Pancreatitis to scan or not?

[GeneralVeers]

I had a 42 year old lady come in with vomiting and severe epigastric pain 40 minutes after eating a spicy burrito. It turns out that she has pancreatitis (lipase ~ 3000). I make her NPO, give pain meds and admit to medicine. Later that evening, the new attending coming on chews me out for not doing a CT scan to rule out myriad unlikely complications. I had always thought that the CT scan was optional, and generally done by the medicine team if the patient doesn't improve clinically.

Do the rest of you scan ALL acute, new onset pancreatitis acutely in the ED?

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[f_w]

You right, he wrong.

Couple of days out if patient deteriorates or doesn't improve, the CT is a worthwhile use of $$s and nephrons. Acutely, in an uncomplicated pancreatitis the yield is rather low.

Must have been a killer burrito. Did she wash it down with a couple of Tequilas by any chance ?

 

[GeneralVeers]

You right, he wrong.

Couple of days out if patient deteriorates or doesn't improve, the CT is a worthwhile use of $$s and nephrons. Acutely, in an uncomplicated pancreatitis the yield is rather low.

Must have been a killer burrito. Did she wash it down with a couple of Tequilas by any chance ?

There was definitely some killer Mexican food going around that day. Had another guy with ACS after a couple of Tacos as well.

She denied alcohol use. PMH diabetes, and gastric bypass with chole. U/S was negative for retained stone.

 

[DrQuinn]

New onset pancreatitis, admit, NPO, IVF. From what I've always read, only CT scan if complications of pancreatitis, i.e. infected pseudocyst, or to rule out other causes.

Incidentally, my intern year I saw a 32 yo male, new onset pancreatitis (Lipase ~ 600), abdominal pain, nausea, vomiting. Admitted him to medicine (I was the rotating intern on medicine), in the AM he had exsquisite abdominal pain, RLQ. CT scan showed an appendix, with the tip at the pancreas, causing inflammatory changes around hte panc.

In retrospect, I don't think there were any indications to CT scan him.

Q

 

[whasupmd2]

What about gallstone pancreatitis? How can you be sure the pt is not obstructed? If it's new onset, and clearly etoh, i don't scan, if there's a possiblity it could be gallstone pancreatitis, i would do CT or U/S, as if the pt is obstructed there's something that can be done about it.

New onset pancreatitis, admit, NPO, IVF. From what I've always read, only CT scan if complications of pancreatitis, i.e. infected pseudocyst, or to rule out other causes.

Incidentally, my intern year I saw a 32 yo male, new onset pancreatitis (Lipase ~ 600), abdominal pain, nausea, vomiting. Admitted him to medicine (I was the rotating intern on medicine), in the AM he had exsquisite abdominal pain, RLQ. CT scan showed an appendix, with the tip at the pancreas, causing inflammatory changes around hte panc.

In retrospect, I don't think there were any indications to CT scan him.

Q

 

[binswanger]

I still don't think you have a reason to scan, use your comprehensive metabolic profile to help you rule out gallstone obstruction (elevated LFTs, bilirubin). We see a ton of pancreatitis and very rarely scan. I think its only indicated after 48-72 hours of no improvement.

 

[whasupmd2]

I still don't think you have a reason to scan, use your comprehensive metabolic profile to help you rule out gallstone obstruction (elevated LFTs, bilirubin). We see a ton of pancreatitis and very rarely scan. I think its only indicated after 48-72 hours of no improvement.

If it's not etoh (which accounts for 75% of acute pancreatitis), then what's the cause? 35% of acute pancreatitis in the US is 2/2 gallstones. (I know the numbers don't add to 100%). But if a person doesn't have a good story for etoh, what else is causing it? Some are "idiopathic" but I believe this is fairly low < 10%? Chalk it up to scorion bite?

Furthermore... Are you sure we can use labs to differentiate? "Laboratory tests may distinguish between these two disorders. The specificity for gallstone pancreatitis of a serum alanine aminotransaminase (ALT) concentration above 150 IU/L (approximately a threefold elevation) is 96%; the positive predictive value is 95%,[140] but sensitivity is only 48%.[165] The aspartate aminotransferase (AST) concentration is nearly as useful as ALT, but the total bilirubin and alkaline phosphatase concentrations are not helpful to distinguish gallstone pancreatitis from other etiologies. A serum lipase/amylase ratio greater than 2:0 has been proposed to discriminate alcoholic pancreatitis from other causes as it is 91% sensitive and 76% specific for detecting alcoholic pancreatitis.[166] The specificity of the ratio for alcoholic pancreatitis may be greater at higher ratios.[167] However, results of other studies[168] indicate that the ratio does not reliably distinguish among causes of pancreatitis.[169] Multiple tests as a score (serum and urine amylase, AST, ALT, alkaline phosphatase, lipase-to-amylase ratio, and erythrocyte mean corpuscular volume) differentiate between biliary and alcoholic pancreatitis with a sensitivity of 92% and a specificity of 94%.[170]" ( Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., p. 928)

I could be totally way off, but this has been my line of thinking...

