Which One Is More Important For The Diagnosis Of Acute Pancreatitis? Blood Tests Or Imaging?
Authors: Dikmetaş Cesareddin , Cander Başar , Bulut Bensu , Atik Dilek , Köksal Ayla , Güven Ramazan 
Published: January 2020

Introduction:Acute pancreatitis (AP); It is defined as a reversible
inflammatory process in which the tissue of the pancreas is affected at various
degrees, accompanied by local tissue or organ systems. It is characterized by a
sudden onset of upper abdominal pain and associated vomiting, fever,
tachycardia, leukocytosis, serum amylase or lipase increase of 3 times normal.
Acute pancreatitis has a spectrum of varying severity of disease ranging from
self-limiting mild disease that is present with abdominal pain to severe fluid
loss, metabolic imbalances, hypotension, sepsis and severe disease that may
lead to death. Mortality rate is 6-23% for acute pancreatitis in different
article.  We report the case with a
diagnosis of acute pancreatitis, who have abdominal pain; but no serum amylase
and lipase elevation. We diagnosed edematous pancreatitis image in the computed
tomography.Case:A 51-year-old male admitted to the emergency department with
sever abdominal pain. He had diabetes mellitus in his medical history; but
drugs used for DM could not be learned due to communicative reasons.On
his presentation to our ED, he was conscious, oriented and cooperative. His
vital signs were as follows: his blood pressure was 130/90 mm Hg, his pulse
rate was 100 beats per min, his respiratory rate was 20 per min, his body
temperature was 36.5°C, and his oxygen saturation was 100% while breathing room
air. He has epigastric tenderness and abdominal guarding on palpation; but no
rebound tenderness or rigitidy was noted on palpation. No
pathological findings were found in the respiratory system, cardiovascular
system and neurological examination. The blood test measurements were WBC:
5.50 10³/uL, Hb:13.2 g/dl, Plt:160.000 10³/uL, Glucose: 444  mg/dl, urea:30.0 mg/dl, serum creatinine:
0.74 mg/dL, AST: 13U/L,,ALT: 15 U/L, GGT:33 U/L, ALP: 107 U/L, Amylase: 28:
U/L, Lipase: 58.8 U/L, CRP: 104.05 mg/L, cardiac  troponine: 0.006 ng/ml. . ECG is normal beat. In abdominal ultrasonography of
the patient; pancreas and midline structures could not be evaluated due to gas.
No ultrasonographic pathology was detected
in other intraabdominal organs and intraabdominal fluid was not seen in the abdominal ultrasonography. Contrast-enhanced computed
tomography (CT) of the abdomen was performed because of persistant, severe
abdominal pain and it revealed peripancreatic diffuse inflammatory densities
(edematous pancreatitis), shown in image 1. The patient was consulted with the
internal medicine clinic.  Internal
Diseases Clinic suggested hydration with intravenous Serum Physiological and
then re-consultation with blood tests. We detected that  WBC: 5.75 10³/uL, Hb:13 g/dl, Plt:150.000
10³/uL, Glukose: 248  mg/dl, urea:18.0
mg/dl, serum creatinine:
0.6 mg/dL, AST: 12U/L,,ALT: 14 U/L, GGT:31 U/L, ALP: 96 U/L, Amylase: 20: U/L,
Lipase: 38.1 U/L, CRP: 120.56 mg/L
cardiac  troponine: 0.006 ng/ml in
blood test after hydration. The patient was re-consulted with
the internal medicine clinic. Internal
Diseases Clinic suggested hospitalization with the diagnosis of edematous
pancreatitis to him.Discussion: Patients with acute pancreatitis are admitted to the emergency department with abdominal pain, nausea and vomiting. Generally, the amylase and lipase elevation are seen in the blood tests and then abdominal computed tomography is performed for further examination and follow-up. When amylase and lipase are detected in normal values, pancreatitis is not thought; but Two of the three criteria for acute pancreatitis must be determined. These criteria are abdominal pain, amylase-lipase elevation and view compatible with pancreatitis in imaging examinations. In this context, a rare diagnosis of pancreatitis can be made without amylase and  lipase elevation. In our case, the patient was diagnosed with pancreatitis because of having abdominal pain and imaging consistent with pancreatitis without elevated amylase and lypase.Conclusion:

As in this case, blood tests are not sufficient for diagnosis of pancreatitis and if there is clinical necessity, the emergency physician should consider imaging examinations for diagnosis of pancreatitis.