Prevalence of normal serum amylase levels in patients with acute alcoholic pancreatitis

Serum TLR9 and NF-κB Biochemical Markers in Patients with Acute Pancreatitis on Admission

Aim

The aim of this study was to investigate the serum TLR9 and NF-κB levels in patients for the diagnosis and prognostication of AP in the emergency department.

Methods

In the current study, we looked at the TLR9 and NF-κB levels in patients for the diagnosis and prognostication of AP in the emergency department.

Results

Of the patients with acute pancreatitis, 22 (49%) were male and 23 (51%) were female. The mean age of the patient group was 62 years, with a range of 25-95 years. The control group consisted of 19 (43.1%) male and 25 (56.9%) female patients. The serum TLR9 and NF-κB levels in patients for the diagnosis and prognostication of AP in the emergency department. p < 0.001 and 8.04 ± 1.76 vs. 4.76 ± 1.13; p < 0.001 and 8.04 ± 1.76 vs. 4.76 ± 1.13; κB levels in patients for the diagnosis and prognostication of AP in the emergency department. p < 0.001 and 8.04 ± 1.76 vs. 4.76 ± 1.13; κB levels in patients for the diagnosis and prognostication of AP in the emergency department. p < 0.001 and 8.04 ± 1.76 vs. 4.76 ± 1.13.

Conclusion

We demonstrated that the TLR9 and NF-κB pathway is activated in acute pancreatitis and increases the inflammatory process. This may help to further understand the pathogenesis of disorder, diagnosis, and clinical severity. We proposed that blockage of these inflammatory pathways may play a role in the prevention of the disease progression and development of inflammatory complications.κB levels in patients for the diagnosis and prognostication of AP in the emergency department.

Superfluous Amylase/Lipase Testing at a University-Affiliated Teaching Hospital: A Retrospective Review

Background: The combination of amylase and lipase tests for diagnosing acute pancreatitis is not better than a lipase test alone; however, both tests are commonly ordered simultaneously. Further, although no data indicate usefulness of monitoring changes in elevated amylase and lipase levels, the tests are often ordered multiple times during the same clinical encounter. Methods: We retrospectively reviewed all amylase and lipase tests performed at a university-affiliated teaching hospital during a 6-month period. We considered amylase and lipase results diagnostic if they were >3 times the upper limit of normal and borderline if they were ≤3 times the upper limit of normal. During a single clinical encounter, we considered amylase tests superfluous if ordered simultaneously with lipase tests or repeated after diagnostic results, questionably superfluous if repeated alone, and nonsuperfluous otherwise. Lipase tests were considered superfluous if repeated after diagnostic results, questionably superfluous if repeated after nondiagnostic results, and nonsuperfluous otherwise. Results: In this study, 3,502 patients had 8,801 tests (4,926 lipase, 3,875 amylase), 4% of which were diagnostic and 10% borderline. Of the 8,801 tests, 45% were superfluous and 9% were questionably superfluous. Nonsuperfluous testing was less frequent (P<0.0001) in the intensive care/stepdown units (22% of 748 tests) than in the emergency department (54% of 6,000 tests) or other settings (31% of 2,053 tests). Among 3,545 simultaneous amylase/lipase tests with nondiagnostic lipase results, 0.6% amylase results were diagnostic. Of the 190 lipase tests repeated after nondiagnostic lipase results, 12% were diagnostic. Conclusion: Superfluous amylase/lipase testing in one teaching hospital is substantial, suggesting significant potential for reducing healthcare costs without compromising the quality of care when evaluating patients for acute pancreatitis.

Role of Biomarkers in Diagnosis and Prognostic Evaluation of Acute Pancreatitis

Acute pancreatitis is a potentially life threatening disease. The spectrum of severity of the illness ranges from mild self-limiting disease to a highly fatal severe necrotizing pancreatitis. Despite intensive research and improved patient care, overall mortality still remains high, reaching up to 30–40% in cases with infected pancreatic necrosis. Although little is known about the exact pathogenesis, it has been widely accepted that premature activation of digestive enzymes within the pancreatic acinar cell is the trigger that leads to autodigestion of pancreatic tissue which is followed by infiltration and activation of leukocytes. Extensive research has been done over the past few decades regarding their role in diagnosis and prognostic evaluation of severe acute pancreatitis. Although many standalone biochemical markers have been studied for early assessment of severity, C-reactive protein still remains the most frequently used along with Interleukin-6. In this review we have discussed briefly the pathogenesis and the role of different biochemical markers in the diagnosis and severity evaluation in acute pancreatitis.

Acute pancreatitis

Acute pancreatitis (AP) is an important cause of morbidity and mortality worldwide and the annual incidence appears to be increasing. It presents as a mild self-limiting illness in 80% of patients. However, one-fifth of these develop a severe complicated life-threatening disease requiring intensive and prolonged therapeutic intervention. Alcohol and gallstone disease remain the commonest causes of AP but metabolic abnormalities, obesity and genetic susceptibility are thought be increasingly important aetiological factors. The prompt diagnosis of AP and stratification of disease severity is essential in directing rapid delivery of appropriate therapeutic measures. In this review, the range of diagnostic and prognostic assays, severity scoring systems and radiological investigations used in current clinical practice are described, highlighting their strengths and weaknesses. Increased understanding of the complex pathophysiology of AP has generated an array of new potential diagnostic assays and these are discussed. The multidisciplinary approach to management of severe pancreatitis is outlined, including areas of controversy and novel treatments.

Usefulness of lipase / amylase ratio in acute pancreatitis in South Indian population

This retrospective study was conducted to assess the serum lipase / amylase ratio in acute pancreatitis for South Indian population attending the clinics of Gastroenterology and Emergency medicine in the last five years. One thousand one hundred and thirty two patients (768 males and 364 females) with acute pancreatitis (AP) were selected for the study. The diagnosis of AP was based on clinical evaluation, Computed Tomography (CT) findings and biochemical parameters such as serum lipase and amylase. Based on the etiology, the groups were divided into alcoholic, biliary and miscellaneous AP. Based on CT findings, groups were divided into mild, moderate and severe AP. Serum lipase, amylase and lipase / amylase ratio were calculated and statistically analyzed. Serum lipase levels in alcoholic group (3226.3 ± 1384.7) were significantly lower in comparison to biliary (6064.5 ± 1640.8) group though the levels were not significantly different from miscellaneous group (2132.3 ± 1210). Serum amylase values were significantly lower in alcoholic group (923.4 ± 557.5) in comparison to biliary (1736.2 ± 390.7) and there was significant difference between alcoholic and miscellaneous group (535.8 ± 477.6). The serum lipase / amylase ratio > 4 occurred in alcoholic group than with biliary and miscellaneous group. The sensitivity and specificity to predict alcoholic AP with lipase / amylase ratio at >4.0 was 84 % and 59 % respectively. In conclusion the serum lipase to amylase ratio greater than 3.0 could be used to differentiate but keeping the cut off at 4.0 would be of higher sensitivity without much change in specificity. The serum lipase to amylase ratio with a cut off of 3.0 or greater is not useful to differentiate the severe AP from milder AP. Hence, serum amylase and lipase are important for evaluation of pancreatitis though it is not a gold standard for the diagnosis or assessment of severity of acute pancreatitis.

