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Difficulty: EasyDiagnostic Workup and Test Sequencing

A 42-year-old man arrives at the emergency department reporting the sudden onset of severe, constant upper abdominal pain that radiates to his mid-back, accompanied by multiple episodes of vomiting. He has no significant past medical history. He reports consuming a six-pack of beer daily. Vital signs show a temperature of 37.4°C (99.3°F), blood pressure of 135/85 mmHg, and heart rate of 110/min. Physical examination reveals tenderness to palpation in the epigastric region with no guarding or rebound. Bowel sounds are decreased.

Which of the following initial diagnostic tests are the most appropriate to order concurrently for this patient? (Select all that apply)

  1. Serum lipaseAnswer
  2. Right upper quadrant abdominal ultrasoundAnswer
  3. C
    Contrast-enhanced computed tomography of the abdomen
  4. D
    Endoscopic retrograde cholangiopancreatography
  5. E
    Stool antigen testing for Helicobacter pylori

Answer

Serum lipase and right upper quadrant abdominal ultrasound
The patient's presentation is classic for acute pancreatitis. The diagnosis requires two of the following three criteria: typical abdominal pain, serum lipase or amylase elevated to at least three times the upper limit of normal, and characteristic findings on imaging. Serum lipase is the most sensitive and specific biochemical marker and should be ordered immediately. Furthermore, guidelines mandate that a transabdominal ultrasound be performed in all patients with acute pancreatitis upon initial presentation. This is necessary to evaluate for gallstones, which is a major, reversible cause of the disease, even in patients who consume alcohol. Therefore, both serum lipase and a right upper quadrant abdominal ultrasound are the most appropriate initial concurrent diagnostic steps.

Step-by-Step Solution

1
Identify the most likely diagnosis based on the clinical presentation.
The patient's sudden, severe epigastric pain radiating to the back, combined with nausea, vomiting, and a history of alcohol use, strongly suggests acute pancreatitis.
Recognizing the classic clinical syndrome is the first step in determining the necessary diagnostic workup.
2
Determine the appropriate laboratory test to confirm the diagnosis.
Serum lipase should be ordered as the primary laboratory investigation.
Serum lipase is highly sensitive and specific for acute pancreatitis and represents one of the core diagnostic criteria (elevation at least three times the upper limit of normal).
3
Determine the appropriate initial imaging study to evaluate the etiology.
Right upper quadrant abdominal ultrasound should be ordered concurrently.
Clinical guidelines recommend that all patients with suspected acute pancreatitis undergo a transabdominal ultrasound to evaluate for a biliary etiology (e.g., gallstones), which alters subsequent management, regardless of the patient's alcohol history.

Key Concept

In patients with suspected acute pancreatitis, the best initial diagnostic workup includes serum lipase to confirm the diagnosis and a right upper quadrant abdominal ultrasound to assess for a biliary etiology.
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Topics

Diagnostic Workup and Test Sequencing

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