Pancreatic Damage Assessment: Clinical Evaluation, Labs, Imaging & Biopsy

Clinical Evaluation

• History: Alcohol, gallstones, medications, trauma, family history, autoimmune.
• Exam: Epigastric tenderness, radiating to back; Cullen's/Grey Turner sign (hemorrhagic); palpable mass (pseudocyst, tumor).

Laboratory Markers

• Amylase/Lipase: Lipase more specific/sensitive for acute pancreatitis (3× ULN diagnostic). Chronic: may be normal.
• CBC: Leukocytosis (inflammation), anemia (chronic bleed/malnutrition).
• LFTs: Obstructive pattern (ALP, GGT, bilirubin ↑) suggests biliary etiology.
• Glucose/HbA1c: Diabetes ↔ pancreatic dysfunction (bidirectional).
• Fecal elastase-1: <200 µg/g = exocrine insufficiency; <100 = severe.
• CA 19-9: Tumor marker (limited sensitivity/specificity; Lewis antigen dependent).

Imaging (Escalating Detail)

• US: First-line; gallstones, duct dilation, pseudocyst. Limited by bowel gas/body habitus.
• CT (pancreas protocol): Necrosis, fluid collections, vascular complications, staging.
• MRI/MRCP: Best for ductal anatomy, subtle parenchymal changes, characterizing cystic lesions.
• EUS: Highest resolution; FNA capability; detects <1 cm lesions.
• ERCP: Therapeutic (stent, stone extraction); diagnostic if MRCP/EUS equivocal.

Biopsy

EUS-FNA or percutaneous for tissue diagnosis (cancer, autoimmune pancreatitis, infection).

Integration

Combine clinical, lab, imaging for etiology (acute vs. chronic pancreatitis, neoplasm, insufficiency) and severity grading (Atlanta, CT severity index).