The role of routine assays of serum amylase and lipase for the diagnosis of acute abdominal pain

INTRODUCTION

We aimed to evaluate the role of routine measurements of serum amylase and lipase in the diagnosis of acute abdominal pain.

PATIENTS AND METHODS

We identified all patients who had serum amylase and lipase assays over a 62-day period at a single university teaching hospital and reviewed their case notes.

RESULTS

We excluded 58 of the 1598 patients on grounds of ineligibility (< 18 years of age and those transferred from other hospitals). A complete data set was obtained for 1520 (98.7%) of the remaining 1540 patients. Only 9.1% of requests were based on a clinical suspicion of acute pancreatitis. Of the 44 (2.9%) patients who had acute pancreatitis, only 28 (63.6%) had an associated rise in serum amylase and/or lipase 3 times above the maximum reference range, the remainder being diagnosed radiologically. At this cut-off range, the sensitivity and specificity for serum amylase were 50% and 99%, and those for serum lipase 64% and 97%, respectively.

CONCLUSIONS

Routine measurements of serum amylase and lipase are unhelpful in the diagnosis of acute abdominal pain unless there is clinical suspicion of acute pancreatitis. In these patients, assay of lipase alone is preferable to assay of amylase alone or both enzymes.

Biochemical markers of acute pancreatitis

Serum amylase remains the most commonly used biochemical marker for the diagnosis of acute pancreatitis, but its sensitivity can be reduced by late presentation, hypertriglyceridaemia, and chronic alcoholism. Urinary trypsinogen-2 is convenient, of comparable diagnostic accuracy, and provides greater (99%) negative predictive value. Early prediction of the severity of acute pancreatitis can be made by well validated scoring systems at 48 hours, but the novel serum markers procalcitonin and interleukin 6 allow earlier prediction (12 to 24 hours after admission). Serum alanine transaminase >150 IU/l and jaundice suggest a gallstone aetiology, requiring endoscopic retrograde cholangiopancreatography. For obscure aetiologies, serum calcium and triglycerides should be measured. Genetic polymorphisms may play an important role in "idiopathic" acute recurrent pancreatitis.

[Hypertriglyceridemic acute pancreatitis. Is its clinical course different from lithiasic acute pancreatitis?]

BACKGROUND AND OBJECTIVE

Although hypertriglyceridemia is an accepted cause of acute pancreatitis, its clinical course is not well defined. What is more, lipemic serum may interfere with an accurate pancreatic enzyme measurement and may hinder the diagnosis of acute pancreatitis. The objective was to analyze the clinical performance of hypertriglyceridemic acute pancreatitis and the diagnosis value of the serum measurement of pancreatic enzymes.

PATIENTS AND METHOD

31 demographic, clinical, analytical and radiological data of 19 hypertriglyceridemic acute pancreatitis were retrospectively analyzed and their results were compared with data of 19 lithiasic acute pancreatitis without hypertriglyceridemia. Diagnosis of acute pancreatitis was based on clinical, radiological and/or laparotomical findings. Serum levels of triglycerides higher than 1,000 mg/dl were considered the cause of acute pancreatitis when other causes were excluded. Acute pancreatitis was considered lithiasic when gallstones were identified by ultrasonography, serum levels of triglycerides were lower than 200 mg/dl and there was no history of alcohol consumption.

RESULTS

Compared with lithiasic acute pancreatitis, hypertriglyceridemic acute pancreatitis showed more personal and family hypertriglyceridemia (9 vs 0), more previous episodes of pancreatitis (13 vs 2), pancreatitis was more severe (13 vs 5) and had more complications (29 vs 5). There was no mortality in either group. The serum levels of amylase and lipase supported the diagnosis in 26% and 58% of patients with hypertriglyceridemic acute pancreatitis compared with 58% and 79% of patients with lithiasic acute pancreatitis, respectively. Hospital stay was longer in hypertriglyceridemic than in lithiasic acute pancreatitis (24 [45] vs 7.6 [3.1] days; p = NS). Demographic and analytical factors which could permit to predict the severity of acute pancreatitis could not be identified.

CONCLUSIONS

Hypertriglyceridemic acute pancreatitis is relapsing and its clinical course is more severe than lithiasic acute pancreatitis. The measurement of amylase and lipase levels is less useful in the diagnosis of hypertriglyceridemic than in lithiasic acute pancreatitis.

Determination of plasma glycoprotein 2 levels in patients with pancreatic disease

CONTEXT

Blood tests possessing higher diagnostic accuracy are needed for all the major pancreatic diseases. Glycoprotein 2 (GP2) is a protein that is specifically expressed by the pancreatic acinar cell and that has previously shown promise as a diagnostic marker in animal models of acute pancreatitis.

OBJECTIVE

This study describes the development of an assay for GP2, followed by the determination of plasma GP2 levels in patients with acute pancreatitis, chronic pancreatitis, and pancreatic cancer.

DESIGN

Rabbit polyclonal antisera and mouse monoclonal antibodies were generated against human GP2 and used to develop an enzyme-linked immunosorbent assay. The assay was tested in patients with an admitting diagnosis of pancreatic disease at 2 tertiary care facilities. The diagnosis of acute or chronic pancreatitis and pancreatic cancer was determined using previously established criteria that incorporated symptoms, radiology, pathology, and serology. Plasma GP2 levels were determined in 31 patients with acute pancreatitis, 16 patients with chronic pancreatitis, 36 patients with pancreatic cancer, and 143 control subjects without pancreatic disease. Amylase and lipase levels were also determined in patients with acute pancreatitis.

