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Diagnostic Criteria for Acute Pancreatitis

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Diagnostic Criteria for Acute Pancreatitis J Hepatobiliary Pancreat Surg (2006) 13:25–32 DOI 10.1007/s00534-005-1048-2 JPN Guidelines for the management of acute pancreatitis: diagnostic criteria for acute pancreatitis Masaru Koizumi1, Tadahiro Takada2,*, Yoshifumi Kawarada3, Koichi Hirata4, Toshihiko Mayumi5, Masahiro Yoshida2, Miho Sekimoto6, Masahiko Hirota7, Yasutoshi Kimura4, Kazunori Takeda8, Shuji Isaji9, Makoto Otsuki10,**, and Seiki Matsuno11,*** 1 Ohara Medical Center Hospital, 33 Kamata aza Nakae, Fukushima 960-0195, Japan 2 Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan 3 Ueno Municipal Hospital, Mie, Japan 4 First Department of Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan 5 Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan 6 Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan 7 Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Science, Kumamoto, Japan 8 Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan 9 Department of Hepatobiliary Pancreatic Surgery and Breast Surgery, Mie University Graduate School of Medicine, Mie, Japan 10 Department of Gastroenterology and Metabolism, University of Occupational and Environmental Health, Japan, School of Medicine, Kitakyushu, Japan 11 Division of Gastroenterological Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan Abstract — Ultrasonography (US) is also one of the procedures that The currently used diagnostic criteria for acute pancreatitis in should be performed in all patients with suspected acute Japan are presentation with at least two of the following three pancreatitis. manifestations: (1) acute abdominal pain and tenderness in — Magnetic resonance imaging (MRI) is one of the most the upper abdomen; (2) elevated levels of pancreatic enzyme important imaging procedures for diagnosing acute pan- in the blood, urine, or ascitic fluid; and (3) abnormal imaging creatitis and its intraperitoneal complications. findings in the pancreas associated with acute pancreatitis. — Computed tomography (CT) is also one of the most im- When a diagnosis is made on this basis, other pancreatic dis- portant imaging procedures for diagnosing acute pancre- eases and acute abdomen can be ruled out. The purpose of atitis and its intraabdominal complications. CT should be this article is to review the conventional criteria and, in par- performed when a diagnosis of acute pancreatitis cannot ticular, the various methods of diagnosis based on pancreatic be established on the basis of the clinical findings, results enzyme values, with the aim of improving the quality of diag- of blood and urine tests, or US, or when the etiology of the nosis of acute pancreatitis and formulating common interna- pancreatitis is unknown. tionally agreed criteria. The review considers the following — When acute pancreatitis is suspected, chest and abdominal recommendations: X-ray examinations should be performed to determine whether any abnormal findings caused by acute pancreati- — Better even than the total blood amylase level, the blood tis are present. lipase level is the best pancreatic enzyme for the diagnosis — Because the etiology of acute pancreatitis can have a cru- of acute pancreatitis and its differentiation from other cial influence on both the treatment policy and severity diseases. assessment, it should be evaluated promptly and accu- —A pivotal factor in the diagnosis of acute pancreatitis is rately. It is particularly important to differentiate between identifying an increase in pancreatic enzymes in the blood. gallstone-induced acute pancreatitis, which requires treat- ment of the biliary system, and alcohol-induced acute pan- creatitis, which requires a different form of treatment. Offprint requests to: M. Koizumi Key words Acute pancreatitis · Criteria for diagnosing acute *President, Japanese Society of Emergency Abdominal pancreatitis · Laboratory diagnosis · Computed tomography Medicine; President, Japanese Society of Hepato- Biliary-Pancreatic Surgery; President, Asian-Pacific Hepato-Pancreato-Biliary Association **Chairman, Intractable Pancreatic Disease Investiga- tion and Research Group of the Japanese Ministry of Health, Labour, and Welfare ***President, Japan Pancreas Society 26 M. Koizumi et al.: Diagnostic criteria for acute pancreatitis Clinical questions fluid; and (3) the presence of abnormal imaging findings in the pancreas that are associated with acute pancreati- CQ1. Are clinical symptoms and signs useful in diag- tis. When a diagnosis is made on this basis, other pan- nosing acute pancreatitis? creatic diseases and acute abdomen can be ruled out. CQ2. Which pancreatic enzymes should