Acute pancreatitis

Acute pancreatitis is a reversible inflammatory condition of the pancreas that varies in intensity from just oedema and adiponecrosis to widespread parenchymal necrosis. It occurs when something causes the digestive enzymes to be activated in the pancreas itself, which self-digest the organ. The disease has a relatively high mortality, around 5%.

Diagnosis and evaluation

The diagnosis of acute pancreatitis is made when two of the following three are present:

Acute, persistent, severe epigastric pain (often radiates to the back)
Elevation in serum lipase or amylase to > 3 the upper normal limit
Characteristic findings of acute pancreatitis on imaging

In case of jaundice, elevated bilirubin, elevated liver tests or cholestatic enzymes, gallstone or another obstruction of the biliary tree is the likely cause.

Imaging

Imaging may be performed with ultrasound, contrast CT, or MRI. It is not necessary to obtain imaging in uncomplicated cases where the first two criteria are fulfilled. Ultrasound is usually the first choice modality. If complications are suspected, CT is usually the better first choice.

On abdominal ultrasound, the pancreas appears enlarged, oedematous, and hypoechoic. There may be peripancreatic fluid and the margins of the pancreas are indistinct. Local complications (peripancreatic fluid collection/acute necrotic collection) are visible as anechoic masses, with internal echoes if they contain necrosis.

On contrast CT, the pancreas is focally or diffusely enlarged. In oedematous pancreatitis there is heterogenous contrast enhancement. In necrotic pancreatitis there is a lack of contrast enhancement. CT may also show a gallstone if present, as well as any complication. Like on ultrasonography, there may be peripancreatic fluid and the pancreatic margins may be indistinct.

Pancreatic cancer

Pancreatic cancer, of which pancreatic adenocarcinoma is the most common histological type, is a malignancy with one of the highest mortality rates. It’s aggressive, causes no early symptoms, and is difficult to treat. It mostly affects elderly men.

Diagnosis and evaluation

Abdominal ultrasound is often the first investigation used in patients presenting with jaundice or epigastric pain. US is highly sensitive for pancreatic masses, and will show an echopoor lesion.

Contrast CT or MRI is required for proper staging and to determine whether it’s resectable or not. Pancreatic cancer is hypodense on CT. It will also show any distant metastases. CT of the thoracic cavity is also indicated to look for metastases.

Splenic rupture

Rupture of the spleen is a potentially life-threatening condition. The spleen has a rich blood supply and rupture may therefore cause severe haemorrhage, haemorrhagic shock, or death.

Diagnosis and evaluation

Patients who have experienced major trauma are usually examined with ultrasound as part of eFAST. If positive, the patient will be taken to surgery. CT may also be used to show the injury. On ultrasonography, blood is hypodense.