From the Guidelines
Diagnosis of pancreatitis requires a combination of clinical assessment, laboratory tests, and imaging studies, with the diagnosis typically established when a patient presents with at least two of three criteria: characteristic abdominal pain, elevated pancreatic enzymes, and imaging findings consistent with pancreatic inflammation. The diagnosis of pancreatitis is crucial as it can rapidly progress to severe disease with significant morbidity and mortality. According to the 2019 WSES guidelines for the management of severe acute pancreatitis 1, the diagnosis of acute pancreatitis requires at least two of the three following criteria: abdominal pain consistent with the disease, biochemical evidence of pancreatitis, and characteristic findings from abdominal imaging.
Clinical Assessment and Laboratory Tests
The clinical assessment should include a thorough history and physical examination to identify potential causes of pancreatitis, such as gallstones or alcohol use. Laboratory tests should include complete blood count, metabolic panel, liver function tests, triglycerides, and calcium levels to assess severity and identify potential causes. The cut-off value of serum amylase and lipase is normally defined to be three times the upper limit of normal 1. C-reactive protein level ≥ 150 mg/l at third day can be used as a prognostic factor for severe acute pancreatitis 1.
Imaging Studies
Imaging studies such as abdominal ultrasound should be performed initially to evaluate for gallstones, while contrast-enhanced CT scan is the gold standard for confirming the diagnosis, assessing severity, and identifying complications 1. MRI or magnetic resonance cholangiopancreatography (MRCP) may be useful when CT is contraindicated or to better visualize the pancreatic and biliary ducts. Endoscopic ultrasound can detect microlithiasis and early chronic changes.
Importance of Early Diagnosis
Early diagnosis is crucial as pancreatitis can rapidly progress to severe disease with significant morbidity and mortality, requiring prompt fluid resuscitation, pain management, and supportive care while addressing the underlying cause such as gallstones, alcohol, or medications. The 2019 WSES guidelines for the management of severe acute pancreatitis 1 emphasize the importance of early diagnosis and treatment to improve outcomes in patients with pancreatitis.
Key Recommendations
- Perform abdominal ultrasound initially to evaluate for gallstones 1
- Use contrast-enhanced CT scan as the gold standard for confirming the diagnosis, assessing severity, and identifying complications 1
- Measure serum triglyceride and calcium levels in the absence of gallstones or significant history of alcohol use 1
- Use C-reactive protein level ≥ 150 mg/l at third day as a prognostic factor for severe acute pancreatitis 1
From the Research
Diagnosis of Pancreatitis
The diagnosis of pancreatitis is based on a combination of clinical signs and symptoms, imaging techniques, and laboratory investigations 2, 3, 4, 5, 6.
- Clinical signs and symptoms include abdominal pain radiating to the back, which is a key criterion for diagnosis 3, 4.
- Imaging techniques such as contrast-enhanced computed tomography (CT) scan or magnetic resonance imaging (MRI) are used to confirm the diagnosis and establish disease severity 2, 3, 4.
- Laboratory investigations include the assessment of pancreatic enzymes, such as lipase and amylase, which are early released from necrotic tissue 2, 5, 6.
Laboratory Tests
- Serum lipase is preferred over total and pancreatic amylase for the diagnosis of acute pancreatitis due to its higher sensitivity and larger diagnostic window 2, 6.
- The combination of amylase and lipase has been discouraged as it marginally improves the diagnostic efficiency of either marker alone and increases the cost of investigation 2, 6.
- Other biomarkers, such as serum and urinary trypsinogen-1, -2, and -3, phospholipase A2, pancreatic elastase, procalcitonin, trypsinogen activated protein, activation peptide of carboxypeptidase B, trypsin-2-alpha1 antitrypsin complex, and circulating DNA, have been suggested but have not found widespread application due to inferior diagnostic accuracy or cumbersome techniques 2.
Diagnostic Criteria
- The diagnosis of acute pancreatitis requires the satisfaction of two out of three criteria: (1) abdominal pain radiating to the back, (2) serum lipase or amylase levels three or more times the upper limit of the normal level, and (3) findings indicating pancreatitis obtained via a CT scan or MRI 3, 4.
- The assessment of serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are also indicated in the diagnosis of acute pancreatitis 3, 4.