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Can we ever be certain of the diagnosis of acute pancreatitis?
  1. A G ACHESON
  1. Kettering General Hospital NHS Trust,
  2. Northamptonshire NN16 8UZ, UK

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Editor,—The recent guidelines for the management of acute pancreatitis written on behalf of the Working Party of the British Society of Gastroenterology (Gut1998;42 (suppl 2):S1–13) outline the initial steps in diagnosis, investigation and treatment of acute pancreatitis.

The supplement summarises the indications for computed tomography (CT) scanning in pancreatitis and one of these is diagnostic uncertainty. Recently, I was involved in the management of two elderly patients who had a clinical history in keeping with acute pancreatitis and amylase concentrations of 2876 IU/l and 4861 IU/l, respectively (normal range 0–220 IU/l). These two patients subsequently died and postmortem examination in each case revealed evidence of gangrenous bowel and no macroscopic or microscopic evidence of pancreatitis.

An amylase concentration of greater than five times normal is often considered diagnostic of acute pancreatitis but previous investigators have shown that significant hyperamylasaemia can be found in conditions other than pancreatitis.1

Perhaps all patients with hyperamylasaemia should fit into this category of “uncertain diagnosis” and therefore undergo early diagnostic CT scanning rather than depending purely on clinical or biochemical findings.

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