This document provides information on the history, examination, and investigations for acute pancreatitis. The history section outlines common symptoms including upper abdominal pain that intensifies and radiates to the back. Examination may reveal signs of dehydration as well as abdominal tenderness and guarding. Laboratory investigations for acute pancreatitis include pancreatic enzymes, liver enzymes, electrolytes, blood glucose, and C-reactive protein. Imaging options are abdominal ultrasound, CT scan, and MRI, with CT being the standard choice to assess severity and complications using the CT severity index. Ultrasound can identify gallstones as a common cause.

1. Compiled and edited by AJ

2. ①HISTORY
• Abdominal pain
– Site: upper abdomen
– Acute onset
– Gradually intensifies in severity
– Duration: varies
– Radiates to the back
– Worsening when drinking alcohol or eating heavy
meal
– Relieve sometimes by sitting upright or leaning
forward
– Associated with nausea, vomiting, anorexia, fever

3. Don’t forget to ask..
• History of previous biliary colic
• History of alcohol consumption
• Any recent operative or other invasive
procedures (e.g. ERCP)
• Any intake of certain medications
• Any viral infection
• Family history of hypertriglyceridemia

4. ②EXAMINATION
General examination
• Pale
• Diaphoretic
• Listless
• Jaundice (minority of
patients)
Vital signs
• Fever
• Tachycardia
• Hypotension
• Tachypnea

5. Abdominal examination
• Abdominal tenderness
• Muscular guarding
(guarding tends to be
more pronounced in the
upper abdomen) and
distention.
• Bowel sounds are often
diminished or absent
because of gastric and
transverse colonic ileus.

6. Uncommon physical findings
• Cullen’s sign: bluish
discoloration around the
umbilicus resulting from
hemoperitoneum
• Grey-Turner’s sign : reddish-
brown discoloration along the
flanks resulting from
retroperitoneal blood
dissecting along tissue planes.
• Erythematous skin nodules :
focal subcutaneous fat
necrosis(size not more than 1
cm, and the site is on extensor
skin surfaces)
• Polyarthritis

7. ③INVESTIGATIONS
LABORATORY
• CBC
– Anemia(hgic), leukocytosis (inflammation, infection)
• Liver enzymes
– ALT if increases more that 150 U/L probably dto
gallstones
• Serum electrolytes, BUN, creatinine
– Low Ca2+
• Blood glucose, cholesterol, triglycerides
– Blood glucose high dto B-cell injury
• ABG
– respiratory distress

8. Laboratory
studies
Serum
amylase
Serum
lipase
C-
reactive
protein
Other
markers

9. • Pancreatic enzymes (serum amylase and
lipase)
– Serum amylase sensitivity of 81-95% but not
specific for pancreatitis
– Serum lipase more preferred dto its improved
sensitivity esp in alcohol-induced pancreatitis, and
its prolonged elevation
– Rise 2-4 times the upper limit of normal is
recommended for dx
– Neither is useful in monitoring or predicting the
severity the episode of acute pancreatitis

11. • Serum C-Reactive Protein: best marker for
severity
• Trypsinogen and elastase have no significant
advantage over amylase or lipase

13. IMAGING IN ACUTE PANCREATITIS
Role:
• To clarify the diagnosis when the clinical picture is
confusing
• Help in determine the possible causes
• Assess severity (Balthazar score)
• Determine prognosis
• Detecting complications

14. 1. Abdominal Ultrasound
• Indicated early in acute pancreatitis
– Pros
• Inexpensive
• Excellent for identifying gallbladder pathology
• Technique of choice of detecting gallstones (Most common
cause of pancreatitis!)
• Evaluate bile‐duct dilation
• May visualize masses and follow up of pseudocyst
– Cons
• Not optimal for pancreas; retroperitoneal location easily
obscured by bowel gas distension
• Less sensitive for stones in distal CBD
• Limited in early assessment of pancreatitis

15. 2. Abdominal X-ray
• Limited role in acute pancreatitis
• Poor visualization of the pancreas and retroperitoneum
• Most common radiologic signs associated with acute
pancreatitis include:
– Free air in the abdomen, indicating a perforated viscus
– The colon cut-off sign, and sentinel loop sign, both
indicating inflammatory process damaging peripancreatic
structures

16. COLON CUT-OFF SIGN
•Markedly distended transverse colon with air
•Absence of gas distal to splenic flexure

17. SENTINEL LOOP SIGN
Mildly dilated, gas-filled segment of small bowel
with or without air fluid level

18. 3. Contrast-Enhanced CT
• Standard imaging of choice
– Pros
• Aid in diagnosis and staging of pancreatitis
• Evaluate complications
• Evaluate common bile duct for stones or other obstructions
• Assess severity of acute pancreatitis (CT Severity Index)
– Cons
• limited in patients who are allergic to intravenous (IV)
contrast or have renal insufficiency.

19. CTSI

20. 3. MRI
• Increasingly used in diagnosis and management of acute
pancreatitis
– Pros
• alternative in situations in which CECT is contraindicated
• Non‐invasive and no use of IV contrast
• Ability to delineate pancreatic and bile ducts (detect
choledocholithiasis missed on U/S )
• Greater sensitivity than CT in detecting mild pancreatitis
– Cons
• Expensive
• Less readily available in non‐tertiary medical centers