What is the evaluation and workup for acute pancreatitis?

From the Guidelines

The evaluation of pancreatitis should begin with clinical assessment, laboratory tests, and imaging studies, prioritizing the determination of etiology and assessment of severity to guide management decisions and improve patient outcomes. The initial evaluation should include serum amylase and lipase testing, which are typically elevated at least three times the upper limit of normal in acute pancreatitis, as well as complete blood count, comprehensive metabolic panel, triglycerides, and calcium levels to assess severity and identify potential causes 1. Abdominal ultrasound is recommended to evaluate for gallstones, while contrast-enhanced CT scan is indicated for patients with severe symptoms, diagnostic uncertainty, or lack of improvement after 48-72 hours, with optimal timing for the first CE-CT assessment being 72–96 h after onset of symptoms 1. MRI/MRCP may be useful when biliary etiology is suspected but ultrasound is inconclusive. Severity assessment using scoring systems like APACHE II, Ranson's criteria, or the modified Glasgow score helps guide management decisions. Patients should be evaluated for common causes including gallstones, alcohol use, medications, hypertriglyceridemia, hypercalcemia, and post-ERCP complications. Initial management includes aggressive IV fluid resuscitation with lactated Ringer's solution, pain control with opioid analgesics, and early oral feeding with a low-fat diet as tolerated. Patients with severe pancreatitis, significant comorbidities, or complications should be monitored in an intensive care setting. Endoscopic retrograde cholangiopancreatography (ERCP) is indicated within 24-48 hours for patients with concurrent cholangitis or biliary obstruction. The determination of etiology is crucial, as it guides the need for definitive treatment and follow-up to avoid recurrence, and should be determined on admission, with a transabdominal US being performed on admission to evaluate for biliary etiology 1. In patients with unexplained pancreatitis who are at risk for underlying pancreatic malignancy, CT or EUS should be performed, with EUS being preferred as the initial test 1. Genetic testing is not currently recommended as part of the initial workup but may be considered in selected patients. The underlying pathophysiology involves inappropriate activation of pancreatic enzymes within the gland, leading to autodigestion, inflammation, and potential systemic complications. Key laboratory parameters include serum amylase and lipase levels, C-reactive protein, hematocrit, urea, and procalcitonin, which can help predict the severity of acute pancreatitis and guide management decisions 1. In summary, the evaluation and workup of pancreatitis should prioritize the determination of etiology and assessment of severity, with a focus on clinical assessment, laboratory tests, and imaging studies to guide management decisions and improve patient outcomes.

From the Research

Evaluation of Pancreatitis

• The diagnosis of acute pancreatitis is typically based on the presence of abdominal pain and elevated levels of serum amylase and/or lipase 2, 3, 4, 5.
• Serum amylase and lipase are important tests in the diagnosis of acute pancreatitis, but they have limitations in terms of sensitivity and specificity 2, 3, 6.
• Lipase is considered a more sensitive test than amylase, especially in cases of alcohol-induced pancreatitis, and it remains elevated for a longer period of time 2, 3.
• The co-ordering of both amylase and lipase tests does not significantly improve diagnostic sensitivity and specificity, and testing lipase alone may be sufficient 3.

Laboratory Tests

• Serum C-reactive protein at 48 hours is considered a useful marker for predicting the severity of acute pancreatitis 2.
• Urinary trypsinogen activation peptides within 12-24 hours of onset may also predict the severity of acute pancreatitis, but this test is not widely available 2.
• Other laboratory tests, such as serum interleukins 6 and 8, may be promising but are still experimental 2.

Diagnostic Criteria

• The diagnosis of acute pancreatitis can be established with any two of the following criteria: abdominal pain consistent with pancreatitis, serum amylase and/or lipase greater than three times the upper limit of normal, and characteristic findings on cross-sectional abdominal imaging 4, 5.
• Multiple criteria and scoring systems have been established for assessing the severity of acute pancreatitis 4, 5.

Management

• The management of acute pancreatitis includes aggressive intravenous hydration, appropriate nutrition, and pain management 4, 5.
• Endoscopic retrograde cholangiopancreatography and surgery may be important aspects of management in certain cases, such as acute gallstone pancreatitis 4, 5.