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THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 2 | 15 Definition Acute pancreatitis refers to acute inflammation of the pancreas, usually accompanied by abdominal pain and elevations of serum pancreatic enzymes. This syndrome is usually a discrete episode which causes varying degrees of injury to the pancreas. Following recovery the pancreatic function usually returns to normal unlike chronic pancreatitis in which the resulting fibrosis and pancreatic dysfunction is irreversible and thus permanent. The most common causes are gallstones or an alcohol binge. Less common causes are listed in Table 1. Table 1: Further causes of acute pancreatitis • Hypercalcaemia • Auto-immune • Drug induced (azathioprine, thiazide diuretics, valproic acid, sulphasalazine etc) • Post traumatic • Hypertriglyceridemia • Pancreatic tumours • Infections (mumps, coxsachie virus) • Idiopathic Diagnosis Patients usually present with epigastric pain which typically radiates to the back, they may have accompanying nausea and vomiting. Serum amylase and lipase levels must be elevated at least 3 times above the laboratory’s reference range to diagnose acute pancreatitis. The serum half-life of amylase is short, and elevations generally return to normal reference ranges within a few days. Lipase has a slightly longer half-life, up to 12 days after an episode, hence its elevation is more valuable when a delay occurs between the pain episode and the time the patient seeks medical attention. Furthermore, elevated lipase levels are more specific to the pancreas than elevated amylase levels. Serum amylase or lipase levels are purely diagnostic and do not indicate whether the disease is mild, moderate, or severe. Serial monitoring of levels during the course of hospitalization doesn’t offer any clinical value and should not be done. Once a working diagnosis of acute pancreatitis is reached laboratory tests are obtained to help determine the severity of the disease and its potential etiology. Full blood count This is done to confirm an inflammatory response, as well as assess the hematocrit, a marker of hemoconcentration. Haemoglobin and platelet count are also important. Urea and electrolytes This is done primarily to look for renal dysfunction which should be corrected. Liver function tests These are done to diagnose potential gall- stone etiology of pancreatitis as well as rule out acute cholangitis. Alanine aminotransferase levels higher than 150U/L suggests gallstone pancreatitis. Combined with ultra- sound demonstrated cholelithiasis confirms the diagnosis. C-reactive protein (CRP) A CRP value should be obtained 24-48 hours after presentation to provide prognostic information as higher levels have been shown to correlate with a propensity towards organ failure. It is also a good serial marker to assess for progression or receding inflammation. Caclium-magnesium and phosphate level Primarily for serum calcium, severe acute pancreatitis may cause saponification which consumes calcium and will require replacement. Arterial blood gas This is an important tool to look for acidosis and respiratory failure. It should be done in all moderate or severe acute pancreatitis patients and provides an important tool for resuscitation goal assessment. Radiology Abdominal x-rays have a limited role in acute pancreatitis and are not routinely indicated. Abdominal ultrasound is the most useful initial test to determine the etiology of pancreatitis and is the technique of choice for detecting gallstones. However, in the setting of acute pancreatitis its sensitivity is reduced to 70%-80% and its ability to identify choledocholithiasis is limited. In the scenario where biliary pancreatitis is suspected a repeat abdominal ultrasound should be performed once the pancreatitis has settled clinically. If it is still equivocal an endoscopic ultrasound is indicated. Ultrasonography cannot measure the severity of disease. Endoscopic ultrasound is a procedure which Acute pancreatitis - Revisiting the clinical basics Correspondence M Brand email: martin.brand@up.ac.za T Govener, M Brand HPB Surgery, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa Steve Biko Academic Hospital, Pretoria, South Africa