Does Early Ed Ct Scanning of Nonsevere First Episodes of Acute Pancreatitis Ever Change Management?

Background:

The American Gastroenterology Association (AGE) states that 2 of 3 features must be present in order to diagnose acute pancreatitis (AP): (1) characteristic abdominal pain, (2) serum amylase and or lipase activity 3 times the upper limit, and/or (3) characteristic computed tomography scan (CTS) findings. However, the yield of CT scanning early in the course of nonsevere AP has been questioned. The objective of this study was to examine if early CT scanning (within 48 hours of symptom onset) in afebrile patients with an emergency department (ED) diagnosis of first episode of AP revealed any unanticipated pathology that altered clinical management.

Methods:

A retrospective chart review of all patients with an ICD‐9 diagnosis of “acute pancreatitis” from January 1, 2011, to May 31, 2012, was performed. Using a structured extraction tool, the 3 authors independently abstracted the data. A predetermined list of inclusion criteria was created and included age > 18, first episode of AP, presence of abdominal pain, symptoms < 48 hours, amylase and lipase > 3 times the upper limit of normal, absence of fever (temperature < 100.4°F), and admission to non‐ICU bed. Patients who met all inclusion criteria were then assessed for use of CT imaging in the ED or within 48 hours of admission and whether the results of the CT scans obtained altered clinical management.

Results:

Two hundred and forty‐eight patients received a diagnosis of acute pancreatitis in the ED, with 145 considered first episodes. Of these 145 patients, 65 met the remaining predetermined criteria. Nineteen of the 65 did not receive CT scans within 48 hours of symptom onset. The remaining 46 patients (70.8% of patients who met criteria) received CTS within 48 hours of symptom onset. Of the 46 who received CTS within 48 hours of symptom onset, 41 received CTS in the ED, whereas 5 received it after admission (but within 48 hours of symptom onset). None of the 46 patients who received CT imaging had unexpected findings (95% CI, 0.923–1.0).

Conclusions:

We have demonstrated that those patients who are afebrile with first episodes of acute pancreatitis not requiring ICU care do not benefit from early abdominal CTS evaluation. If these results can be reproduced, eliminating CTS in these cases would result in significant cost savings, decrease radiation exposure for our patients, and could potentially improve ED throughput.