Diagnostic Criteria and Management of Pancreatitis

Clinical Presentation and Diagnostic Criteria

The American College of Gastroenterology recommends that upper abdominal pain radiating to the back, accompanied by nausea and vomiting, is a key clinical presentation of acute pancreatitis 1
Severe cases of pancreatitis may present with body wall ecchymoses such as Cullen's sign or Grey-Turner's sign, and epigastric or diffuse abdominal tenderness on examination 1

Serum lipase is the preferred diagnostic marker over amylase due to greater specificity and longer elevation, with a diagnostic threshold of lipase >3 times the upper limit of normal 1
CT scanning with intravenous contrast is the preferred confirmatory imaging test when diagnosis is uncertain, but should be delayed until 72 hours after symptom onset to avoid underestimating pancreatic necrosis 2
Ultrasound has limited utility for diagnosing pancreatitis itself, but is essential for identifying gallstones as the etiology 1

The American College of Gastroenterology recommends that liver chemistries, including bilirubin, AST, ALT, and alkaline phosphatase, should be assessed at admission to investigate the cause of pancreatitis 2, 3, 1
Abdominal ultrasonography should be performed at admission to screen for cholelithiasis or choledocholithiasis 2, 3
A detailed alcohol history quantified in units per week should be taken to investigate the cause of pancreatitis 2, 3
The APACHE II score, Glasgow score, and C-reactive protein should be assessed to determine the severity of pancreatitis 2, 4
A C-reactive protein level >150 mg/L at 48 hours after disease onset indicates severe disease 2, 1

Persistent organ failure during the initial 72 hours requires ICU/intermediate care unit triage, and hematocrit >44% and urea >20 mg/dL are additional severity markers 2, 1
The American College of Gastroenterology recommends that etiology should be established in 75-80% of cases through repeated ultrasounds, MRCP, or EUS, and that "idiopathic" pancreatitis should not be accepted without vigorous investigation 2, 3