RESULTS

The GP2 assay's sensitivity values were 0.94 for acute pancreatitis, 0.81 for chronic pancreatitis, and 0.58 for pancreatic cancer, which were greater than the 0.71 for acute pancreatitis and 0.43 for chronic pancreatitis (P =.02) observed for amylase. The lipase assay sensitivity for acute pancreatitis was 0.66. The accuracy of the GP2 assay was greater than that of the amylase or lipase assays for acute pancreatitis (GP2 vs lipase, P =.004; GP2 vs amylase, P =.003) when analyzed using receiver operator characteristic curves. When daily serial blood samples were obtained for 13 patients with acute pancreatitis, GP2 levels remained abnormally elevated for at least 1 day longer than the amylase or lipase levels.

CONCLUSION

The GP2 assay is a useful new marker for acute and chronic pancreatitis.

[Validity of serum amylase and lipase in the differential diagnosis between acute/acutized chronic pancreatitis and other causes of acute abdominal pain]

BACKGROUND

Raised serum amylase and lipase levels are observed in several abdominal diseases.

AIM

Assessing the validity of serum amylase and lipase for the differential diagnosis between acute pancreatitis/acutized chronic pancreatitis, biliary tract disease, perforated gastroduodenal ulcer and acute appendicitis. PATIENTS E METHODS: Prospective study including 134 individuals: 38 with acute pancreatitis/acutized chronic pancreatitis, 35 with biliary tract disease, 17 with perforated gastroduodenal ulcer and 44 with acute appendicitis, mean age (standard deviation) of 42.4 +/- 17.7, 46.7 +/- 18.3, 47.8 +/- 12 and 33.7 +/- 17.8 years, respectively. Serum amylase and lipase were determined at admission to the emergency department.

RESULTS

For the diagnosis of acute pancreatitis/acutized chronic pancreatitis, when the cutt-off levels of serum amylase were set at the upper normal range level or up to 5-fold as high, the sensitivity decreased from 92% to 74%, the specificity increased from 85% to 99%, the positive predictive value increased from 71% to 97%, and the negative predictive value decreased from 96% to 91%. For serum lipase levels similar figures were obtained for sensitivity and negative predictive value, but the specificity and positive predictive value were lower. When the combination of raised serum amylase or lipase were analyzed, a minor increase was observed in sensitivity and negative predictive value.

CONCLUSIONS

For the diagnosis of acute pancreatitis/acutized chronic pancreatitis: 1) the best cut-off level for both tests was 2-times the upper normal range; 2) the sensitivities of serum amylase and lipase were similar; 3) the specificity and positive predictive value of serum amylase were slightly higher than observed for serum lipase; 4) the sensitivity but not the specificity increased when at least one between amylase or lipase was raised.

Alcohol-induced pancreatic injury

Alcoholic pancreatitis is a major complication of alcohol abuse. Until recently, it was generally accepted that alcoholic pancreatitis was a chronic disease from the outset. However, evidence is now emerging in support of the 'necrosis-fibrosis' hypothesis that alcoholic pancreatitis begins as an acute process and that repeated episodes of acute injury lead to the changes of chronic pancreatitis (acinar atrophy and fibrosis) resulting in exocrine and endocrine dysfunction. The treatment of acute pancreatitis follows the regimen of bed rest, nasogastric suction, analgesia and intravenous support. The role of additional therapeutic measures such as prophylactic antibiotics, antioxidants and enteral nutrition in severe cases has not yet been precisely defined. The treatment of chronic pancreatitis involves attention to its three cardinal features: pain, maldigestion and diabetes. With respect to the pathogenesis of alcoholic pancreatitis, the focus of research over the past 30 years has shifted from the sphincter of Oddi and ductular abnormalities to the acinar cell itself. It has now been established that the acinar cell is capable of metabolizing alcohol and that direct toxic effects of alcohol and/or its metabolites on acinar cells may predispose the gland to injury in the presence of an appropriate trigger factor. A significant recent development relates to the characterization of pancreatic stellate cells, increasingly implicated in alcoholic pancreatic fibrosis. This chapter summarizes the natural history, clinical features, current trends in treatment as well as recent advances in our understanding of the pathogenesis of alcoholic pancreatitis.

Pancreatitis

In the past decade, our understanding of the genetic basis, pathogenesis, and natural history of pancreatitis has grown strikingly. In severe acute pancreatitis, intensive medical support and non-surgical intervention for complications keeps patients alive; surgical drainage (necrosectomy) is reserved for patients with infected necrosis for whom supportive measures have failed. Enteral feeding has largely replaced the parenteral route; controversy remains with respect to use of prophylactic antibiotics. Although gene therapy for chronic pancreatitis is years away, our understanding of the roles of gene mutations in hereditary and sporadic pancreatitis offers tantalising clues about the disorder's pathogenesis. The division between acute and chronic pancreatitis has always been blurred: now, genetics of the disorder suggest a continuous range of disease rather than two separate entities. With recognition of pancreatic intraepithelial neoplasia, we see that chronic pancreatitis is a premalignant disorder in some patients. Magnetic resonance cholangiopancreatography and endoscopic ultrasound are destined to replace endoscopic retrograde cholangiopancreatography for many diagnostic indications in pancreatic disease.

A critical evaluation of laboratory tests in acute pancreatitis

An ideal laboratory test in the evaluation of a patient with acute pancreatitis (AP) should, in addition to accurately establishing the diagnosis of AP, provide early assessment of its severity and identify the etiology. None of the tests available today meet all these criteria, and presently there is no biochemical test that can be considered the "gold standard" for the diagnosis and assessment of severity of AP. In the diagnosis of AP, serum amylase and lipase remain important tests. Advantages of amylase estimation are its technical simplicity, easy availability, and high sensitivity. However, its greatest disadvantage is its low specificity. A normal amylase would usually exclude the diagnosis of AP, with the exception of AP secondary to hyperlipidemia, acute exacerbation of chronic pancreatitis, and when the estimation of amylase is delayed in the course of the disease. The major advantage of lipase is an increased sensitivity in acute alcoholic pancreatitis and in patients who initially present to the emergency room days after the onset of the disease, as lipase remains elevated longer than amylase. Although once considered to be specific for AP, nonspecific elevations of lipase have been reported in almost as many disorders as amylase, thus decreasing its specificity. Simultaneous estimation of amylase and lipase does not improve the accuracy. Other enzymes for the diagnosis of AP--pancreatic isoamylase, immunoreactive trypsin, and elastase--are more cumbersome and expensive and have no clear role in the diagnosis of AP. No enzyme assay has a predictive role in determining the severity or etiology of AP. Once the diagnosis of AP is established, daily measurements of enzymes have no value in assessing the clinical progress of the patient or ultimate prognosis and should be discouraged. A host of new serological and urinary markers have been investigated in the last few years. Their main use is in predicting the severity of AP. At present, serum C-reactive protein at 48 h is the best available laboratory marker of severity. Urinary trypsinogen activation peptides within 12-24 h of onset of AP are able to predict the severity but are not widely available. Serum interleukins 6 and 8 seem promising but remain experimental.

