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Zorluk: KolayDiagnostic Workup and Test Sequencing

A 52-year-old woman comes to the emergency department with a 12-hour history of severe, constant epigastric pain that radiates to her mid-back. The pain is associated with severe nausea and three episodes of non-bilious emesis. She has no history of alcohol use and takes no medications. Vital signs are temperature 37.7°C (99.9°F), blood pressure 135/85 mmHg, pulse 110/min, and respirations 18/min. Physical examination shows pronounced epigastric tenderness without rebound or rigidity. Bowel sounds are hypoactive. To establish the diagnosis and determine the likely etiology, which of the following investigations should be ordered as part of the initial diagnostic workup? (Select all that apply.)

  1. Serum lipase concentrationCevap
  2. Right upper quadrant abdominal ultrasonographyCevap
  3. C
    Computed tomography of the abdomen with intravenous contrast
  4. D
    Endoscopic retrograde cholangiopancreatography
  5. E
    Magnetic resonance cholangiopancreatography

Cevap

The correct initial investigations to order are a serum lipase concentration and right upper quadrant abdominal ultrasonography.
The patient's presentation of severe epigastric pain radiating to the back is classic for acute pancreatitis. The diagnosis of acute pancreatitis requires the presence of two of three criteria: typical abdominal pain, elevated pancreatic enzymes (lipase greater than 3 times the upper limit of normal), and characteristic imaging findings. Serum lipase is the preferred initial laboratory test due to its high sensitivity and specificity. Furthermore, because gallstones are the most common etiology of acute pancreatitis (especially in a patient with no history of alcohol use), right upper quadrant ultrasonography is strictly indicated in all patients at the time of initial presentation to assess for cholelithiasis and biliary dilation.

Adım Adım Çözüm

1
Identify the primary clinical syndrome based on the patient's presentation.
The patient has severe epigastric pain radiating to the back with nausea and vomiting, which is highly characteristic of acute pancreatitis.
Recognizing the classic clinical presentation directs the selection of appropriate, cost-effective initial diagnostic tests.
2
Determine the necessary laboratory tests to confirm the diagnosis.
Serum lipase concentration is selected because it is highly sensitive and specific for pancreatic inflammation.
The diagnosis of acute pancreatitis requires at least two of the following: typical abdominal pain, serum lipase (or amylase) greater than 3 times the upper limit of normal, and characteristic findings on imaging.
3
Select the most appropriate initial imaging modality to determine the etiology.
Right upper quadrant abdominal ultrasonography is selected to evaluate for the presence of gallstones.
Gallstones are the single most common cause of acute pancreatitis. Current guidelines recommend early transabdominal ultrasound for all patients with acute pancreatitis to detect a potential biliary etiology.

Anahtar Kavram

The initial diagnostic workup for suspected acute pancreatitis includes a serum lipase level to confirm the diagnosis and a right upper quadrant abdominal ultrasound to assess for a biliary etiology (gallstones).
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Diagnostic Workup and Test Sequencing

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