Diagnostic_standards_for_acute_pancreati (1)

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World J. Surg. 21, 136-142, 1997
WORLD
Journal of
SURGERY
< //.	© 1997 by the Societe
Internationale de Chirurgie
Diagnostic Standards for Acute Pancreatitis
John H.C. Ranson, B.M., B.Ch., M.A.
Department of Surgery, New York University School of Medicine, New York, New York 10016, U.S.A.
Abstract. An accurate history and thorough physical examination will
often raise clinical suspicion of acute pancreatitis in the differential
diagnosis of a patient presenting with acute abdominal pain. An accurate
diagnosis is needed to eliminate etiologies of acute abdominal pain and to
appropriately direct therapy. Confirmation of the diagnosis is most often
made by evaluation of serum amylase and lipase levels. Although hyper-
amylasemia is found in the majority of patients with acute pancreatitis,
other nonpancreatic acute abdominal conditions may be present with
hyperamylasemia. CT scanning provides an accurate confirmation of
clinical and laboratory findings and offers excellent anatomic and mor-
phologic representation of the pancreas and peripancreatic tissue. The
following article, written by the late John H.C. Ranson, presents a
discussion of the modalities available for diagnosing acute pancreatitis.
—Peter Shamamian, M.D.
Acute pancreatitis is a common condition that appears to be
increasing in incidence [1, 2], and it is often difficult to diagnose.
In a study by Bockus et al., of 94 patients admitted for acute
pancreatitis, the initial diagnosis was found to be incorrect in 43%
[3]. Pancreatitis was most commonly misdiagnosed as acute
cholecystitis (20%), perforated viscus (7%), or intestinal obstruc-
tion (5%). In patients with fatal acute pancreatitis the correct
diagnosis is not made until the time of autopsy in 41.6% of cases
[4].There is, unfortunately, no clinical or laboratory criterion that
permits certain diagnosis of acute pancreatitis in all patients.
Operative or autopsy findings are available for only a few patients.
Radiographic findings on computed tomography (CT) can be
diagnostic, but this study may also be normal in patients with mild
disease.
The diagnostic features of acute pancreatitis are reviewed here.
It should be stressed that the initial diagnosis depends primarily
on an accurate, well directed history and careful physical exami-
nation.
Clinical Features
The term acute pancreatitis encompasses a wide spectrum of
clinical and pathologic findings with varied clinical features. It
may closely mimic extrapancreatic conditions that are as different
as myocardial infarction and acute gastroenteritis.
Correspondence to: Peter Shamamian, M.D., New York University
Medical Center, Department of Surgery, 530 First Avenue, Suite 6B, New
York, NY 10016, U.S.A.
Patient Characteristics
Pancreatitis is uncommon in children and increases in frequency
with increasing age. The rate per 100,000 population in the United
States is 2.7 in those under 15 years old. It is roughly 100-fold
greater in those 15 to 44 years old and 200-fold greater in those
over 65 years old [1].
The frequency of pancreatitis in men and women is approxi-
mately equal. Alcohol-related pancreatitis tends to be more common
in men, and biliary pancreatitis is more common in women. The sex
ratio, therefore, varies with the dominant etiology.
It is reported that the rate of pancreatitis in black Americans is
three times greater than in whites. The reasons are unknown [1].
Previous Episodes
Previous episodes of similar but milder abdominal pain are
reported in about 50% of patients with acute pancreatitis. This
entity may represent previous mild pancreatitis or perhaps biliary
colic. A previous episode of pancreatitis has been documented in
approximately 20% of patients, especially in those with alcohol-
associated disease [3].
Symptoms
Abdominal pain is the dominant initial symptom in most patients.
Characteristically, the pain is most severe in the upper abdomen
and often radiates to the back or both flanks. The pain may begin
after a heavy meal or during a drinking binge. It initially increases
rapidly in intensity, but its onset is less sudden than that due to a
perforated viscus. The intensity of pain varies widely but may be
severe. Mild pain may be partially relieved by sitting up or by lying
curled on the right or left side.