Early prediction of acute pancreatitis: prospective study comparing computed tomography scans, Ranson, Glascow, Acute Physiology and Chronic Health Evaluation II scores, and various serum markers

The aim of this study was to assess the predictability of the outcome of acute pancreatitis using the Ranson, Glascow, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores, the computed tomography (CT) scan, and several serum markers. Altogether, 137 consecutive patients with acute pancreatitis confirmed by CT scan were prospectively included. Blood samples were obtained daily for 6 days. The predictive value of each parameter was studied by univariate and multivariate analyses comparing mild and severe pancreatitis. A total of 111 attacks were graded as mild (81%) and 26 as severe (19%). Ranson (p = 0.3) and APACHE II (p = 0.049) scores appeared insufficiently predictive in the univariate analysis. Pancreatic imaging by CT scan was insufficiently predictive (p > 0.05), whereas the presence of extrapancreatic fluid collections was more indicative of outcome (p <0.05). With the univariate analysis, the four most reliable serum markers were pancreatic amylase (p <0.001), neutrophil elastase (p <0.05), albumin (p <0.002), and C-reactive protein (p <0.001). Results became homogeneous when the CT results were added; serum albumin plus extrapancreatic fluid collections (negative predictive value 92%-96% and positive predictive value 67%-100%) comprised the best indicator of severity. None of the parameters tested achieved sufficient predictability when used alone. Serum albumin plus extrapancreatic fluid collections comprise the best indicator of severity at the time of admission.

Laboratory diagnostic tests in acute pancreatitis

The diagnosis of acute pancreatitis depends on a combination of clinical assessment and laboratory testing. Although the serum amylase is the cornerstone laboratory test used in establishing the diagnosis of acute pancreatitis, there are limitations in the sensitivity and specificity that may be important for the clinician to recognize. The serum lipase level may be especially useful in patients with alcohol-induced acute pancreatitis. A new urinary test strip that uses trypsinogen-2 may have a role in establishing the diagnosis of acute pancreatitis. In addition, several new laboratory tests and new interpretations of old laboratory tests may assist in establishing the etiology and severity of acute pancreatitis. This review summarizes important aspects of standard laboratory tests and novel laboratory approaches in establishing the diagnosis, etiology, and severity of acute pancreatitis.

The Ratio of Trypsin-2-α1-Antitrypsin to Trypsinogen-1 Discriminates Biliary and Alcohol-induced Acute Pancreatitis

Background: Rapid determination of the etiology of acute pancreatitis (AP) enables institution of appropriate treatment. We evaluated the ability of trypsinogen-1, trypsinogen-2, trypsin-1-α1-antitrypsin (AAT), and trypsin-2-AAT in serum to identify the etiology of AP.

Methods: The study consisted of 67 consecutive patients with AP admitted to Helsinki University Central Hospital. Forty-two had alcohol-induced AP, 16 had biliary AP, and 9 had unexplained etiology. Serum samples were drawn within 12 h after admission. Trypsinogen-1, trypsinogen-2, trypsin-1-AAT, and trypsin-2-AAT were determined by time-resolved immunofluorometric assays. Logistic regression was used to estimate the ability of the serum analytes to discriminate between alcohol-induced and biliary AP. The validity of the tests was evaluated by ROC curve analysis.

Results: Patients with alcohol-induced AP had higher median values of trypsin-1-AAT (P = 0.065), trypsinogen-2 (P = 0.034), and trypsin-2-AAT (P &lt;0.001) than those with biliary AP, who had higher values of amylase (P = 0.002), lipase (P = 0.012), and alanine aminotransferase (P = 0.036). The ratios of trypsin-2-AAT to trypsinogen-1, lipase, or amylase efficiently discriminated between biliary and alcohol-induced AP (areas under ROC curves, 0.92–0.96).

Conclusions: Trypsinogen-2 and trypsin-2-AAT are markedly increased in AP of all etiologies, whereas trypsinogen-1 is increased preferentially in biliary AP. The trypsin-2-AAT/trypsinogen-1 ratio is a promising new marker for discrimination between biliary and alcohol-induced AP.

Amylase and lipase in the emergency department evaluation of acute pancreatitis

Serum amylase and lipase levels are commonly obtained in the emergency department for the diagnosis of acute pancreatitis. The role of these enzymes has frequently been the subject of confusion and controversy. This article comprehensively reviews the history, biochemistry, clinical, and laboratory literature on both enzymes as used in the evaluation of pancreatitis. Specific guidelines are presented to assist the Emergency Physician in the appropriate use and interpretation of these clinical laboratory tests.

Amylase normal, lipase elevated: is it pancreatitis? A case series and review of the literature

OBJECTIVE

This study was undertaken to identify clinical scenarios in which the lipase is significantly elevated (three times above the upper limit of normal) but the amylase is normal, and to examine whether or not pancreatitis is the likely cause for this seemingly unusual constellation of laboratory results.

METHODS

Twenty-five patients were retrospectively identified over a 2-yr period, which fulfilled the above criteria. A thorough review of their charts was conducted. In addition, a critical review of the literature was performed.

RESULTS

It appears that isolated elevation of lipase in this case series was either related to renal insufficiency (two patients), to nonpancreatic sources of lipolytic enzymes due to malignant tumors (two), to acute cholecystitis (two) or esophagitis (one), to delayed blood withdrawal (at least five patients), to hypertriglyceridemia (two), or to subclinical pancreatitis in patients without abdominal pain (three).

CONCLUSIONS

1. An elevated lipase should not be equated with evidence for pancreatitis if the amylase is normal. 2. A simultaneous determination of both amylase and lipase is recommended for the evaluation of patients with abdominal pain.

