Biliary System |
| Last updated (28 October 2003) |
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Pancreatitis is readily confirmed by measuring the serum amylase. Other pancreatic enzymes (lipase, trypsin) are raised in patients with pancreatits and may be more specific, but are not routinely available.
There are other causes of a raised amylase besides pancreatitis, and some patients with severe pancreatitis may not have a raised amylase, so it is wise to do an abdominal CT scan (if this is available) to confirm the diagnosis. The CT will also offer prognostic information, with respect to the prospect of progression to multi organ dysfunction syndrome.
I would take a careful clinical history focused on the nature of the pain, preciptating factors (especially alcohol), and whether the patient had experienced this problem previously and if so, what the cause was. Following that I would do a physical examination.
Simple urinalysis may be helpful, with respect to biliary pathology, I would especially check the dipstick results for bilirubin and urobilinogen. Blood and protein on urinalysis would raise the possibility of another cause of the patients pain.
The most useful commonly available blood test for pancreatitis is serum amylase, but this is not always raised and can be increased due to other reasons.
If there is doubt about the clinical diagnosis, it may be confirmed by an abdominal CT scan if this is available.
There are many causes of pancreatitis, the main two are gallstones and alcohol. Rarer causes include, trauma (including endoscopic retrograde pancreatography, a duodenal ulcer pressing on the pancreas and surgery), viral infections, drugs and metabolic dergangements such as hyperlipidemia and hypercalcemia.
The main causes are gallstones and alcohol.
Alcohol consumption may be suspected if the patient drank alcohol in the hours or days prior to the attack. There may be previous attacks of the pain following alcohol consumption. Gallstones are best detected on a focused ultrasound examination of the gall bladder and biliary tree. The bile duct may be dilated due to the presence of a gallstone in the lower duct, or it may be dilated due to oedema from the pancreatitis.
Rarer causes include adverse drug reactions, viral infections, trauma and metabolic derangements. A drug history would be important and it would be wise to check the calcium and lipid levels.
In this particular patient, there was no history of alcohol consumption, the ultrasound was negative, as was the metabolic screen. Following repeated attacks of pancreatitis and repeated negative investigations (ultrasound, MRCP, blood tests). The patient was offered a cholecystectomy.
