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Year : 2016 Month : July Volume : 5 Issue : 60 Page : 4181-4184

A STUDY ON DIAGNOSTIC ACCURACY OF BIOCHEMICAL MARKERS AND TRANS-ABDOMINAL ULTRASONOGRAPHY IN COMPARISON TO MULTI-DETECTOR COMPUTED TOMOGRAPHY IN DETECTION OF ACUTE PANCREATITIS

Biplab Debbarma1, Kaushik Tripura2

1Assistant Professor, Department of Radiodiagnosis, Tripura Medical College & Dr. BRAM Teaching Hospital, Hapania, Tripura West.
2Assistant Professor, Department of Community Medicine, Tripura Medical College & Dr. BRAM Teaching Hospital, Hapania, Tripura West.

CORRESPONDING AUTHOR

Dr. Kaushik Tripura,
Email : tripurakaushik@gmail.com

ABSTRACT

Corresponding Author:
Dr. Kaushik Tripura,
Assistant Professor,
Department of Community Medicine,
Tripura Medical College
& Dr. BRAM Teaching Hospital,
Hapania, Agartala-799014, Tripura West.
E-mail: tripurakaushik@gmail.com

ABSTRACT

Acute pancreatitis is an acute, mainly diffuse, inflammatory process of the pancreas. Computed Tomography (CT) scan is the modality of choice for diagnosis of acute pancreatitis. But non-availability of Computed Tomography (CT) scan in all health facilities made detection of acute pancreatitis is problemsome.

OBJECTIVES

1. To assess the diagnostic accuracy of Biochemical Markers and Trans-Abdominal Ultrasonography in comparison to Multidetector Computed Tomography in diagnosis of acute pancreatitis. 2. To compare the findings of Trans-Abdominal Ultrasonography with Multidetector Computed Tomography.

MATERIALS AND METHODS

100 clinically suspected for acute pancreatitis patients were tested for abnormal biochemical markers, followed by examined by USG and then by MDCT in Radiodiagnosis Department of AGMC and GBP Hospital and findings were compared. Sensitivity, specificity, positive predictive value and negative predictive value were calculated.

RESULTS

The sensitivity and specificity of trans-abdominal ultrasonography was calculated as 75% (CI 64.06% - 84.01%) and 100% (CI 83.16%-100%).  

CONCLUSION

USG had similar sensitivity, but higher specificity value than serum markers (Amylase and Lipase).

KEYWORDS

Acute Pancreatitis, Trans–Abdominal Ultrasonography, Multi-Detector Computed Tomography, Sensitivity, Specificity.

INTRODUCTION

In 1992, Atlanta classification defined acute pancreatitis as “an acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems associated with raised pancreatic enzyme levels in blood and/or urine.”(1) Autodigestion is the cause of acute pancreatitis with annual incidence rate of 5 to 35 per 100,000 population (0.005%-0.035%).(2) Gallstones and alcohol abuse are the predominant cause (80%).(3) Serum amylase and lipase are the routine investigation done in suspected cases of acute pancreatitis. Serum amylase is elevated within 24 hrs. of onset and remains so for 1-3 days. Lipase is the most specific test, one of the best single enzyme to measure.(4) Ultrasound is easily accessible, quick and detects gall bladder or common bile duct stone as the aetiological factors in

addition to features of acute pancreatitis.(5) Computed Tomography (CT) scan is the modality of choice with an accuracy of 87%.(6) But non-availability of Computed Tomography (CT) scan in all health facilities detection of acute pancreatitis is problemsome. So this study is conducted with the following objectives.

OBJECTIVES

  1. To assess the diagnostic accuracy of biochemical markers and Trans-Abdominal Ultrasonography in comparison to Multi-Detector Computed Tomography (MDCT) in diagnosis of acute pancreatitis.
  2. To compare the findings of acute pancreatitis of Trans-Abdominal Ultrasonography with Multi-Detector Computed Tomography (MDCT).