 

[margaritaboy]

I'm with you guys. I never CT a pancreatitis unless there is strong suspicion for complications or pancreatic mass.

Ultrasound is not unreasonable if there is clinical suspicion for a stone, but again, most stones are not radio opaque and CT would not be useful for this.

 

[f_w]

The question is not whether to image or not, the question is whether the attending was a prick for no good reason when he chewed out the intern.

Doing the US to check for stones and bil-dil is on a different page (US for once is actually the better test). CT is interesting if you want to look for dead pancreas, PV thrombosis or other real badness. Doing it in the ED to differentiate stone vs. booze pancreatitis is imho a waste of time and money. You won't be able to look for the complications yet and for the question of stones and bil-dil there is a better test available.

 

[margaritaboy]

The question is not whether to image or not, the question is whether the attending was a prick for no good reason when he chewed out the intern.

So True!

 

[whasupmd2]

So True!

Agree regarding the attending issue. Work is stressful enough without having an attending that's not a team player.

I would argue, however, that CT actually is pretty good, and several studies actually suggest, better than U/S for obstruction. Not good for stones, obviously. In terms of imaging modality, I'd go for CT vs. U/S. Of course, this is only in a pt that i'd be suspicious regarding biliary pancreatitis. O/w, totally with y'all (which is most cases), if it's etoh or clearly not obstruction, let the floor team pull the trigger regarding CT if pt doesn't improve, etc.

 

[positiveaob]

There was definitely some killer Mexican food going around that day. Had another guy with ACS after a couple of Tacos as well.

She denied alcohol use. PMH diabetes, and gastric bypass with chole. U/S was negative for retained stone.

Just curious if they did a CT from the floor, and if so what did it show? Because the patient you described didnt have a h/o etoh use and the U/S was neg.

 

[GeneralVeers]

Just curious if they did a CT from the floor, and if so what did it show? Because the patient you described didnt have a h/o etoh use and the U/S was neg.

I'll follow up on it tomorrow. The patient was just admitted this morning (around 5 AM). I'm sure a CT will be done, since our medicine service is notorious for mental masturbation.

Does anyone know if gastric bypass puts you at a greater risk of pancreatitis? This patient had one 2 years prior to the attack.

 

[ERMudPhud]

If its not busy I routinely ask the hospitalist if they want a scan before the patient goes up and the almost routinely say no.

 

[f_w]

I would argue, however, that CT actually is pretty good, and several studies actually suggest, better than U/S for obstruction.

It is great for obstruction. But it doesn't tell you whether the obstruction is caused by all the nasty edema in the head of the pancreas, a mass, or by a stone. If you have a bunch of stones in the gallbag and bil-dil, the leap to an impacted stone is not so far.

 

[southerndoc]

If it's not etoh (which accounts for 75% of acute pancreatitis), then what's the cause? 35% of acute pancreatitis in the US is 2/2 gallstones. (I know the numbers don't add to 100%). But if a person doesn't have a good story for etoh, what else is causing it? Some are "idiopathic" but I believe this is fairly low < 10%? Chalk it up to scorion bite?

Furthermore... Are you sure we can use labs to differentiate? "Laboratory tests may distinguish between these two disorders. The specificity for gallstone pancreatitis of a serum alanine aminotransaminase (ALT) concentration above 150 IU/L (approximately a threefold elevation) is 96%; the positive predictive value is 95%,[140] but sensitivity is only 48%.[165] The aspartate aminotransferase (AST) concentration is nearly as useful as ALT, but the total bilirubin and alkaline phosphatase concentrations are not helpful to distinguish gallstone pancreatitis from other etiologies. A serum lipase/amylase ratio greater than 2:0 has been proposed to discriminate alcoholic pancreatitis from other causes as it is 91% sensitive and 76% specific for detecting alcoholic pancreatitis.[166] The specificity of the ratio for alcoholic pancreatitis may be greater at higher ratios.[167] However, results of other studies[168] indicate that the ratio does not reliably distinguish among causes of pancreatitis.[169] Multiple tests as a score (serum and urine amylase, AST, ALT, alkaline phosphatase, lipase-to-amylase ratio, and erythrocyte mean corpuscular volume) differentiate between biliary and alcoholic pancreatitis with a sensitivity of 92% and a specificity of 94%.[170]" ( Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., p. 928)

I could be totally way off, but this has been my line of thinking...

This can usually be answered by figuring out if the patient has RUQ or epigastric tenderness, a positive Murphy sign, etc. Then again, I'm in a program that ultrasounds nearly everyone. If I don't have a clear reason for their pancreatitis, I throw the ultrasound probe on myself to see if there are any stones, gallbladder wall thickening, pericholecystic fluid, or CBD dilation.

 

[southerndoc]

Does anyone know if gastric bypass puts you at a greater risk of pancreatitis? This patient had one 2 years prior to the attack.

If it's a true bypass (i.e., a Roux-en-Y) and not just a stapling, then yes, there is an increased risk of pancreatitis.