The second most prominent symptoms are nausea and vomit-
ing, which are almost invariably present. Vomiting may be re-
peated but is usually not copious in volume. The vomitus com-
prises primarily gastric and duodenal contents and is not feculent.
Physical Examination
Findings on physical examination are varied in nature and degree.
In patients with mild pancreatitis physical examination may be
largely unrevealing, whereas with severe disease the patient may
Ranson: Pancreatitis: Diagnostic Standards
	
137
Table 1. Routine laboratory findings in 100 patients with acute
pancreatitis versus those in 100 patients with other acute abdominal
emergencies.
Acute
pancreatitis	Other
Laboratory test	 (%)	 (%)
Serum amylase (Somogyi units/dl)
> 500 59 1
200-500 36 4
< 200 5 95
Hematocrit (%)
>45 31 23
<45 69 77
White blood cell count (cells/mm3)
> 12,000 41 53
< 12,000 59 47
Blood glucose (mg/dl)
> 300 7 0
200-300 9 7
Diabetics excluded: < 200 84 93
Serum calcium (mg/dl)
>9 76 67
8-9 15 31
<8 9 2
Serum LDH (IU/L)
> 225 48 24
< 225 52 76
Serum GOT (Sigma-Frankel units/dl)
> 100 37 8
< 100 63 92
be hypotensive and comatose. Characteristically, the patient is
restless with a rapid pulse and respiratory rate. Cyanosis may be
present in severe cases. The abdomen is usually moderately
distended and may exhibit a characteristic fullness of the epigas-
trium. Tenderness is usually most marked over the upper abdo-
men but may be generalized. Moderate muscle spasm is usual, but
true rigidity is infrequent [5-8]. Grey Turner's sign or a gray-
green discoloration of the flank is present in about 1% of patients.
It is impossible to know how frequently the diagnosis of
nonlethal acute pancreatitis is missed, as no diagnosis is made in
most such cases. However, with fatal acute pancreatitis, the
diagnosis is missed in 30% to 40% of patients until the time of
autopsy [9, 10]. The diagnosis may be particularly difficult in two
circumstances. The first is following surgery in the upper abdo-
men, when abdominal pain and vomiting may be attributed to the
recent surgery, and the possibility of concomitant pancreatitis is
overlooked. The second circumstance occurs in patients who do
not have significant abdominal pain. They may present with
cardiopulmonary collapse, confusion, or hypothermia. In most
such cases the diagnosis can be made if it is considered. Accord-
ingly, when unexplained collapse occurs in the postoperative or
other settings, biochemical and imaging studies for possible
pancreatitis should be considered.
Laboratory Findings
Routine laboratory findings in 100 patients with acute pancreatitis
are shown in Table 1. They are compared with those in 100
patients with acute cholecystitis, perforated ulcer, intestinal ob-
struction, and appendicitis. The initial serum amylase was ele-
vated in 95% of patients with acute pancreatitis and in 5% of
those with other acute abdominal conditions.
Two of the five patients with acute pancreatitis and reported
normal serum amylase levels had lipemic serum. In the presence
of hyperlipidemia, serum amylase activity may be inhibited [11].
Elevated serum amylase levels may be demonstrated by dilution
of serum in this setting.
Hyperglycemia or glycosuria may be associated with acute
pancreatitis. Marked elevations of serum glucose levels are more
common with pancreatitis than with other abdominal conditions.
Hypocalcemia is also a well recognized feature of acute pancre-
atitis but may occur in patients with perforated peptic ulcer as well
[12]. If gastroduodenal perforation can be excluded, an initial
serum calcium level below 8 mg/dl supportsa diagnosis of acute
pancreatitis. Elevation of serum glutamic oxaloacetic transami-
nase (SGOT) and lactic dehydrogenase (LDH) are more common
in patients with pancreatitis than in those with other acute
intraabdominal conditions but usually are not helpful for diagnos-
ing pancreatitis.
