assess exocrine pancreatic function but wouldn't identify the structural cause of his persistent pain.
The patient's history of recurrent pancreatitis and persistent symptoms despite alcohol cessation make it essential to evaluate for possible structural complications of chronic pancreatitis, and the abdominal CT with pancreatic protocol is the most appropriate initial test for this purpose. If the CT is inconclusive, further evaluation with endoscopic ultrasound or other tests may be necessary to determine the cause of his symptoms.
From the Research
Diagnostic Approach
To determine the best course of action for the 44-year-old gentleman with epigastric pain and a history of acute recurrent pancreatitis, we need to consider the available diagnostic tests. The patient's symptoms and history are suggestive of chronic pancreatitis, and the following tests can be considered:
- Abdominal CT with pancreatic protocol: This test can help identify pancreatic calcifications, atrophy, and ductal dilatation, which are common findings in chronic pancreatitis 2. CT imaging is also useful in detecting complications of acute pancreatitis, such as pseudocysts and necrosis 3.
- Secretin-enhanced MRCP: This test can help evaluate the pancreatic duct and identify any abnormalities, such as strictures or dilatation, which can be seen in chronic pancreatitis.
- Endoscopic ultrasound: This test can provide detailed images of the pancreas and help identify any masses, cysts, or other abnormalities. It is also useful in evaluating the severity of chronic pancreatitis and detecting any complications 4.
- Fecal elastase: This test can help evaluate pancreatic exocrine function, which can be impaired in chronic pancreatitis.
Considerations
When choosing a diagnostic test, it's essential to consider the patient's history, symptoms, and the potential risks and benefits of each test. In this case, the patient has a history of acute recurrent pancreatitis and has quit drinking, but continues to smoke. The patient's symptoms, such as epigastric pain radiating to the back and worsening after meals, are suggestive of chronic pancreatitis.
Test Selection
Based on the available evidence, an abdominal CT with pancreatic protocol would be a reasonable first step in evaluating this patient. This test can help identify any pancreatic calcifications, atrophy, or ductal dilatation, which can be seen in chronic pancreatitis 2. If the CT results are inconclusive or suggest further evaluation is needed, additional tests, such as secretin-enhanced MRCP or endoscopic ultrasound, can be considered. Fecal elastase may also be useful in evaluating pancreatic exocrine function, but it is not as sensitive or specific as imaging tests in diagnosing chronic pancreatitis.