CT A/P for pancreatitis

[realruby2000]

when do you CT these? if the lipase is elevated, I call it pancreatitis and usually call it a day. the only time i would CT it would be if it were chronic/recurrent and I was looking for psuedocysts or somthing else thats weird about the patient.

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[Whisker Barrel Cortex]

when do you CT these? if the lipase is elevated, I call it pancreatitis and usually call it a day. the only time i would CT it would be if it were chronic/recurrent and I was looking for psuedocysts or somthing else thats weird about the patient.

Although your clinical colleagues will give you better advice, I can tell you from a radiology prospective your approach is pretty good. The other reason for imaging is if the patient if more severely ill and there is concern for necrotizing pancreatitis, which changes the prognosis and therapy significantly. Most of the time, these patients will be admitted and the admitting team will order the CT anyway. Another consideration is to get an US to eval for cholelithiasis and CBD dilatation (meaning a stone may have passed or be stuck in the distal CBD in the pancreatic head) as an etiology of the pancreatitis. That way you can stop calling them alcoholic and don't need to ask about recent scorpion bites as the cause.

Remember that a CT for acute pancreatitis without IV contrast is pretty useless b/c the findings on the scan that change the clinical management (necrosis, pancreatic CA) are not visible without IV contrast (you may already know this, but since I've had this discussion with several clinicians in the past, I figured I'd pass it on). A non-con can only tell you if the pancreas is inflamed, which, in most cases, you already knew from labs and symptoms.

 

[DrQuinn]

agreed. I've only ordered a CT a/p with IV/PO in a patient with either chronic pancreatitis with a fever or a crapload of consittutional complaints, or a patient that is super sick. otherwise, if its a regular ol' pancreatitis, just admit to medicine. if they want to do the u/s/CT, its up to them. If the patient is stable, I dont' care.

Q

 

[f_w]

I typically suggest to get the CT 2-3 days out rather than at the time of admission.

Often, the pancreatitis patients are somewhat dehydrated when they hit the ED. 97% of the time you are going to get away with giving IV contrast in that setting, but it is certainly preferable have the patient nicely tuned up. Also, waiting a couple of days gives you an idea about pancreatic pseudocyst formation (as WBC pointed out, if the patient is in poor shape and you are concerned about necrosis or hemorrhage, an immediate CT can be helpful).

CT looks for complications of pancreatitis.

US, MRCP and ERCP look for causes of pancreatitis.

All have a role to play, rarely in the ED setting.

 

[Big Ben]

Little role for CT A/P unless this pt looks headed toward a CCMU.

I think an USN is reasonable though doesn't necessariliy have to happen in the ED. While not every pancreratitis pt will need a CT A/P, they all will eventually need an USN unless another etiology is obvious.

Finding gallstone panc helps the primary team. I definetly get them for the team for any LFT abnormalities which would suggest a need for a quick ERCP in house.

 

[BellKicker]

Agree with the above. I lean towards scanning sicker patients - and I base that on leukocytosis, lipase level (although I shouldn't), lactate, ca (often forgotten but you look like a rock star if it's low) and fever. Basically, a poor man Ranson's.

The decision tree in my mind leads to two questions: do you start antibiotics and do you call the surgeons.

 

[fennek]

this is probably the wrong thread to ask but i'll ask anyway..

what if a patient has chronic pancreatitis, but is allergic to IV contrast? will MRI do any good in recognizing the abovementioned complications?

 

[f_w]

what if a patient has chronic pancreatitis, but is allergic to IV contrast? will MRI do any good in recognizing the abovementioned complications?

Yes.