Laboratory Diagnosis
Serum Amylase
Elman et al. in 1929 demonstrated the value of serum amylase
measurements in patients with acute pancreatitis, and it remains
the most widely used diagnostic test of acute pancreatitis [13]. The
reported sensitivity is difficult to estimate because an elevated
amylase level is frequently used as a diagnostic criterion [14-17].
In a collective review of 5781 patients with acute abdominal
conditions, Stefanini et al. reported that 20% had elevated serum
amylase levels [18]. Moreover, 75% of patients with hyper-
amylasemia had acute pancreatitis and 25% had other conditions.
Of the latter, only 53% had illnesses that might be confused with
pancreatitis. The nonpancreatic intraabdominal diseases most
commonly associated with elevated amylase levels are perforated
peptic ulcer, biliary disease, intestinal obstruction, and mesenteric
infarction.
Urinary Amylase
Elevated amylase levels occur in the urine of patients with
pancreatitis, a reflection of glomerular filtration of increased
serum amylase concentrations combined with decreased tubular
reabsorption during pancreatitis. Urinary amylase levels may
remain elevated longer than serum levels. Furthermore, elevated
serum amylase levels secondary to macroamylasemia may be
detected by decreased urinary amylase levels. Urinary amylase
measurements have little other advantage over serum measure-
ments.
The normal urinary clearance of serum amylase is about 3
ml/min. Because the creatinine clearance is usually 100 ml/min,
the ratio of amylase clearance to creatinine clearance (ACCR) is
approximately 2% to 4%. In patients with pancreatitis this ratio is
increased and may exceed 10%. Although an increased ACCR
was thought to be helpful for the diagnosis, it has been shown to
have little value because of its low specificity [19-23].
Isoamylase Measurements
Amylase activity in the serum derives not only from the pancreas
but from the salivary glands and to a lesser extent other tissues as
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World J. Surg. Vol. 21, No. 2, February 1997
Table 2. Incidence of radiographic signs suggesting acute pancreatitis
on initial chest and abdominal radiographs in 73 patients with acute
pancreatitis.
Radiographic sign	 Incidence (%)
Segmental small bowel ileus 41
Colonic dilation 22
Obscure psoas margin 19
Increased epigastric soft tissue density 19
Increased gastrocolic separation 15
Gastric greater curvature distortion 14
Duodenal ileus 11
Pleural effusion 4
Pancreatic calcification 3
One or more of the above signs 79
well, including the fallopian tube, lung, and liver. These amylases
have differing physicochemical properties. Normal serum amylase
has three isoamylase peaks with isoelectric points of 7.0, 6.4, and
6.0. Pancreatic isoamylase has an isoelectric point of 7.0 and can
be isolated from other isoamylases. Although not available on a
routine basis, pancreatic isoenzyme measurements are more
specific than total amylase levels and may persist after the onset of
disease [14, 24-29].
Lipase
Serum lipase originates for the most part from the pancreas.
Reports indicate that it is more specific and more sensitive than
amylase levels for detecting acute pancreatitis [17, 21, 30]. The
serum lipase level has not been widely used, perhaps because the
available assays were not suitable for widespread rapid use. The
availability of simple methods to measure lipase levels may lead to
wider use of this diagnostic parameter [31, 32].
Other Tests
Serum immunoreactive trypsin, chymotrypsin, elastase, phospho-
lipase A2 , a2 macroglobulin levels, methemalbumen, carboxypep-
tidases, and carboxyl ester hydrolase levels have been reported to
be of possible value for the diagnosis of pancreatitis. At this time,
their superiority to measurements of amylase and lipase levels is
unproved [15, 17, 21, 30, 33-37].