Alcohol and the pancreas

Alcoholic pancreatitis is a major, often lethal complication of alcohol abuse. Until recently it was generally accepted that alcoholic pancreatitis was a chronic disease from the outset. However, there is now emerging evidence in favour of the necrosis-fibrosis hypothesis that alcoholic pancreatitis begins as an acute process and that repeated acute attacks lead to chronic pancreatitis, resulting in exocrine and endocrine failure. Over the past 10-15 years, the focus of research into the pathogenesis of alcoholic pancreatitis has shifted from possible sphincteric and ductular abnormalities to the acinar cell itself which has increasingly been implicated as the initial site of injury. Recent studies have shown that the acinar cell can metabolize alcohol at rates comparable to those observed in hepatocytes. In addition, it has been demonstrated that alcohol and its metabolites exert direct effects on the pancreatic acinar cell which may promote premature digestive enzyme activation and oxidant stress. The challenge remains to identify predisposing and triggering factors in this disease.

CT and US of the pancreas

The diagnostic capabilities of pancreatic imaging continue to improve with technological advancements in computed tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI). To update the practicing radiologist, this article summarizes the current literature on pancreatic imaging, with particular emphasis on CT and US. Pertinent clinical considerations of the disease entities are included, along with illustrative material from the authors' experience.

Clinical update: management of acute pancreatitis

The management of acute pancreatitis commences with confirming the diagnosis and establishing the aetiology. Improved methods of assessing the biliary tree may reduce the number of patients regarded as having idiopathic pancreatitis. Detailed clinical and laboratory protocols, designed to assess severity, have no major advantage over clinical assessment. The contrast-enhanced computed tomography scan is important to assess the degree of pancreatic necrosis and to detect local complications. The treatment of pancreatitis continues to be largely supportive. However, controlled studies support the use of antibiotics in severe acute pancreatitis and indicate a possible role for the use of octreotide and antioxidants. The place of endoscopic and surgical intervention is becoming better defined. Once an attack has passed, further investigation is often required in a bid to prevent further episodes of inflammation.

What is the best biochemical test to diagnose acute pancreatitis? A prospective clinical study

OBJECTIVE

To determine which biochemical test is best to distinguish acute pancreatitis from other pancreatic and nonpancreatic diseases associated with hyperamylasemia.

DESIGN

We conducted a prospective clinical study of 836 consecutive patients who had a total serum amylase test requested by a physician during a 7-month period.

MATERIAL AND METHODS

Radioimmunoassay and enzymatic activity methods were used to measure pancreas-specific proteins of varied size, charge, and stability. In addition, scoring systems were used for the diagnosis of pancreatitis, and statistical analyses were done to determine sensitivity and specificity.

RESULTS

We found minor differences in sensitivity and specificity for diagnosis of acute pancreatitis among pancreatic isoamylase, phospholipase A2, colipase, lipase, and carboxylester lipase. Of these tests, the combination of isoamylase and phospholipase A2 had a small but statistically significant increased sensitivity (90%; 95% confidence interval [CI] = 74 to 98%) and specificity (93%; 95% CI = 91 to 95%) over isoamylase (90% and 92%, respectively; 95% CI = 90 to 94%) and phospholipase A2 (90% and 75%, respectively; 95% CI = 72 to 78%) alone for the diagnosis of acute pancreatitis.

CONCLUSION

Pancreas-specific proteins are satisfactory for diagnosing acute pancreatitis if the test is validated by the laboratory. Clinically, the slight advantage of using both isoamylase and phospholipase A2 does not outweigh the expense of performing two assays; we recommend using isoamylase to diagnose acute pancreatitis.

The prognostic significance of moderate hyperamylasemia in the evaluation of the emergency department patient

Hyperamylasemia of greater than five times the upper limit of the normal range (200 IU/L) is highly specific for the diagnosis of pancreatitis, but the meaning of lower values is unclear. The purpose of this study was to evaluate the prognostic significance of amylase values > 200 and < 1000 IU/L. A controlled historical cohort study was conducted to determine whether moderate hyperamylasemia is associated with an increased severity of outcome compared to patients with normal amylase values. Subjects met certain inclusion criteria and had a serum amylase of > 200 and < 1000 IU/L (normal < 200 IU/L). The case group consisted of 44 patients (medium serum amylase = 307.5 IU/L) and resembled the control group of 77 patients (median serum amylase = 117.5 IU/L) with regard to sex distribution and presenting complaint. However, the case group was older, was on more medications, and had a shorter duration of symptoms prior to the ED visit (< 72 h). Analysis of clinically important outcomes revealed that the groups were similar in terms of 6-month mortality, general admission rate, ICU admission rate, and rate of surgical intervention. The proportion of patients who had radiologically or endoscopically documented gastrointestinal pathology was also similar. The results demonstrate that patients with moderate hyperamylasemia (i.e. amylase < 1000 IU/L), notwithstanding the fact that they are older, are on more medications, and have more acute symptomatology, did not have a worse outcome than patients with the same complaints and normal amylases.

Trypsin activity. A new marker of acute alcoholic pancreatitis

A normal serum amylase level is found in up to 32% of patients with acute alcoholic pancreatitis. This underlines the need for more sensitive diagnostic tests in this frequent cause of pancreatitis. Animal and human studies have shown that chronic alcohol consumption leads to important modifications in trypsinogen metabolism. The present work has prospectively analyzed admission serum trypsin activity with a new biochemical test and usual markers such as amylase, lipase, and immunoreactive trypsin in 32 attacks of acute pancreatitis. Seventeen were due to alcohol and 15 to other causes, including 11 with gallstone pancreatitis. High trypsin activity (median: 235 units/liter; range: 165-853) was found in all patients with acute alcoholic pancreatitis even when the amylase level was normal on admission (3/17: 18%). Trypsin activity did not differ between nonalcoholic pancreatitis (N = 15): 84 units/liter (42-98), alcoholic controls (N = 15): 77 units/liter (40-122), and healthy controls (N = 62): 81 units/liter (15-143). The difference was not related to the severity of disease or circulating alpha 2-macroglobulin, alpha 1-protease inhibitor, or immunoreactive trypsinogen levels. Lipase/amylase ratio was less discriminant than trypsin activity between alcoholic and nonalcoholic diseases. We conclude that serum trypsin activity seems specific to acute alcoholic pancreatitis and should be included in new prospective studies assessing biochemical testing of alcohol-related pancreatic diseases.

