An endoscopy shows the pancreas

Pancreatitis: examinations & diagnosis

Since the symptoms of inflammation of the pancreas are varied, it is important for the internist to recognize the disease and differentiate it from other, similar clinical pictures.

Cause similar signs of illness:

  • Pancreatic cancer
  • Heart or lung infarction
  • Breakthrough of stomach or duodenal ulcer
  • Inflammation of the gallbladder
  • Ectopic pregnancy

First of all, the internist will ask the patient in detail about the symptoms and previous illnesses. In addition, it scans the abdomen, because low tension in the abdominal wall is typical for acute inflammation of the pancreas. One speaks of the so-called rubber belly in contrast to the board-hard abdominal wall, which is already painful to the touch, in the case of peritonitis.

The internist will then arrange for one or more of the following examination methods:

Laboratory tests

By examining blood, the internist determines whether the levels of digestive enzymes in the pancreas are increased. Elevated values ​​for lipase and alpha-amylase are typical. Since the determination of lipase in serum is more specific compared to amylase, amylase is no longer measured.

Abdominal pain in combination with an increase in serum lipase more than three times allows the diagnosis of pancreatitis. These two criteria apply to both acute and chronic pancreatitis flare-ups. The determination of the serum lipase should not be carried out in the absence of abdominal pain. This is because an increase in lipase can also be present in a healthy pancreas. An unnecessary further diagnosis would then only be initiated.
Dead tissue and the severity of the disease can also be determined in the blood. However, there is no connection between the level of serum lipase and the degree of damage to the pancreas. Blood sugar and calcium are checked as well as kidney and liver function. Signs of inflammation are increased levels of C-reactive peptide (CRP) and an increased number of white blood cells (leukocytes). A CRP of over 100 mg / dl is usually already necrotizing pancreatitis.

If gallstones are the cause of the inflammation, the bile acid levels and liver enzymes are also increased.

Functional diagnostics

Elastase in the stool

In chronic pancreatitis, the destruction of the cells that make digestive enzymes occurs at different rates. This leads to impaired digestion of the food (exocrine insufficiency, maldigestion). The protein-splitting enzyme elastase is not destroyed in contrast to the fat-splitting lipase. The concentration of this enzyme can therefore be measured in the stool. A decrease in stool elastase already suggests severe pancreatic insufficiency.

Fat in stool

The inadequate digestion of dietary fat due to a lack of lipase leads to increased excretion of fat in the stool. In a few special laboratories, the fat excretion can be measured in the stool collected over three days. In healthy people, it is less than 15 g per day.

Diabetes diagnostics

In the course of the disease, inflammation-related destruction of the cells of the so-called endocrine pancreas usually also occurs, resulting in diabetes mellitus. As part of the diagnosis of the onset of diabetes, a glucose stress test is carried out.

Imaging diagnostics

Ultrasound examination (sonography)

In most cases, the internist examines the patient using ultrasound, as this examination is easy to perform and does not pose any risk to the patient. This allows the internist to visualize the extent of the inflammation and any swelling in the pancreas. Fluid-filled cavities (cysts), dead tissue and accumulations of water in the stomach or lungs can also be seen. It is not uncommon for the internist to discover gallstones in this way. However, minor changes in the pancreas often go undetected.

X-ray examination

Lung and bowel function are checked with an X-ray examination: A paralyzed bowel, for example, has air bubbles that are clearly visible on the X-ray image. Water in the lungs or in the abdomen can be seen as well as calcifications in the pancreas or gallstones.

Computed tomography / magnetic resonance tomography

The two procedures are mainly used in the case of severe inflammation or if the internist cannot come to a clear judgment despite the ultrasound. Computed tomography with contrast agent administration enables particularly sharp images of the pancreas and makes the extent of the destroyed tissue, possible bleeding and fluid-filled cavities (cysts) visible. In this way, the doctor can also differentiate between the mild and severe forms of the inflammation.

Magnetic resonance imaging is a good way of differentiating fluid from tissue. It is possible to visualize the pancreatic ducts and bile ducts via MRCP (magnetic resonance cholangio-pancreatography). So z. B. Detect narrowing of the ducts (stenoses) and enlargements (dilatations) in chronic pancreatitis. Stones in the corridors are shown as recesses in the fluid-filled corridors. A representation of the vessels (ME angiography) is also possible.

ERCP (endoscopic retrograde cholangiopancreatography)

This endoscopic examination is used when bile duct stones have been diagnosed. The internist pushes the endoscope through the esophagus and stomach to the joint opening of the biliary and pancreatic ducts in the duodenum. With the help of a contrast agent, he can precisely localize the stone and pull it out with the help of a small basket on the endoscope under X-ray control. Usually the duct stone or stones are larger than the opening of the papilla in the duodenum. Then the papilla must be cut open with the aid of a wire under the action of an electric current (papillotomy). Since the opening cannot be cut open as far as desired, larger stones can be smashed with various methods using the endoscope before they are then removed from the passage. If complete stone removal is not possible in one session, a stent is placed in the bile duct via ERCP to ensure bile drainage.

Bile duct stones can often be detected using ultrasound. The detection of stones in the gallbladder is usually easier with ultrasound, since air in the intestine can make it difficult to visualize the bile duct.

Bile duct stones can be detected from the inside using MRCP (magnetic resonance cholangio-pancreatography) or, even more sensitively, with ultrasound examination. Here the ultrasound head sits on the tip of the endoscope (endosonography). The ERC with stone removal is only carried out in the same session if there is positive evidence.

Due to the risk that ERCP can also cause pancreatitis or worsen existing pancreatitis, this diagnostic procedure is no longer used. Your domain is therapy, as bile duct stones must be removed. If the bile duct stones are not removed, the clinical course of pancreatitis can worsen or life-threatening bile duct inflammation can develop. This can be the result of blood poisoning (septic cholangitis).

Endosonography

It is an ultrasound examination from the inside. The ultrasound head sits on the tip of an endoscope. Since loops of intestine, which are filled with air, lie in front of the pancreas and ultrasound waves pass this air poorly, the pancreas can often not be shown well with the usual external sonography (transabdominal sonography). With endoscopic ultrasound, the sound waves travel through the stomach wall or the duodenum directly into the pancreas. This method is the gold standard for diagnosing chronic pancreatitis at an early stage.

Puncture of the pancreas

If the dead tissue is suspected of being infected with bacteria, the doctor uses a thin needle to remove some cell material from the affected area (puncture). He controls the puncture with the help of ultrasound or computed tomography. Through a laboratory examination of the material obtained, the doctor can precisely determine the types of bacteria and select a suitable antibiotic. In some cases, a single puncture can remove the entire source of infection.

In the diagnosis of acute as well as chronic pancreatitis, these imaging methods are used differently depending on the stage and complication of the disease. CT is ideally suited to differentiating between necrotizing and edematous pancreatitis. It is also used to illustrate possible complications of chronic pancreatitis, e.g. B. pseudocysts, inflammatory enlargements of the pancreatic head. A congestion of the bile ducts due to a disturbance of the outflow of the bile with a swelling of the pancreatic head can already be detected in the sonography.