Radiology
Plain radiographs of the chest and abdomen are a standard part of
the evaluation of patients with acute abdominal findings. These
findings are often examined only for the possible presence of free
air, an intestinal gas pattern indicating intestinal obstruction, or
calcification in the biliary or urinary tracts. Most patients with
acute pancreatitis have one or more of the radiographic findings
listed in Table 2 [38]. The incidence of the various findings is also
shown. The diagnostic value of the signs varies considerably, with
demonstration of an enlarged pancreatic head by a gas-filled
duodenum being the most specific (Fig. 1).
Ultrasonographic evaluation of the pancreas may show in-
creased size and decreased echodensity as well as possible fluid
collections [39]. Computed tomography (CT) is more costly and
involves radiation exposure but clearly provides superior imaging
of the pancreas and peripancreatic retroperitoneum [40]. CT
findings reported for acute pancreatitis include diffuse or segmen-
Fig. 1. Plain abdominal radiograph demonstrating duodenal ileus in a
patient with acute pancreatitis. From Ranson, J.H.C.: Acute pancreatitis.
In Current Problems in Surgery, Vol. 16, No. 11, St. Louis, Mosby-Year
Book Inc., 1979.
Fig. 2. CT image of acute pancreatitis demonstrating pancreatic enlarge-
ment and fluid in the left anterior pararenal space.
tal enlargement of the pancreas, irregularity of the pancreatic
contour with obliteration of the peripancreatic fat planes, heter-
ogeneous appearance and areas of decreased density within the
pancreas, and variable ill-defined fluid collections. Fluid accumu-
lation may occur within the pancreas or outside the gland in the
lesser sac and in the pararenal spaces (Fig. 2) [41]. CT findings
supporting a diagnosis of pancreatitis are present in 85.5% of our
patients [42]. The frequency of CT findings depends on the
severity of the pancreatitis being studied. Normal CT findings
Ranson: Pancreatitis: Diagnostic Standards
	
139
Table 3. Etiologic factors of acute pancreatitis.
Metabolic
Alcohol abuse
Hyperlipoproteinemia
Hypercalcemia
Drugs
Genetic
Scorpion venom
Mechanical
Cholelithiasis
Postoperative (gastric, biliary)
Pancreas divisum
Posttraumatic
Retrograde pancreatography
Pancreatic duct obstruction: pancreatic tumor, Ascaris infestation
Pancreatic ductal bleeding
Duodenal obstruction
Vascular
Postoperative (cardiopulmonary bypass)
Periarteritis nodosa
Atheroembolism
Infection
Mumps
Coxsackie B
Cytomegalovirus
Cryptococcus
have been reported in 24% to 67% of patients [40, 43, 441. The
clinical course of patients with normal findings on CT is usually
benign.
Preliminary experiences with magnetic resonance imaging have
not identified major advantages compared to contrast-enhanced
CT [45].
In the absence of CT scanning, a water-soluble contrast study of
the upper gastrointestinal tract can help exclude perforation or
obstruction of the stomach or small intestine. The differential
diagnosis of acute pancreatitis from obstructive cholangitis or
gangrenous cholecystitis associated with elevated amylase levels
maybe particularly difficult. In this situation, ultrasonography may
demonstrate gallbladder stones but does not provide sufficiently
precise anatomic information. Biliary scanning is not reliable, as
cystic duct obstruction may be demonstrated during acute pan-
creatitis even in the absence of biliary lithiasis. Direct imaging of
the biliary tree by percutaneous transhepatic cholangiography or
endoscopic retrograde cholangiography may be required to ex-
clude cystic duct or common bile duct obstruction [46].
Diagnostic Paracentesis
Paracentesis and examination of the peritoneal exudate or of the
return following lavage of the peritoneal cavity has been used in
the diagnosisof acute abdominal findings [47, 48]. The gross
appearance, amylase content, and white blood cell count of the
peritoneal fluid in patients with acute pancreatitis vary widely and
overlap with those in patients with other causes of peritonitis.
