Which One Is More Important For The Diagnosis Of Acute Pancreatitis? Blood Tests Or Imaging?

Öz

Introduction:

Acute pancreatitis (AP); It is defined as a reversible inflammatory process in which the tissue of the pancreas is affected at various degrees, accompanied by local tissue or organ systems. It is characterized by a sudden onset of upper abdominal pain and associated vomiting, fever, tachycardia, leukocytosis, serum amylase or lipase increase of 3 times normal. Acute pancreatitis has a spectrum of varying severity of disease ranging from self-limiting mild disease that is present with abdominal pain to severe fluid loss, metabolic imbalances, hypotension, sepsis and severe disease that may lead to death. Mortality rate is 6-23% for acute pancreatitis in different article.  We report the case with a diagnosis of acute pancreatitis, who have abdominal pain; but no serum amylase and lipase elevation. We diagnosed edematous pancreatitis image in the computed tomography.

Case:

A 51-year-old male admitted to the emergency department with sever abdominal pain. He had diabetes mellitus in his medical history; but drugs used for DM could not be learned due to communicative reasons.On his presentation to our ED, he was conscious, oriented and cooperative. His vital signs were as follows: his blood pressure was 130/90 mm Hg, his pulse rate was 100 beats per min, his respiratory rate was 20 per min, his body temperature was 36.5°C, and his oxygen saturation was 100% while breathing room air. He has epigastric tenderness and abdominal guarding on palpation; but no rebound tenderness or rigitidy was noted on palpation. No pathological findings were found in the respiratory system, cardiovascular system and neurological examination. The blood test measurements were WBC: 5.50 10³/uL, Hb:13.2 g/dl, Plt:160.000 10³/uL, Glucose: 444  mg/dl, urea:30.0 mg/dl, serum creatinine: 0.74 mg/dL, AST: 13U/L,,ALT: 15 U/L, GGT:33 U/L, ALP: 107 U/L, Amylase: 28: U/L, Lipase: 58.8 U/L, CRP: 104.05 mg/L, cardiac  troponine: 0.006 ng/ml. . ECG is normal beat.
In abdominal ultrasonography of the patient; pancreas and midline structures could not be evaluated due to gas. No ultrasonographic pathology was detected in other intraabdominal organs and intraabdominal fluid was not seen in the abdominal ultrasonography. Contrast-enhanced computed tomography (CT) of the abdomen was performed because of persistant, severe abdominal pain and it revealed peripancreatic diffuse inflammatory densities (edematous pancreatitis), shown in image 1. The patient was consulted with the internal medicine clinic.  Internal Diseases Clinic suggested hydration with intravenous Serum Physiological and then re-consultation with blood tests. We detected that  WBC: 5.75 10³/uL, Hb:13 g/dl, Plt:150.000 10³/uL, Glukose: 248  mg/dl, urea:18.0 mg/dl, serum creatinine: 0.6 mg/dL, AST: 12U/L,,ALT: 14 U/L, GGT:31 U/L, ALP: 96 U/L, Amylase: 20: U/L, Lipase: 38.1 U/L, CRP: 120.56 mg/L cardiac  troponine: 0.006 ng/ml in blood test after hydration.
The patient was re-consulted with the internal medicine clinic. Internal Diseases Clinic suggested hospitalization with the diagnosis of edematous pancreatitis to him.

Discussion:

Patients with acute pancreatitis are admitted to the emergency department with abdominal pain, nausea and vomiting. Generally, the amylase and lipase elevation are seen in the blood tests and then abdominal computed tomography is performed for further examination and follow-up. 
When amylase and lipase are detected in normal values, pancreatitis is not thought; but Two of the three criteria for acute pancreatitis must be determined. These criteria are abdominal pain, amylase-lipase elevation and view compatible with pancreatitis in imaging examinations. In this context, a rare diagnosis of pancreatitis can be made without amylase and  lipase elevation. In our case, the patient was diagnosed with pancreatitis because of having abdominal pain and imaging consistent with pancreatitis without elevated amylase and lypase.

Conclusion: 

As in this case, blood tests are not sufficient for diagnosis of pancreatitis and if there is clinical necessity, the emergency physician should consider imaging examinations for diagnosis of pancreatitis.

Anahtar Kelimeler

• Abdominal Pain,Pancreatitis,Amylase,Lipase

Kaynakça

1. REFERENCES1. Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg 1993;128:586-90.
2. REFERENCES2. Carroll JK, Herrick B, Gipson T, Lee SP. Acute pancreatitis: diagnosis, prognosis, and treatment. Am Fam Physician 2007;75:1513-20.
3. REFERENCES3. Demirci H, Polat Z, Kantarcıoğlu M, Öztürk K, Sakin YS, Uygun A, Bağcı S. An Atypical Presentation in Acute Pancreatitis: Normal Amylase Level. Ankara Med J, 2014, 14 (Annex 1): 1 – 2
4. REFERENCES4.Al- Bahrani AZ, Ammori BJ. Clinical laboratory assessment of acute pancreatitis. Clinica Chimica Acta 2005; 362:26-48.
5. REFERENCES5. Byrne MF, Mitchell RM, Stiffler H, Jowell PS, Branch MS, Pappas TN, et al. Extensive investigation of patients with mild elevations of serum amylase and/or lipase is “low yield”. Can J Gastroenterol 2002;16: 849-54.
6. REFERENCES6. Lillemoe KD, Yeo CJ, Management of complications of pancreatitis. Current Problems in Surgery, 1 (1): 1- 98, 1998.
7. REFERENCES7. Levant JA, Secrist DM, Resin H, et al. Nasogastric suction in the treatment of alcoholic pancreatitis: a controlled study. JAMA 229: 51, 1974.
8. REFERENCES8. Tamer et al. Evaluation of Acute Pancreatitis Sakaryamj;2011(1):17-21

9. REFERENCES9. Mitchell RM, Byrne MF, Baillie J. Pancreatitis.Lancet 2003; 361: 1447-55.
10. REFERENCES10. Koizumi M, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, et al. JPN Guidelines for the management of acute pancreatitis: diagnostic criteria for acute pancreatitis. J Hepatobiliary Pancreat Surg. 2006; 13:25-32.
11. REFERENCES11. Vissers RJ, Abu-Laban RB. Acute and chronic pancreatitis. In: Tintinalli JE, Kelen GD, Stapczynski JS (eds.), Emergency medicine. A comprehensive study guide. 5th edition, New York: McGraw-Hill, 2000: 588-592.
12. REFERENCES12. Pekmezci S. Approach and Treatment in Acute Pancreatitis. I.U. Cerrahpasa faculty of Medicine, Continuous Medical Training Activities Hepato-Biliary System and Pancreatic Diseases Symposium Series No: January, 28, 2002; p. 239-262
13. REFERENCES13. Agarwal N, Pitchumoni CS, Sivaprasad AV. Evaluating tests for acute pancreatitis. Am J Gastroenterol. 1990;85(4):356.