Normal amylase levels in the presentation of acute pancreatitis

Recent literature suggests that serum amylase levels are not an appropriate screen for the diagnosis of acute pancreatitis because specificity and sensitivity are poor. Evidence from several studies supports the use of lipase determinations to diagnose acute pancreatitis, and recent improvements in this assay have made it more readily available to the emergency physician. This retrospective review compares the use of serum amylase to lipase levels in the diagnosis of acute pancreatitis in 52 patients who presented to the emergency department, with the hospital discharge diagnosis serving as the gold standard to which the assays were compared. Serum lipase was found to be more sensitive than serum amylase (95% vs 79%); serum amylase levels decreased to normal significantly faster than lipase levels.

Acute pancreatitis

Acute pancreatitis is an inflammatory disease of variable clinical severity. The pathologic conditions that correlate with clinical severity and with local systemic complications range from mild edema to pancreatic an peripancreatic necrosis. This article discusses diagnosis, etiology, laboratory evaluation, and imaging studies with respect to acute pancreatitis. Assessing the prognosis, detecting complications, and therapy are discussed also.

Biochemical models as early predictors of the etiology of acute pancreatitis

In this study we observed the discriminative ability of five commonly measured laboratory tests to distinguish between gallstone- and non-gallstone-associated pancreatitis. We also assessed the ability of the lipase-amylase ratio to discriminate between alcohol- and non-alcohol-induced pancreatitis. One hundred sixty-two patients with acute pancreatitis were included in the study. Group A consisted of patients presenting to our hospital in 1988 and 1989. Group B consisted of patients presenting in 1992. Models developed using group A patients were validated using group B patients. For gallstone pancreatitis, AST (threshold value 80 IU/liter) alone and a three-factor model, AST, ALP and bilirubin (threshold values of 80 IU/liter, 115 IU/liter, and 15 mumol/liter, respectively) were the best predictors, correctly classifying at least 80% of cases in group A and B. A lipase-amylase ratio of two correctly classified only 48% of cases in group A and 54% in group B. We conclude that biochemical models are useful in predicting the presence of gallstone pancreatitis but not alcoholic pancreatitis.

Relation of diagnostic serum amylase levels to aetiology and severity of acute pancreatitis

The sensitivity of diagnostic serum amylase (greater than 1000 iu/l) was assessed in 417 patients with acute pancreatitis as a result of gall stones (258), alcohol (104), or miscellaneous causes (55), of whom 111 (27%) had a clinically severe attack (including 34 deaths). On hospital admission, an amylase value diagnostic of pancreatitis was found in 96.1% of all mild cases and in 87.4% of severe cases (p less than 0.001); at 48 hours these values were 33.3% and 48.2% respectively (p = 0.026). Diagnostic amylase levels for alcoholic patients were found in 86% of mild cases on admission and in 76% of severe cases (p less than 0.001, compared with other groups). The diagnostic levels were also significantly lower at 24 hours for both the alcoholic and miscellaneous groups compared with the gall stone group (p less than 0.001). Eight of 27 (30%) patients with a serum amylase activity less than 1000 iu/l had pancreatic necrosis compared with 12 of the remaining 390 (3.1%) patients (p less than 0.001); the mortality was also significantly different (44% v 5.6% respectively, p less than 0.001). These data support the view that more sensitive tests for acute pancreatitis are needed for routine use especially in those whose disease has an alcoholic aetiology.

Serum lipase: a better test to diagnose acute alcoholic pancreatitis

OBJECTIVE

To determine whether serum lipase is a better test than serum amylase to diagnose acute alcoholic pancreatitis.

PATIENTS

Two hundred two asymptomatic chronic alcoholics (Group A) and 29 patients with image-proven pancreatitis (Group P).

MEASUREMENTS

Serum lipase was measured using the Kodak Ektachem clinical chemistry slide. Serum amylase was estimated using the Kodak Ektachem clinical chemistry slide or the Beckman Astra amylase chemistry module.

RESULTS

The level of serum amylase in Group A ranged from 17 to 347 U/L (mean 71, SD +/- 36 U/L) and in Group P from 180 to 2,985 U/L (mean 722, SD +/- 663 U/L). Thirteen of 29 patients (45%) with image-proven pancreatitis had levels that overlapped those found in asymptomatic alcoholics. The serum lipase levels in Group A ranged from 34 to 600 U/L (mean 186, SD +/- 111 U/L), while in Group P, the corresponding figures were 1,011 to 25,706 U/L (mean 5,822, SD +/- 5,664 U/L). None of the 29 patients with image-proven pancreatitis had levels that overlapped those found in asymptomatic alcoholics.

CONCLUSIONS

Serum lipase is a better test that serum amylase to diagnose acute alcoholic pancreatitis.

The syndrome of alcoholic ketoacidosis

PURPOSE

To further elucidate the clinical spectrum of alcoholic ketoacidosis (AKA).

PATIENTS AND METHODS

A case series of 74 patients with AKA defined as a wide anion gap metabolic acidosis unexplained by any other disorder or toxin, including any patient with a history of chronic alcohol abuse. The setting was the Medical Emergency Department at Grady Memorial Hospital in Atlanta, Georgia, a university-affiliated inner-city hospital.

RESULTS

AKA is a common disorder in the emergency department, more common than previously thought. The acid-base abnormalities are more diverse than just a wide-gap metabolic acidosis and often include a concomitant metabolic alkalosis, hyperchloremic acidosis, or respiratory alkalosis. Lactic acidosis is also common. Semiquantitative serum acetoacetate levels were positive in 96% of patients. Elevated blood alcohol levels were present in two thirds of patients in whom alcohol levels were determined, and levels consistent with intoxication were seen in 40% of these patients. Electrolyte disorders including hyponatremia, hypokalemia, hypophosphatemia, hyperglycemia, hypocalcemia, and hypomagnesemia were common on presentation. The most common symptoms were nausea, vomiting, and abdominal pain. The most common physical findings were tachycardia, tachypnea, and abdominal tenderness. Altered mental status, fever, hypothermia, or other abnormal findings were uncommon and reflected other underlying processes.

CONCLUSIONS

AKA is a common disorder in chronic malnourished alcoholic persons. The acid-base abnormalities reflect not only the ketoacidosis, but also associated extracellular fluid volume depletion, alcohol withdrawal, pain, sepsis, or severe liver disease. Although the pathophysiology is complex, the syndrome is rapidly reversible and has a low mortality.