Paracentesis does not therefore usually provide strong positive
evidence of pancreatitis. Its main usefulness is when it demon-
strates findings such as bile or dietary fiber, indicating life-
threatening extrapancreatic disease.
Diagnostic Laparotomy
Although a reasonably certain diagnosis of acute pancreatitis can
be reached in most patients on the basis of clinical, radiographic,
and laboratory findings, there are patients in whom diagnostic
celiotomy is required to exclude life-threatening extrapancreatic
disease. In this regard, it should be stressed that strong positive
evidence of acute pancreatitis does not exclude the possibility of
concomitant extrapancreatic abnormalities in the occasional pa-
tient.
If diagnostic celiotomy is undertaken, exploration must be
complete and establish the diagnosis beyond question. The pan-
creas should be inspected and the extent of inflammation, asso-
ciated fluid collections, pancreatic and peripancreatic necrosis,
and hemorrhage noted. The presence of gallstones should be
evaluated, although palpation of the gallbladder in this setting
fails to detect stones in about 20% of patients who harbor
cholelithiasis. Any further choice of surgical procedure should be
determined by specific therapeutic goals.
Etiologic Diagnosis
The more common identified causes of acute pancreatitis are
listed in Table 3. About 60% to 80% of these patients either
harbor gallstones or have a history of alcohol abuse. In many
instances the etiology can be determined by an accurate history.
Others, such as those with hyperlipoproteinemia, require bio-
chemical evaluation, which may have to await subsidence of the
acute episode. In most etiologic groups, management of the acute
episode is not greatly altered by knowledge of the etiology. In
patients with gallstone-associated pancreatitis, early management
may include endoscopic retrograde cholangiography. Attempts
have therefore been made to identify this etiologic subgroup. It
has been found that the patient's age, serum amylase, alkaline
phosphatase, glutamyl transpeptidase, and transaminase levels
were significantly higher in patients with gallstone pancreatitis
[49-51]. Several scoring systems have been reported. Blarney et al.
identified five factors: alkaline phosphatase >_ 300 IU/L, age >_ 50
years, alanine aminotransferase ? 100 IU/L, female sex, and
amylase ? 4000 IU/L. The incidence of gallstones rose from 5%
if none of these findings was present to 100% when all five were
present [50]. Early ultrasonography has been reported to have a
lower sensitivity than biochemical findings in detecting gallstone
disease. However, a combination of ultrasonography and bio-
chemical measures has an overall accuracy of 93.2% [49].
Prognostic Assessment
The clinical spectrum of acute pancreatitis ranges from mild,
self-limiting symptoms to a fulminant, rapidly lethal disease. Early
objective identification of the risk of major complications or death
is essential for appropriate management of individual patients and
for assessment of the efficacy of treatment.
Clinical Criteria
A number of early clinical findings have been reported to have
prognostic value. They include age, Grey Turner's sign, and the
severity of abdominal findings on physical examination. In most
instances these clinical findings cannot be objectively quantified.
In patients with acute pancreatitis, recurrent episodes are
common unless the etiologic findings can be identified and
corrected. In general, the virulence of each new recurrent attack
tends to diminish. In our experience the mortality of the first
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World J. Surg. Vol. 21, No. 2, February 1997
Table 4. Measurements reported to be of early prognostic value in
acute pancreatitis.
Measurement	 Reference
Hemodynamic tests 52
Hematocrit 53
White blood cell count 5
Coagulation factors 54
Complement activation 55
C-reactive protein 56
Serum amylase 57
Serum phospholipase A 2 58
Serum elastase 56
Serum calcium 59
Blood glucose 60
Renal function 60
Respiratory insufficiency 60
Acidosis 60
Liver function 60
Serum methemalbumin 60
Serum ribonuclease 61
Serum cyclic adenosine 3'5'-monophosphate 62
a,-Protease inhibitor 63
az Macroglobulin 64
Trypsinogen activation peptides 65
episodes was 9.6%. It fell to 5.3% during the second episode and
was 1.1% for subsequent episodes.
