Pitfalls in diagnosing acute pancreatitis

We thank Jolobe for his letter (Gut 2005;54:1207–8) which mentions the difficulty of establishing the diagnosis of acute pancreatitis in patients with diabetic ketoacidosis. We did not address diagnostic tests and medical intensive care treatment of acute pancreatitis in our article, but reviewed the interventional and surgical treatment strategies in acute pancreatitis. There is no doubt that treatment of acute pancreatitis, including organ failure in its early phase, is solely supportive. Due to improvements in intensive care medicine, mortality of severe disease has decreased dramatically over the past decades. However, to treat patient adequately, the correct diagnosis has to be made. Therefore, the first step in the diagnostic process of acute pancreatitis is to think of this disease. According to the latest classification from Atlanta, acute pancreatitis is an acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems. From a clinical point of view, acute upper abdominal pain and elevated pancreatic enzyme levels are needed to diagnose acute pancreatitis. As pointed out by Jolobe in his letter, acute pancreatitis is still underdiagnosed under certain clinical conditions, including diabetic ketoacidosis, but also in other clinical situations, such as shock of unknown origin, patients under intensive care treatment, as well as rare causes of the disease. As acute pancreatitis can be associated with diabetic ketoacidosis and the association between these two is a two way cause-and-effect relationship, early imaging of the pancreas is recommended in these patients to establish the correct diagnosis. Our article focused on the surgical and interventional treatment of severe acute pancreatitis.