Isoamylase determination by isoelectric focusing in pancreatic disorders. A potential clinical aid

Isoamylase analysis by isoelectric focusing was performed in the serum of 30 healthy volunteers, 65 patients with acute or chronic pancreatic diseases, nine with acute abdomen, four with macroamylasemia, and four with duodenal duplication. In controls, up to four fractions (2 salivary, 2 pancreatic) were found; the pancreatic fractions were as a mean 44.7% (SD 8.6) of total. In chronic pancreatitis, only patients with steatorrhea showed a significant reduction of pancreatic isoamylase (p less than 0.001). In all patients with acute pancreatitis or pseudocysts, an additional fraction (similar to the so-called P3 fraction) was resolved. Moreover, additional isoenzymes were found in all patients with severe acute pancreatitis or pseudocysts, and not in controls or patients with mild forms, acute abdomen or duodenal duplication. A similar pattern was shown in a stored control serum after 10 mo at -20 degrees C. These fractions disappeared after successful surgical drainage. No specific alteration was found in pancreatic cancer. Amylase fractionation by isoelectric focusing can be used to confirm an acute pancreatitis, and to monitor patients with pancreatic pseudocysts and collections after surgical drainage.

Serum enzymes and other laboratory tests in acute pancreatitis

This review evaluates selective enzymes and blood tests available for the diagnosis and prognosis of acute pancreatitis. It is concluded that serum amylase and lipase measurements represent the best available diagnostic methods. Newer alternative assays still require careful evaluation.

Acute pancreatitis and normoamylasemia. Not an uncommon combination

A consecutive series of 352 attacks of acute pancreatitis (AP) was studied prospectively in 318 patients. AP was ascertained by contrast-enhanced CT scan in all but four cases in which diagnosis was made at operation or autopsy. Sixty-seven of these cases (19%) had normal serum amylase levels on admission (i.e., less than 160 IU/L, a limit that includes 99% of control values), a figure considerably higher than generally admitted. When compared to AP with elevated serum amylase, normoamylasemic pancreatitis was characterized by the following: (1) the prevalence of alcoholic etiology (58% vs. 33%, respectively, p less than 0.01), (2) a greater number of previous attacks in alcoholic pancreatitis (0.7 vs. 0.4, p less than 0.01); and (3) a longer duration of symptoms before admission (2.4 vs. 1.5 days, p less than 0.005). In contrast AP did not appear to differ significantly in terms of CT findings, Ranson's score, and clinical course, when comparing normo- and hyperamylasemic patients, although there was a tendency for normoamylasemic patients to follow milder courses. Serum lipase was measured in 65 of these normoamylasemic cases and was found to be elevated in 44 (68%), thus increasing diagnostic sensitivity from 81% when amylase alone is used to 94% for both enzymes. A peritoneal tab was obtained in 44 cases: amylase concentration in the first liter of dialysate was greater than 160 IU/L in 24 cases (55%), and lipase was greater than 250 U/L in 31 cases (70%). Twelve of these 44 cases had low peritoneal fluid and plasma concentrations for both enzymes. Thus little gain in diagnostic sensitivity was obtained when adding peritoneal values (96%) to serum determinations. AP is not invariably associated with elevated serum amylase. Multiple factors may contribute to the absence of hyperamylasemia on admission, including a return to normal enzyme levels before hospitalization or the inability of inflamed pancreases to produce amylase. Approximately two thirds of cases with normal amylasemia were properly identified by serum lipase determinations. AP does not appear to behave differently when serum amylase is normal or elevated, and should therefore be submitted to similar therapeutic regimens in both conditions.

Determination of a glucose-containing tetrasaccharide in urine of patients with acute pancreatitis

The oligosaccharide Glc alpha 1-6Glc alpha 1-4Glc alpha 1-4Glc (Glc4), formed by amylolytic degradation of starch and glycogen, is excreted at extremely high levels in the urine of patients with acute pancreatitis. To determine if Glc4 is a useful indicator for this disease, we studied 55 patients admitted to the hospital because of acute abdominal pain (possibly acute pancreatitis). The highest values of Glc4 excretion in urine was found in a group of 11 patients with acute pancreatitis. The Glc4 values, but not serum and urine amylase values obtained at admission, correlated significantly with the severity of the disease. In two patients, followed through convalescence, the Glc4 excretion remained elevated for 7 and 2 wk in contrast to serum and urine amylase that returned to normal levels within a few days. It seems probable that glycogen, released from the liver and subsequently degraded by amylase originating from the pancreas, can be measured as Glc4 in the urine. This might be valuable for diagnosing acute pancreatitis and gives indications of the prognosis.

Serial computed tomography scanning in acute pancreatitis: a prospective study

One hundred and two patients with acute pancreatitis had abdominal computed tomography (CT) scans within 72 hours of admission, at one week and at six weeks. Twenty eight attacks were clinically severe, 74 clinically mild. Ninety three (91%) admission scans, 85 (84%) one week scans, and 52 (51%) six week scans were abnormal. The aetiology of the pancreatitis could be inferred from 28 (27%) of admission scans, the CT sign of fatty liver having a sensitivity of 21% and specificity of 100% for alcoholic aetiology. The sensitivity of CT for gall stone aetiology was 34%, specificity 100%. The pancreatic size indices (max anteroposterior measurement of head x max anteroposterior measurement of body) of those patients with severe attacks were significantly greater than those with mild attacks on admission, at one week and at six weeks (p less than 0.004). Fourteen pseudocysts were detected by CT, five (36%) of which were clinically apparent. The pseudocyst size indices (max anteroposterior x max transverse measurement) of the pseudocysts which were clinically apparent were significantly greater than those which were not apparent (p less than 0.01) and only those pseudocysts with a size index greater than or equal to 15 cm2 required treatment.

Acute pancreatitis

In order to recognize acute pancreatitis in the setting of the acute abdomen, the surgeon must be thoroughly familiar with the numerous etiologies of the disease. No specific test is available to diagnose acute pancreatitis. CT scanning is arguably the most useful single tool, but surgical judgment is critical. Most cases of acute pancreatitis resolve spontaneously without sequelae, but the spectrum of the disease also includes highly lethal forms associated with a variety of systemic complications. Operative intervention is indicated when other, more rapidly fatal, abdominal processes cannot be reliably excluded and when local complications develop.