Table 4 lists some of the measurements reported to be of early
prognostic value [5, 52-65]. In many instances, clinical evaluation
involves only small numbers of patients. In others the measure-
ment has been correlated with "necrotizing" pancreatitis, rather
than with the overall clinical course.
A distinction must be drawn between diagnostic tests and
prognostic measurements. Thus serum pancreatic ribonuclease
determination is a measurement that, if levels rise during the
course of acute pancreatitis, has been reported to indicate pan-
creatic necrosis. It is a diagnostic, rather than a prognostic,
measurement, as early levels do not discriminate severity of
disease or probability of complications in the future.
Correlations have also been reported between a t -protease
inhibitor, a2-macroproteins, complement factors C3 and C4, and
C-reactive protein and necrotizing pancreatitis. Most of these
measures are diagnostic, rather than prognostic.
Most intriguing, from a morphologic standpoint, has been the
use of contrast-enhanced CT. Radiographic enhancement of the
pancreas following contrast injection has been interpreted as
evidence of tissue viability. Failure of enhancement has been
interpreted as evidence of tissue necrosis. Estimations of pancre-
atic necrosis using contrast-enhanced CT have been reported to
correlate well with operative estimates of the extent of pancreatic
necrosis [66]. The timing of these studies relative to the onset of
symptoms of pancreatitis, however, is not always reported. The
prognostic (in contrast to diagnostic) value of this study in terms
of necrosis is uncertain. Furthermore, identification of the pres-
ence of necrosis is of value only if it is shown to be associated with
specific complications or overall morbidity. In our studies, approx-
imately 70% of patients who had nonenhancement on early
contrast-enhanced CT went on to develop infection of devitalized
pancreatic and peripancreatic tissue. Approximately 30% of pa-
tients, however, escaped this complication. In our experience, the
risk of pancreatic infection in patients with early normal pancre-
Table 5. Early objective prognostic signs that correlate with the risk of
major complications or death from acute pancreatitis.
At admission or diagnosis
Age > 55 years
White blood cell count > 16,000/µl
Blood glucose level > 200 mg/dl
Serum lactic dehydrogenase concentration > 350 IU/L
Serum glutamic oxaloacetic transaminase > 250 Sigma-Frankel units/dl
During initial 48 hours
Hematocrit decrease of > 10%
Blood urea nitrogen increase of > 5 mg/dl
Serum calcium level < 8 mg/dl
Arterial P02 < 60 mmHg (8 kPa)
Base deficit > 4 mEq/L
Estimated fluid sequestration > 6000 ml
atic enhancement was only 8.5%. Therefore although nonen-
hancement is a finding of ominous prognostic significance in terms
of infection, its overall sensitivity and specificity are limited.
A study of the prognostic value of CT findings, not based on
enhancement following contrast administration, was reported in
1985. Early CT findings were grouped into five categories: (1)
normal; (2) peripancreatic enlargement alone; (3) inflammation
confined to the peripancreatic area; (4) one peripancreatic fluid
collection; and (5) two or more fluid collections. The frequencies
of these findings in our population of patients were 14.5%, 22.9%,
20.5%,14.5%, and 27.7%, respectively. There was a weak relation
between the grade of CT finding and overall morbidity, but it was
of little clinical value. CT findings, however, did provide a
valuable guide to the risk of late pancreatic sepsis. In patients with
CT grades A or B, the incidence of abscess was zero. In those with
grades C or D, it was 11.8% and 16.7%, respectively; and in those
with grade E it was 60.9%.
Multiple Prognostic Criteria
In 1974 we developed the 11 early objective prognostic criteria
listed in Table 5 [67]. These signs were developed from a
statistical analysis of the relation between early measurements
and overall morbidity and mortality of acute pancreatitis. The
relation between the number of signs present and morbidity in a
group of 450 patients is shown in Fig. 3. More complex statistical
methods or examination of specific etiologic groups may improve
accuracy. Several modifications of these multiple criteria have
been proposed. Overall accuracy of differing modifications are
roughly comparable. All suffer from lack of simplicity and a
48-hour delay in final assessment.