 

[bartleby]

As far as someone with a first episode of pancreatitis without a clear precipitant (just emptied out a liquor cabinet singlehanded), they should be imaged to rule out what others have pointed out is the second most likely diagnosis (gallstones). U/s is fine for ruling out cholelithiasis and an obstructing common bile duct stone (+/- CBD dilatation). Ct also works in people whose habitus is not conducive to u/s.

Many (including me) would argue that in a person who is not presenting wth acute cholangitis or biliary obstruction either by clinically or in their labs can be imaged just as well on the floor as they can taking up a much-needed bed in the ED. If someone has a mild case of pancreatitis who you are thinking about discharging, I would image them prior to sending them home.

While gallstones show up poorly, if at all, on plain films, they are readily visualized on CT, as they are more than dense enough be visualized. CT provides a volumetric reconstruction which is far more sensitive than plain films. Think about all that non-dense soft tissue which shows up on a CT that you don't see on plain films.

Ultrasound is not unreasonable if there is clinical suspicion for a stone, but again, most stones are not radio opaque and CT would not be useful for this.

 

[Dimoak]

If it's a true bypass (i.e., a Roux-en-Y) and not just a stapling, then yes, there is an increased risk of pancreatitis.

I agree, from what I've read, gastric bypass can inhibit the body's ability to absorb Vitamin E, potentially leading to chronic pancreatitis. I don't know about acute cases, however, but it seems it could be reasonably related.

 

[docB]

Often these things are due to the culture of the institution. Frequently gross departures from EBM are culture based which is another way of saying that it's hard to break people of their bad habits. For example, in my area most pancreatitis is uninsured. Consequently the medicine docs are very interested in finding a surgical reason for it. They are also stuck if they admit the patient and then find stones as an inpt because they won't be able to get a surg consult due to the lack of insurance. So we get a lot of requests for CT scans prior to the admit. It sucks but it's just the way it goes around here.

 

[f_w]

While gallstones show up poorly, if at all, on plain films, they are readily visualized on CT, as they are more than dense enough be visualized. CT provides a volumetric reconstruction which is far more sensitive than plain films. Think about all that non-dense soft tissue which shows up on a CT that you don't see on plain films.

The density of gallstones can be anything from fat (cholesterol) to dense calcium and any value in between. Frequently they are isodense to bile and their presence can only be presumed based on secondary signs. What benefit do you derive from the volumetric features of CT ? Are you interested in liver volumes at 2 in the morning ?

 

[DrQuinn]

Often these things are due to the culture of the institution. Frequently gross departures from EBM are culture based which is another way of saying that it's hard to break people of their bad habits. For example, in my area most pancreatitis is uninsured. Consequently the medicine docs are very interested in finding a surgical reason for it. They are also stuck if they admit the patient and then find stones as an inpt because they won't be able to get a surg consult due to the lack of insurance. So we get a lot of requests for CT scans prior to the admit. It sucks but it's just the way it goes around here.

There's alcoholic pancreatitis in Vegas? I never woudla guessed....

Q

 

[GeneralVeers]

Update:

I checked the patient's labs this morning, and her lipase had dropped to ~900 (2/3 decrease). Her LFTs and LDH are still severely elevated, however. Her HgB also remained stable.

Also, no CT scan was done. Seems like even medicine didn't think it was necessary. With a negative ultrasound it would be hard to find a surgical reason for the pancreatitis. I'm still leaning towards the prior gastric surgery precipitating the event.

 

[eddieberetta]

While gallstones show up poorly, if at all, on plain films, they are readily visualized on CT, as they are more than dense enough be visualized. CT provides a volumetric reconstruction which is far more sensitive than plain films. Think about all that non-dense soft tissue which shows up on a CT that you don't see on plain films.

Plain films are useless. CT is not recommended to evaluate for gallstone pancreatitis.

US is the preferred modality for identifying biliary tract stones and biliary dilation. Many biliary stones are isodense to bile on CT, US does not use ionizing radiation, and does not require IV contrast (as a pancreatitis protocol CT would).

CT is the preferred modality for identifying complications of pancreatitis such as venous thrombosis, pseudoaneurysm, necrotizing change and to document size and location of pseudocysts/abscesses.

In the acute setting emergent imaging is rarely required. Non-emergent US the next day is reasonable to exclude gallstone pancreatitis. CT is recommended only in patients with prolonged course where complications are suspected.

 

[southerndoc]

Update:

I checked the patient's labs this morning, and her lipase had dropped to ~900 (2/3 decrease). Her LFTs and LDH are still severely elevated, however. Her HgB also remained stable.

Also, no CT scan was done. Seems like even medicine didn't think it was necessary. With a negative ultrasound it would be hard to find a surgical reason for the pancreatitis. I'm still leaning towards the prior gastric surgery precipitating the event.

Sounds like a ductal stone that has since passed if there was a negative RUQ ultrasound with good visualization of the CBD. Was an ERCP done?

 

[drsutter]

i don't think you can say always in medicine. I will scan/ultrasound patient if i suspect something else

 

[GeneralVeers]

Update on the patient:

Medicine told me today that they did a scan late last week. She ended up having necrotic bowel, which was apparently causing the pancreatitis. She is still in the ICU after surgery.

Interesting case, never would have thought of necrotic bowel as a cause.