Many other serum proteins have been evaluated in AP. Serum trypsin appears to be as good as amylase and lipase for the diagnosis of AP, but its measurement is more time-consuming and less readily available.1 ' Elastase I remains elevated longer than amylase and lipase, but it is also not routinely available. Polymorphonuclear elastase, phospholipase A2 , ribonuclease, alpha-macroglobulin, and C-reactive protein are proteins found in the serum in AP. All these proteins appear to be of greatest utility in the determination of disease severity, rather than in diagnosis.
Measurement of the urinary amylase level, the amylase-creatinine clearance ratio, and the urinary lipase level have all been evaluated in the diagnosis of AP. Although these tests have been shown to be useful, they have not proven to be consistently beneficial as compared with serum amylase and lipase levels, and they are therefore not routinely employed. Determination of urinary trypsinogen-2 is a newer diagnostic test that can be rapidly performed and has been demonstrated to have excellent sensitivity and specificity for AP.
Certain laboratory tests have been shown not only to support the diagnosis of gallstone pancreatitis but also to indicate the presence of common bile duct stones. The serum level of bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase, alanine amino transferase, and aspartate amino transferase, when combined, can serve as an independent predictor of the presence of a common bile duct stone in gallstone AP.
The rise in the transferases, alkaline phosphatase, and gamma-glutamyl transpeptidase appears to be related to the injury to hepatocytes and biliary epithelium that occurs with the passage of stones. The elevation in these laboratory values is usually transient and resolves quickly with stone passage. Persistently elevated serum bilirubin levels suggest continued biliary obstruction. Radiographic Procedures
Plain chest and abdominal radiographs, ultrasound, CT, magnetic resonance imaging (MRI), and ERCP have all been used to support the clinical and laboratory suspicion of AP. Findings on chest radiography that suggest AP but are not specific for the disease include left pleural effusion, elevated left hemidiaphragm, and left basilar atelectasis. These findings reflect the presence of a significant peridiaphragmatic retroperitoneal inflammatory process in the region of the pancreas. Chest radiography may also be useful in delineating other causes of abdominal pain in a patient with suspected AP. Plain abdominal radiographs reveal nonspecific abnormalities in more than half the patients with AP. An air-filled duodenum or a dilated proximal jejunal loop, referred to as the sentinel-loop sign, represents a local ileus caused by adjacent inflammation. The colon cutoff sign ( Fig. 2-2 ) may be seen, and it reflects distention of the colon to the level of the transverse colon, with no air present in the splenic flexure and more distal colon. The plain abdominal radiograph may also reveal cholelithiasis, nonspecific ileus pattern, and the presence of pancreatic calcifications ( Fig. 2-3 ).
Abdominal ultrasound can be used to detect pancreatic swelling, pancreatic edema, and acute peripancreatic fluid collections. Acute fluid collections are present in or adjacent to the pancreas early in the course of disease, Figure 2-2 Supine abdominal radiograph demonstrating the "colon cutoff" sign. Bowel gas is present in the ascending and transverse colon but Is absent from the descending colon.
Figure 2-3 Abdominal radiograph revealing a heavily calcified pancreas in a patient with long-standing chronic alcoholic pancreatitis.
Figure 2-4 A, CT scan of a patient with acute pancreatitis after endoscopic retrograde pancreatography. The pancreas is diffusely edematous and enlarged. B, CT scan of a patient with acute pancreatitis. The pancreas is enlarged and edematous. Peripancreatic fluid collections are present anterior to the pancreas in the lesser sac and posteriorly in the left pararenal space.
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