The APACHE II (acute physiology and chronic health evalua-
tion) illness grading system has been applied to prognostic
assessment of pancreatitis [68, 69]. Reports indicate that the
accuracy of this system is comparable to that of specific multiple
prognostic criteria. It is more complex but has the advantage that
it may be applied at times other than at diagnosis.
Conclusions
In most patients acute pancreatitis can be diagnosed on the basis
of careful clinical evaluation combined with biochemical and
radiographic studies. When positive findings are present, CT
examination may provide valuable confirmation in selected cases.
Ranson: Pancreatitis: Diagnostic Standards
	
141
Fig. 3. Incidence of death and complications that required at least 7 days
of intensive care related to the number of positive prognostic signs. From
Ranson, J.H.C.: Acute pancreatitis. In Current Problems in Surgery, Vol.
16, No. 11, St. Louis, Mosby-Year Book Inc., 1979.
Biochemical measurements and ultrasonography may be helpful
for early identification of those patients who harbor gallstones.
We continue to use the prognostic criteria listed in Table 5 to
identify patients with a high risk of life-threatening complications.
Early contrast-enhanced CT provides additional morphologic
information in severely ill patients and those with an atypical
clinical course.
Resume
La pancreatitc aigue est une maladie relativement frequente dont
l'incidence est en hausse. Son diagnostic est difficile. Dans une
etude presentee par Bockus a partir de 94 admissions pour
pancreatite aigue, le diagnostic etait inexact chez 43 % des cas. La
pancreatite a ete prise le plus souvent pour une cholecystitc aigue
(20%), une perforation de viscere creux (7%) ou une occlusion
intestinale (5%). Chez le patient ayant une pancreatite aigue
fatale, le diagnostic correct n'a pas ete fait avant 1'autopsie dans
41.6% des cas. Il n'existe aucun critere clinique ou biologique qui
permette le diagnostic certain de pancreatite aigue a tous les
coups. Les donnees operatoires ou autopsiques ne sont dis-
ponibles que chez un faible pourcentage des patients. Les donnees
de la tomodensitometrie sont parfois diagnostiques, mais cet
examen peut titre normal chez le patient ayant une forme mineure
de la maladie. Les criteres diagnostiques de la pancreatite aigue
sont passes en revue. I1 faut souligner que le diagnostic initial
depend principalement d'un interrogatoire precis ainsi que d'un
examen physique soigneux.
Resumen
La pancreatitis aguda es una entidad comun, con frecuencia de
dificil diagnostico, cuya incidencia es creciente. En un estudio
realizado por Bockus en 94 pacientes hospitalizados por pancre-
atitis aguda, el diagn6sti co inicial resulto incorrecto en 43% de
los casos. Comunmente se confundio la pancreatitis aguda con
colecistitis aguda (20%), viscera perforada (7%) u obstruccion
intestinal (5%). En los casos de pancreatitis aguda letal, el
diagnostico correcto solo es establecido en el momento de la
autopsia, lo cual ocurre en 41.6% de los casos. Desafortunada-
mente no existen criterios clinicos o de laboratorio que permitan
un diagnostico certero de pancreatitis aguda en la totalidad de los
pacientes. Los hallazgos operatorios o de necropsia estan dis-
ponibles solo en una pequeiia minoria de los casos. Los hallazgos
radiologicos en tomografia computadorizada pueden ser diagnos-
ticos de la entidad, pero el estudio puede aparecer normal en los
pacientes con enfermedad leve. Es por ello que en el presente
articulo se revisan las caracteristicas diagnosticas. Debe hacerse
enfasis en que el diagnostico inicial depende, primordialmente, de
una Bien orientada historia clinica y de un meticuloso examen
fisico.
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