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

Abstract

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.