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Key Features

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Essentials of Diagnosis
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  • Epigastric abdominal pain radiating to the back

  • Nausea and vomiting

  • Elevated serum amylase and lipase

  • Evidence of pancreatic inflammation by CT or ultrasound

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General Considerations
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  • Causes of pancreatic obstruction

    • Stones

    • Choledochal cyst

    • Tumors of the duodenum

    • Pancreas divisum

    • Ascariasis

  • Acute pancreatitis has been seen following treatment with

    • Sulfasalazine

    • Thiazides

    • Valproic acid

    • Azathioprine

    • Mercaptopurine

    • Asparaginase

    • Antiretroviral drugs (especially didanosine)

    • High-dose corticosteroids

  • May also occur

    • In cystic fibrosis, systemic lupus erythematosus, α1-antitrypsin deficiency, diabetes mellitus, Crohn disease, glycogen storage disease type I, hyperlipidemia types I and V, hyperparathyroidism, Henoch-Schönlein purpura, Reye syndrome, organic acidopathies, Kawasaki disease, or chronic kidney disease

    • During rapid refeeding in cases of malnutrition

    • Following spinal fusion surgery

    • In families

  • Alcohol-induced pancreatitis should be considered in the teenage patient

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Clinical Findings

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Symptoms and Signs
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  • Acute onset of persistent (hours to days), moderate to severe upper abdominal and midabdominal pain occasionally referred to the back, frequently associated with vomiting or nausea; these classic symptoms are less common is infants and younger children

  • Abdomen is tender, but not rigid, and bowel sounds are diminished, suggesting peritoneal irritation

  • Abdominal distention is common in infants and younger children

  • Jaundice is unusual

  • Ascites may be noted

  • Left-sided pleural effusion is present in some patients

  • Periumbilical and flank bruising indicate hemorrhagic pancreatitis

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Differential Diagnosis
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  • Gastritis

  • Peptic ulcer disease

  • Duodenal ulcer

  • Hepatitis

  • Liver abscess

  • Cholelithiasis

  • Cholecystitis

  • Choledocholithiasis

  • Acute gastroenteritis or atypical appendicitis

  • Pneumonia

  • Volvulus

  • Intussusception

  • Nonaccidental trauma

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Diagnosis

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Laboratory Findings
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  • Elevated serum amylase or lipase (more than three times normal) is key finding

    • Elevated serum lipase persists longer than serum amylase

    • Because amylase or lipase may not be elevated in infants younger than 6 months, elevated immunoreactive trypsinogen may be more sensitive

  • Pancreatic lipase can help differentiate nonpancreatic causes (eg, salivary, intestinal, or tuboovarian) of serum amylase elevation

  • Leukocytosis, hyperglycemia (serum glucose > 300 mg/dL), hypocalcemia, falling hematocrit, rising blood urea nitrogen, hypoxemia, and acidosis may all occur in severe cases and imply a poor prognosis

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Imaging
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  • Plain radiographic films of the abdomen may show a localized ileus (sentinel loop)

  • Ultrasonography

    • Used to assess for biliary tract disease leading to pancreatitis

    • Can show decreased echodensity of the pancreas in comparison with the left lobe of the liver

    • Pancreas is often difficult to visualize due to overlying gas

  • CT scanning

    • Visualizes pancreas more consistently

    • Better for detecting pancreatic phlegmon, pseudocyst, necrosis, or abscess formation

  • The computed tomography severity index (CTSI) is useful in identifying patients at increased risk for serious complications

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Diagnostic Procedures
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  • ERCP or MRCP may be useful in

    • Confirming patency of the main pancreatic duct in cases of abdominal trauma

    • Recurrent acute pancreatitis

    • Revealing stones, ductal strictures, and ...

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