Diagnostic tests of acute pancreatitis are not easy to do, as blood tests alone will not accurately assess the exact state of a patient. A severe case of acute pancreatitis belongs into the hands of the best specialists. In a university setting this would be a team with a gastroenterologist, general surgeon and likely a cardiologist, all in the ICU setting.
Depending on the type of complications other specialists may have to be called in depending on what organ system is affected. For instance, if sepsis is a problem (as it often will), then a specialist for infectious diseases would be brought in. In a smaller hospital there might be only a surgeon and an internist available. Here are the common tests that are done: A complete blood count, serum lipase and amylase as well as phospholipase A2, if available.
This latter enzyme is responsible for lung tissue damage, if it finds its way into the blood stream. With serum amylase the lab can now do subtypes p and s, which stands for pancreatic and salivary. Only the pancreatic amylase is important in acute pancreatitis.
However, the height of the serum p-type amylase still will not predict the outcome in a particular patient, but it can be useful to monitor the recovery. Another test that is done is an arterial blood gas to see whether the oxygen tension in the blood is low (this would be indicative of lung damage). Liver enzymes, creatinine levels to check kidney function as well as serum calcium are just some of the initial blood tests that are done. As the patient is being monitored there will be other tests that would come up depending on the clinical situation that will need to be done.
A CT scan of the pancreas and abdomen has some merit as the authors in Ref. 6 describe. They developed a CT severity index, which goes from 0 to 10 and accurately predicted the clinical outcome. The authors used this CT severity index as a parameter to predict accurately the length of hospital stay, need for necrosectomy (surgical removal of necrotic tissue) and the mortality rate in severe acute pancreatitis cases.
They concluded that an early CT scan shortly after hospital admission is mandatory in the work up of the patient. In the case of a gall stone in the bile ducts, ultrasound examination can give useful information to determine whether or not the common bile duct is dilated. If this is the case, a gastroenterologist trained in endoscopic retrograde cholangiopancreatography (ERCP) should be called in. You may rightly ask what this unspeakable doctor lingo means.
Here is the solution to this puzzle: the gastroenterologist is a specialist for stomach and digestive tract diseases.” Endoscopic” means using the same procedure as for stomach and duodenal ulcers with the help of a fiberoptic instrument through which the specialist can see exactly what is going on. Finally, if we spell cholangiopancreatography like that, it becomes clear that this means “bile duct”-“pancreas duct”-“picture”. So, what’s going on is that the specialist works with a special side-viewing endoscope and advances this through the sphincter of Oddi in the duodenum, which is the opening of the common bile duct/pancreatic duct.
At this point the specialist introduces another tube (=a telescopic cannula) and injects a contrast material into it. X-rays will then show exactly how the bile duct and the pancreatic duct systems look and whether or not a gall stone or a pancreatic stone is present.
Furthermore, minor surgical procedures can be performed to dilate the sphincter of Oddi (cutting of the sphincter or “spincterotomy”), to extract a stone with a mini forceps or to place a stent, which is a little plastic tube, to allow drainage of bile and pancreatic juice in case of a chronic stricture of the opening. This is a fairly harmless procedure and many patients have had remarkable recoveries once their problems had been identified and solved. In the hands of the specialist there are some other sophisticated tests available including an MRI scan, if this is necessary.
1. M Frevel Aliment Pharmacol Ther 2000 Sep (9): 1151-1157.
2. M Candelli et al. Panminerva Med 2000 Mar 42(1): 55-59.
3. LA Thomas et al. Gastroenterology 2000 Sep 119(3): 806-815.
4. R Tritapepe et al. Panminerva Med 1999 Sep 41(3): 243-246.
5. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapters 20,23, 26.
6. EJ Simchuk et al. Am J Surg 2000 May 179(5):352-355.
7. G Uomo et al. Ann Ital Chir 2000 Jan/Feb 71(1): 17-21.
8. PG Lankisch et al. Int J Pancreatol 1999 Dec 26(3): 131-136.
9. HB Cook et al. J Gastroenterol Hepatol 2000 Sep 15(9): 1032-1036.
10. W Dickey et al. Am J Gastroenterol 2000 March 95(3): 712-714.
11. M Hummel et al. Diabetologia 2000 Aug 43(8): 1005-1011.
12. DG Bowen et al. Dig Dis Sci 2000 Sep 45(9):1810-1813.
13. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999.Chapter 31, page 311.
14. O Punyabati et al. Indian J Gastroenterol 2000 Jul/Sep 19(3):122-125.
15. S Blomhoff et al. Dig Dis Sci 2000 Jun 45(6): 1160-1165.
16. M Camilleri et al. J Am Geriatr Soc 2000 Sep 48(9):1142-1150.
17. MJ Smith et al. J R Coll Physicians Lond 2000 Sep/Oct 34(5): 448-451.
18. YA Saito et al. Am J Gastroenterol 2000 Oct 95(10): 2816-2824.
19. M Camilleri Am J Med 1999 Nov 107(5A): 27S-32S.
20. CM Prather et al. Gastroenterology 2000 Mar 118(3): 463-468.
21. MJ Farthing : Baillieres Best Pract Res Clin Gastroenterol 1999 Oct 13(3): 461-471.
22. D Heresbach et al. Eur Cytokine Netw 1999 Mar 10(1): 7-15.
23. BE Sands et al. Gastroenterology 1999 Jul 117(1):58-64.
24. B Greenwood-Van Meerveld et al.Lab invest 2000 Aug 80(8):1269-1280.
25. GR Hill et al. Blood 2000 May 1;95(9): 2754-2759.
26. RB Stein et al. Drug Saf 2000 Nov 23(5):429-448.
27. JM Wagner et al. JAMA 1996 Nov 20;276 (19): 1589-1594.
28. James Chin, M.D. Control of Communicable Diseases Manual. 17th ed., American Public Health Association, 2000.
29. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 157, page1181.
30. Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc., pages 976-983: “Chapter 107 – Acute Abdomen and Common Surgical Abdominal Problems”.
31. Marx: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc. , p. 185:”Abdominal pain”.
32. Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7th ed., Copyright © 2002 Elsevier, p. 71: “Chapter 4 – Abdominal Pain, Including the Acute Abdomen”.
33. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.