eMedicine Specialties > Emergency Medicine > Gastrointestinal

Pancreatitis: Differential Diagnoses & Workup

Author: Ghattas Khoury, MD, Clinical Professor, President, Lebanese Order of Physicians, Department of Surgery, American University of Beirut
Coauthor(s): Samer S Deeba, MD, Fellow, Department of Surgery, St Mary's Hospital, Imperial College, London
Contributor Information and Disclosures

Updated: Jan 26, 2009

Differential Diagnoses

Aneurysm, Abdominal
Hepatitis
Cholangitis
Mesenteric Ischemia
Cholecystitis and Biliary Colic
Obstruction, Large Bowel
Cholelithiasis
Obstruction, Small Bowel
Gastroenteritis

Other Problems to Be Considered

Perforated viscus
Acute peritonitis
Choledocholithiasis
Macroamylasemia
Macrolipasemia
Intestinal obstruction
Pancreatic cancer
Malabsorption syndromes/processes

Workup

Laboratory Studies

  • A complete blood count (CBC) demonstrates leukocytosis (WBC >12,000) with the differential being shifted toward the segmented polymorphs.
  • If blood transfusion is necessary, as in cases of hemorrhagic pancreatitis, obtain type and crossmatch.
  • Measure blood glucose level because it may be elevated from B-cell injury in the pancreas.
  • Obtain measurements for BUN, creatine (Cr), and electrolytes (Na, K, Cl, CO2, P, Mg); a great disturbance in the electrolyte balance is usually found, secondary to third spacing of fluids.
  • Measure amylase levels, preferably the amylase P, which is more specific to pancreatic pathology. Levels more than 3 times higher than normal strongly suggest the diagnosis of acute pancreatitis.
  • Lipase levels also are elevated and remain high for 12 days. In patients with chronic pancreatitis (usually caused by alcohol abuse), lipase levels may be elevated in the presence of a normal serum amylase level.
  • Perform liver function tests (eg, alkaline phosphatase, serum glutamic-pyruvic transaminase [SGPT], serum glutamic-oxaloacetic transaminase [SGOT], G-GT) and bilirubin, particularly with biliary origin pancreatitis.
  • Urinary trypsinogen activation peptide and increased serum trypsinogen2 and trypsin 2-alpha 1 antitrypsin complex values can identify pancreatitis, and they are used in some hospitals in addition to the above, especially to identify pancreatitis post ERCP with accuracy.

Imaging Studies

  • Perform plain kidneys, ureters, bladder (KUB) radiography with the patient in the upright position to exclude viscus perforation (ie, air under the diaphragm). In patients with a recurrent episode of chronic pancreatitis, peripancreatic calcifications may be noted.
  • Ultrasonography can be used as a screening test. If overlying gas shadows secondary to bowel distention are present, it may not be specific.
  • CT is the most reliable imaging modality in the diagnosis of acute pancreatitis. The criteria for diagnosis are divided by Balthazar and colleagues into 5 grades6 , as follows:
    • Grade A - Normal pancreas
    • Grade B - Focal or diffuse gland enlargement
    • Grade C - Intrinsic gland abnormality recognized by haziness on the scan
    • Grade D - Single ill-defined collection or phlegmon
    • Grade E - Two or more ill-defined collections or the presence of gas in or nearby the pancreas
  • The use of contrast material intravenously is yet to be proved detrimental on the microcirculation of the pancreas in cases of severe necrotizing pancreatitis.

Other Tests

  • Urine para-aminobenzoic acid test (ie, bentiromide [Chymex] test) is used for chronic pancreatitis to assess for the reserve function of the pancreas. In patients with severe pancreatic insufficiency and malabsorption, the sensitivity is 80–90%. In those with mild-to-moderate functional impairment, the sensitivity is as low as 37–46%.
  • Serum trypsinogen assay or the serum trypsin test can also be used to assess the function of the pancreas in chronic pancreatitis. Only a very low level of serum trypsinogen (<20 ng/mL) is reasonably specific (90%) for chronic pancreatitis, and these are seen in advanced chronic pancreatitis with steatorhea.7
  • Both of these tests are available to test for the pancreatic reserve in chronic pancreatitis, and their specificity is similar in the advanced versus the moderate chronic pancreatitis. Ordering them is according to availability.8

Procedures

  • In the case of biliary pancreatitis where a dilated obstructed common bile duct is diagnosed by CT or any other imaging modality and an elevated plasma bilirubin (>5 mg/dL), an ERCP with a sphincterotomy is warranted within the first 72 hours.
  • Biliary pancreatitis should always be treated eventually with a cholecystectomy after the process has subsided.

More on Pancreatitis

Overview: Pancreatitis
Differential Diagnoses & Workup: Pancreatitis
Treatment & Medication: Pancreatitis
Follow-up: Pancreatitis
References
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References

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  2. Banks PA. Epidemiology, natural history, and predictors of disease outcome in acute and chronic pancreatitis. Gastrointest Endosc. Dec 2002;56(6 Suppl):S226-30. [Medline].

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  6. Balthazar EJ. Staging of acute pancreatitis. Radiol Clin North Am. Dec 2002;40(6):1199-209. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Ghattas Khoury, MD, Clinical Professor, President, Lebanese Order of Physicians, Department of Surgery, American University of Beirut
Ghattas Khoury, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Samer S Deeba, MD, Fellow, Department of Surgery, St Mary's Hospital, Imperial College, London
Disclosure: Nothing to disclose.

Medical Editor

Jerome FX Naradzay, MD, FACEP, Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina
Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eugene Hardin, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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