Serum elastase 1 in inflammatory pancreatic and gastrointestinal diseases and in renal insufficiency. A comparison with other serum pancreatic enzymes

Serum elastase 1 has been evaluated in 115 patients with pancreatic and nonpancreatic gastrointestinal diseases and in 36 healthy controls. Increased serum elastase 1 values were found in all 27 patients with acute pancreatitis. If the diagnostic cutoff was established as the 2-fold increase above the upper normal range, sensitivity of elastase 1 (100%) was superior to pancreatic lipase (90%), immunoreactive trypsin (87%) and pancreatic amylase (78%). Specificity was 96% for elastase 1 at this cutoff. No distinction was possible between edematous and necrotizing acute pancreatitis on the basis of peak serum elastase 1 concentrations. Among 32 patients with chronic pancreatitis increased serum elastase 1 values were found in 22% and decreased values in 16% of patients, showing a striking parallelism to serum values of pancreatic lipase and immunoreactive trypsin. Specificity, established in controls and 49 patients with different gastrointestinal diseases, was 77% for elastase 1, 76% for immunoreactive trypsin, 83% for pancreatic lipase and 91% for pancreatic amylase. In addition, we investigated 21 patients with severe chronic renal diseases. In patients with renal insufficiency elastase was increased in 33%, comparable to the frequency of increased amylase and pancreatic amylase serum levels, whereas immunoreactive trypsin was increased in 95%. Immunoreactive trypsin showed a significant correlation to creatinin serum concentration, whereas the other enzymes did not.

Use of amylase isoenzymes in laboratory evaluation of hyperamylasemia

Amylase isoenzyme analysis by agarose gel electrophoresis and lipase concentration by radioimmunoassay were performed in 98 consecutive hyperamylasemic patients. Total pancreatic (P-type) isoamylase was elevated in 89% of patients with clinical evidence of pancreatitis, and in only 11% of those without pancreatitis. Of 43 patients in whom the clinical diagnosis was obscure, 44% demonstrated an increase in pancreatic amylase and three (7%) had an increase in salivary (S-type) amylase. Lipase concentration by radioimmunoassay correlated well with lipase activity (r = + 0.69, P less than 0.05) and was as effective as amylase isoenzymes in distinguishing patients felt likely to have pancreatitis from those who were unlikely. Amylase isoenzymes or serum lipase concentration may be useful tests in the laboratory evaluation of hyperamylasemia when the etiology is obscure.

Value of the P3 amylase fraction as an indicator of the long-term prognosis of acute pancreatitis

The value of the serum P3 amylase fraction in the prediction of the course of acute pancreatitis (AP) after the initial episode was studied prospectively. Eighty-eight patients with AP were included. Amylase, lipase, trypsin and the P3 amylase fraction were measured in serum obtained at the time of discharge. Patients were followed for 60 days after discharge and divided into two groups: 75 patients who did not have complications, of whom 22.6 per cent displayed elevation of one or more pancreatic enzymes at discharge (17.3 per cent hypertrypsinaemia, 9.3 per cent hyperlipasaemia and 6.6 per cent P3 fraction); and 13 patients who had an unsatisfactory outcome (4 died, 4 developed a pseudocyst and 5 presented with recurrent pancreatitis). All of the latter group had an increase in at least one enzyme at the time of discharge (92.3 per cent P3 fraction, 69.2 per cent trypsin, 15.3 per cent lipase, and 7.6 per cent amylase). Both the persistence of the P3 fraction and hypertrypsinaemia were significantly more frequent in patients with an unfavourable outcome than in those with an uncomplicated course (P less than 0.001). On the other hand, persistent elevation of total amylase and lipase were unrelated to outcome. The hospitalization time was similar in both groups (good outcome 21.4 +/- 1.9 days, unfavourable outcome 17.3 +/- 5.3 days). It is concluded that the presence of P3 amylase fraction or hypertrypsinaemia at the time of discharge from hospital in a patient with acute pancreatitis suggests a risk of a later complication. Careful surveillance until enzyme levels become normal is urged. It is suggested that isoamylase P3 determination is the most sensitive assay to screen for the complications of acute pancreatitis.

Problems of pancreatitis

Pancreatitis is not one disease but several and perhaps many. Diagnosis is imperfect in all forms and the usual lack of histologic material has hampered attempts to understand the pathogenesis and possible interrelationships of the different forms of pancreatic inflammation. Acute pancreatitis does not as a rule evolve into chronic pancreatitis, even after multiple recurrences. Recurrent acute attacks can be ended by identifying and treating the factor causing the disease, including recently recognized entities such as accessory papilla stenosis associated with pancreas divisum. Attempts to improve the treatment of severe acute pancreatitis are focussing upon preventing injury to pancreatic cell structures, enhancing endogenous mechanisms for capture and disposal of activated enzymes, and upon early detection and debridement of damaged pancreatic and peripancreatic tissues. Pancreatic duct stricture or obstruction as a consequence of scarring from necrotizing pancreatitis may produce recurrent symptoms, now designated as obstructive pancreatitis. Obstructive pancreatitis has its own unique histologic characteristics and is appropriately treated by resection of the blocked segment of pancreas when the point of obstruction is distal to the papilla. Chronic pancreatitis differs from acute or obstructive pancreatitis in that it is difficult or impossible to halt its progression. The role of intraductal protein precipitates, whether of enzymes or perhaps of other unique pancreatic secretory proteins, in the pathogenesis of the disease is being evaluated. The goal of surgical treatment is not to cure, but to reduce pain, overcome associated obstruction of the bile duct or duodenum, and to treat pancreatic duct disruptions including pseudocysts and internal pancreatic fistulas. Because continuing deterioration of pancreatic function is to be expected in chronic pancreatitis, maximum conservation of pancreatic tissue by avoiding resectional procedures is advisable.

Acute pancreatitis and its complications. Diagnostic and therapeutic strategies

The most common causes of acute pancreatitis are biliary tract disease and alcoholism, but other causes account for about 10% of cases. Acute pancreatitis can be divided clinically into mild and severe (necrotic) disease. Risk of complications and death varies with the etiology, severity, and number of episodes and is highest in severe cases and biliary tract-related disease. Amylase determination is the best diagnostic serum screening test. Ultrasonography, computed tomography, and endoscopic retrograde pancreatography are also extremely useful in diagnosis. Treatment of acute pancreatitis usually consists of supportive measures; the roles of peritoneal lavage and surgery remain controversial. Pseudocysts occur in about 25% of patients but can be treated successfully with appropriate therapy.

Acute pancreatitis

This paper provides a review of recent advances in the understanding and management of acute pancreatitis. The mortality of acute severe pancreatitis remains disappointingly high. While there have been relatively few recent advances in the surgical management of acute pancreatitis, several nonsurgical developments appear promising.