Pancreatitis, Acute - Acute Pancreatitis

  • Diagnosis
  • Background
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • Abdominal pain in epigastrium

Laboratory Testing

  • Lipase
    • ≥3 times normal level is diagnostic
    • More sensitive and specific for pancreatic disease than amylase
    • Amylase less sensitive – doesn’t necessarily need to be ordered
    • Serial measures not necessary as they do not provide prognostication
  • CBC – leukocytosis common in severe disease
  • Metabolic panel (sodium, potassium, BUN, creatinine, calcium, glucose, HCO3)
    • Calcium, BUN and glucose aberrations may be associated with prognosis
  • C-reactive protein – concentration ≥150 mg/dL within the first 72 hours after presentation suggests acute necrotizing pancreatitis
    • Order 48 hours after illness onset to prevent false negatives
  • Procalcitonin – may have value in differentiating between mild and severe disease
    • Should be obtained at admission

Imaging Studies

  • US/CT/ERCP – all used to confirm diagnosis or to assess local complications such as fluid collections and neurosis

Prognosis

  • Prognostic criteria

Differential Diagnosis

  • Acute cholecystitis
  • Acute coronary syndromes
  • Aortic dissection
  • Appendicitis
  • Cholangitis
  • Diabetic ketoacidosis
  • Ectopic pregnancy
  • Gastric outlet obstruction
  • Gastric volvulus
  • Intestinal obstructions
  • Mesenteric ischemia
  • Nephrolithiasis
  • Pancreatic cancer
  • Perforated duodenal/gastric ulcer
  • Tubo-ovarian abscess

Acute pancreatitis is a reversible inflammatory process of the pancreas that may be associated with a systemic inflammatory response that can cause multiorgan impairment.

Epidemiology

  • Incidence – 30-40/100,000 in the U.S.
  • Age – peaks in 40s
  • Sex
    • Gallstone-induced pancreatitis, M<F
    • Alcohol-induced pancreatitis, M>F

Risk Factors

Pathophysiology

  • Inappropriate or premature activation of trypsinogen thought to be the initiating event
  • Early stages are characterized by interstitial edema of pancreatic parenchyma and necrosis of peripancreatic fat
  • In 20% of patients, pancreatitis progresses to coagulation necrosis of glandular elements

Clinical Presentation

Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Amylase, Serum or Plasma 0020013
Method: Quantitative Enzymatic

Limitations 

False positives occur in macroamylasemia, renal failure, esophageal perforation, pregnancy and mumps parotitis

Lipase, Serum or Plasma 0020014
Method: Quantitative Enzymatic

Limitations 

False positives occur in renal failure, intestinal perforation

CBC with Platelet Count and Automated Differential 0040003
Method: Automated Cell Count/Differential

Comprehensive Metabolic Panel 0020408
Method: Quantitative Ion-Selective Electrode/Quantitative Enzymatic/Quantitative Spectrophotometry

Procalcitonin 0020763
Method: Immunofluorescence

Limitations 

Procalcitonin levels measured shortly after the systemic infection process begins (usually <6 hours) may still be low because other noninfectious conditions also induce procalcitonin

Review procalcitonin levels of 0.50–2.00 ng/mL in light of patient’s specific clinical background and individual condition

C-Reactive Protein 0050180
Method: Quantitative Immunoturbidimetry

Limitations 

Obtain ≥48 hours after illness begins to help prevent false negatives

Trypsin-Like Immunoreactivity 0070003
Method: Quantitative Radioimmunoassay

Guidelines

Pezzilli R, Zerbi A, Di Carlo V, Bassi C, Fave GF, Working Group of the Italian Association for the Study of the Pancreas on Acute Pancreatitis. Practical guidelines for acute pancreatitis. Pancreatology. 2010; 10(5): 523-35. PubMed

General References

AlMofleh I. Severe acute pancreatitis: pathogenetic aspects and prognostic factors. World J Gastroenterol. 2008; 14(5): 675-84. PubMed

Baron TH. Managing severe acute pancreatitis. Cleve Clin J Med. 2013; 80(6): 354-9. PubMed

Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC, Gooszen HG, Dutch Acute Pancreatitis Study Group. The Atlanta Classification of acute pancreatitis revisited. Br J Surg. 2008; 95(1): 6-21. PubMed

Carroll JK, Herrick B, Gipson T, Lee SP. Acute pancreatitis: diagnosis, prognosis, and treatment. Am Fam Physician. 2007; 75(10): 1513-20. PubMed

Frossard J, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008; 371(9607): 143-52. PubMed

Gupta K, Wu B. In the clinic. Acute pancreatitis. Ann Intern Med. 2010; 153(9): ITC51-5; quiz ITC516. PubMed

Harper SJ, Cheslyn-Curtis S. Acute pancreatitis. Ann Clin Biochem. 2011; 48(Pt 1): 23-37. PubMed

Johnson CD, Besselink MG, Carter R. Acute pancreatitis. BMJ. 2014; 349: g4859. PubMed

Mofidi R, Patil PV, Suttie SA, Parks RW. Risk assessment in acute pancreatitis. Br J Surg. 2009; 96(2): 137-50. PubMed

Quinlan JD. Acute pancreatitis. Am Fam Physician. 2014; 90(9): 632-9. PubMed

Stevens T, Parsi MA, Walsh M. Acute pancreatitis: problems in adherence to guidelines. Cleve Clin J Med. 2009; 76(12): 697-704. PubMed

Medical Reviewers

Last Update: August 2016