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Difficulty: MediumDiagnostic Workup and Test Sequencing

A 42-year-old previously healthy woman arrives at the emergency department reporting the sudden onset of severe, continuous pain in her upper abdomen that radiates directly to her mid-back. She has vomited three times since the pain started four hours ago. She reports no recent alcohol use or new medications. Her temperature is 37.8°C (100.0°F), blood pressure is 135/85 mm Hg, pulse is 110/min, and respiratory rate is 18/min. Examination reveals significant tenderness in the epigastric region with voluntary guarding, but no rebound tenderness or rigidity. Bowel sounds are hypoactive. Which of the following diagnostic studies should be ordered concurrently as part of this patient's initial evaluation? (Select all that apply)

  1. Serum lipase concentrationAnswer
  2. Transabdominal ultrasonography of the right upper quadrantAnswer
  3. C
    Intravenous contrast-enhanced computed tomography of the abdomen
  4. D
    Serum amylase concentration
  5. E
    Hepatobiliary iminodiacetic acid (HIDA) scan

Answer

The correct initial diagnostic tests are a serum lipase concentration and transabdominal ultrasonography of the right upper quadrant.
The patient's presentation of severe epigastric pain radiating to the back with nausea and vomiting is classic for acute pancreatitis. The diagnosis of acute pancreatitis requires two of three criteria: characteristic abdominal pain, elevated serum lipase (typically greater than three times the upper limit of normal), and characteristic findings on cross-sectional imaging. Therefore, a serum lipase measurement is an essential initial test to confirm the diagnosis. Concurrently, because gallstones are the most common etiology of acute pancreatitis, current guidelines strongly recommend a transabdominal right upper quadrant ultrasound in all patients during their initial evaluation to assess for cholelithiasis and biliary duct dilation.

Step-by-Step Solution

1
Evaluate the clinical presentation.
The patient presents with severe epigastric pain radiating to the back, accompanied by nausea and vomiting, which is the classic presentation for acute pancreatitis.
Recognizing the most likely diagnosis dictates the initial diagnostic workup.
2
Apply the diagnostic criteria for acute pancreatitis.
Diagnosis requires at least two of the following: characteristic abdominal pain, serum lipase >3 times the upper limit of normal, and characteristic imaging findings.
Because the clinical pain is characteristic, measuring serum lipase is the most sensitive and specific next step to fulfill the criteria.
3
Determine the necessary concurrent workup for etiology.
Gallstones are the most common cause of acute pancreatitis worldwide. Right upper quadrant ultrasonography is the most sensitive non-invasive test for cholelithiasis.
Guidelines mandate early ultrasound in all patients with acute pancreatitis to identify biliary etiologies that might require early intervention.

Key Concept

The initial evaluation of suspected acute pancreatitis requires concurrent measurement of serum lipase to establish the diagnosis and a right upper quadrant transabdominal ultrasound to evaluate for biliary etiology.
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Diagnostic Workup and Test Sequencing

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