be mea- In Japan, many surgeons and physicians specializing sured to diagnose acute pancreatitis? in digestive system diseases and emergency medicine CQ3. What is the optimal examination for are familiar with abdominal ultrasonography (US) and diagnosing acute pancreatitis? perform it routinely. Magnetic resonance imaging CQ4. Is US effective in diagnosing acute (MRI) is less popular than X-rays or computed tomo- pancreatitis? graphy (CT) scanning and is not a routine procedure in CQ5. Is MRI effective in diagnosing acute emergency examinations for abdominal diseases. pancreatitis? The purpose of this article is to review the conven- CQ6. Is CT effective in diagnosing acute tional criteria and, in particular, the various methods of pancreatitis? diagnosis based on pancreatic enzyme values, with the CQ7. Are plain X-ray examinations useful in aim of improving the quality of the diagnosis of acute diagnosing acute pancreatitis? pancreatitis and of formulating common, internation- CQ8. Is the etiology of a specific case of acute ally agreed upon criteria. pancreatitis necessary for its diagnosis? Diagnostic criteria Clinical symptoms and signs Introduction Clinical question (CQ) 1. Are clinical symptoms and The diagnosis of acute pancreatitis has been based on signs useful in diagnosing acute pancreatitis? the clinical manifestations and results of blood- It is essential to interview all patients (including those biochemistry tests, but there are few common criteria with consciousness disorders or who are in a state of that strictly specify the parameters to be used in shock), take their medical histories, and perform a diagnosis. physical examination (Recommendation A) The criteria currently used to diagnose acute pancre- atitis in Japan were originally developed by the Re- Abdominal pain, pain radiating to the back, anorexia, search Group for Intractable Diseases and Refractory fever, nausea and vomiting, and decreased bowel sounds Pancreatic Diseases, which was sponsored by the are frequent manifestations of acute pancreatitis (Tables Japanese Ministry of Health and Welfare (now the 1 and 2) (Level 4).1,2 However, these features are not Japanese Ministry of Health, Labour, and Welfare). specific to acute pancreatitis, and when a patient pre- The Research Group states that acute pancreatitis sents with these manifestations, acute pancreatitis must should be diagnosed if the patient presents with at least be differentiated from other acute abdominal diseases. two of the following three criteria: (1) acute abdominal Acute pancreatitis accounts for 2% to 3% of all acute pain and tenderness in the upper abdomen; (2) elevated abdominal diseases (Level 2b, unknown)3,4 and in a very levels of pancreatic enzymes in blood, urine, or ascitic few patients there is no abdominal pain (Level 2b).5 Table 1. Symptoms and signs of acute pancreatitis Symptoms and signsa (%) Symptoms and signsb (%) Abdominal pain 90 Abdominal pain 95 Abdominal muscular rigidity 80 Pain radiating to the back 50 Fever 80 Anorexia 85 Nausea, vomiting 70 Nausea, vomiting 75 Metorism 60 Decreased bowel sounds 60 Ileus, subileus 55 Fever 60 Jaundice 30 Abdominal guarding 50 Shock 20 Shock 15 Neurological symptoms 10 Jaundice 15 Hematoemesis 10 a Adapted from Malfertheiner P. and Kemmer T.P.1 b Adapted from Corsetti and Arvan2 M. Koizumi et al.: Diagnostic criteria for acute pancreatitis 27 Acute pancreatitis is sometimes manifested by tis are 85% to 100% and 84.7% to 99.0% (Level 2a),8 discoloration of the skin, such as Grey Turner’s sign (on respectively. The blood lipase value is more sensitive the lateral abdominal wall), Cullen’s sign (around the than blood amylase (Levels 2b-4)11–13 and provides diag- navel), and Fox’s sign (over the lower portion of the nostic capability similar to that of blood P-amylase inguinal ligament). However, because these signs ap- (Level 2b).13 Blood lipase is considered a valuable diag- pear in only 3% (Level 2b)6 of patients, and because nostic tool, because abnormally high values persist for they are also observed in patients with other diseases longer than abnormal blood amylase levels (Level 2b),14 (Level 4)7 and are often seen 48 to 72h after the onset of and it is more sensitive in terms of detecting the pres- pancreatitis, their diagnostic significance is low. ence of acute alcohol-induced pancreatitis. The com- bined use of blood amylase and blood lipase levels (Level 2a)8 does not facilitate the diagnosis of acute Blood and urine tests pancreatitis. The above findings lead to the conclusion that the Blood lipase blood lipase level is an important indicator in the diag- nosis of acute pancreatitis and that the measurement of CQ2. Which pancreatic enzymes should be mea-
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