 

MATERIALS AND METHOD

The present study was conducted from November 2011 to April 2013 in the Radio-diagnosis and Biochemistry Department of Agartala Government Medical College and GB Pant Hospital; 104 patients of clinically suspected acute pancreatitis were referred from other Clinical Departments to Radiology Department for evaluation during the study period; 100 patients were included in the study because 4 patients were refused to participate in the study. Biochemical markers were tested in Autoanalyzer–XL 300 in the Biochemistry Department. Serum amylase was estimated by direct substrate methodand serum lipase by enzymatic method.(7,8) Ultrasonography machine, model Sequina, manufacturer L and T, Probe 3.5 to 5 MHz and model SonoAce X8, manufacturer Medison, probe 2 to 5 MHz were used for the study. All CT examinations were performed in 16 slice Multi-Detector Computed Tomography (MDCT) (Philips, Brilliance 16). All scans were viewed for the presence of acute pancreatitis, any associated aetiological factors like gallstone and its complications. Findings were compared with CT scan findings. Ethical permission was taken from Institutional Ethical Committee of Agartala Govt. Medical College. Written consent was obtained from the participants.

Statistical Analysis

The data were entered in spread sheet and analysed using SPSS 21 statistical software. Sensitivity, specificity, positive predictive value and negative predictive value were calculated.

RESULTS

Demographic Variables

Frequency (n 100)

Gender

Male

Female

 

74

26

Total

100

Age Group (In years)

20–39

40-59

60 & above

 

31

53

16

Total

100

Table 1: Demographic Distribution

  • of the Study Participants

 

In the present study (Table No. 1), majority of the participants were male (74%) followed by female (26%).  Majority of the participants were in the age group of 40–59 years (53%) followed by 20–39 years (31%).

 

Probable Cause of

Acute Pancreatitis

Frequency

(n=100)

Alcohol

Gall stones

Alcohol & Gall stones

Blunt trauma

Unknown

60

17

10

02

11

Total

100

Table 2: Distribution of the Study Participants

According to Probable Cause of Acute Pancreatitis

 

In this study (Table No. 2), the most probable cause of acute pancreatitis among majority of the study participants were found to be alcohol (60%) followed by gallstones (17%) and unknown (11%).

Biomarker Level

Frequency (n=100)

Serum Amylase

>3 Fold

>2 Fold

>1 fold

WNL

 

69

09

16

06

Total

100

Serum Lipase

>3 Fold

>2 Fold

>1 fold

WNL*

 

77

08

08

07

Total

100

Table 3: Distribution of the Study Participants

According to Biomarker Level

 

*Within normal limit

In the present study (Table No. 3), it shows that serum amylase has increased more than >3 folds among 69 study participants and serum lipase has increased >3 folds among 77 study participants.

Trans-Abdominal USG

Frequency (n=100)

Acute Pancreatitis

Present

Absent

 

60

40

Total

100

Multi-Detector

Computed Tomography

Frequency

(n=100)

Acute Pancreatitis

Present

Absent

 

80

20

Total

100

Table 4: Distribution of Study Participants

According to Trans-Abdominal USG & MDCT

 

In the present study (Table No. 4), it shows that in trans–abdominal ultrasonography signs of acute pancreatitis present among 60 study participants and that in Multi-Detector Computed Tomography signs of acute pancreatitis present among 80 study participants.

 

Findings

Transabdominal USG

MDCT

Frequency

(%)

Frequency (%)

  1. Focal or Diffuse Enlargement of The Pancreas
  2. Pancreatic Gland Abnormalities and Inflammation
  3. Peri-Pancreatic Collection
  4. Pseudo-Pancreatic Cyst
  5. Pancreatic Necrosis

55 (91.67%)

 

 

60 (100)

 

 

7 (11.6%)

 

8 (13.3%)

 

2 (3.33%)

60 (75%)

 

 

70 (87.5%)

 

 

16 (20%)

 

8 (10%)

 

2 (2.5%)

Table 5: Comparison between USG &

MDCT Findings of Acute Pancreatitis

In this present study, (Table No. 5) focal or diffuse enlargement of the pancreas seen among 55 cases of acute pancreatitis detected by trans-abdominal ultrasonography and among 60 cases of acute pancreatitis detected by multi-detector computed tomography.

 

Biomarker Level

Multi-Detector

Computed Tomography

Total

Acute Pancreatitis

Present Frequency (%)

Acute Pancreatitis

Absent Frequency (%)

Serum Amylase >3 fold

Serum Amylase ≤3 fold

60

 

20

9

 

11

69

 

31

Total

80

20

100

Serum Lipase

>3 fold

Serum Lipase

≤3 fold

65

 

15

12

 

8

77

 

23

Total

80

20

100

Table 6: Cross Tabulation between

Biomarker Level and MDCT Finding

 

Among (Table No. 6) 69 patients with elevated serum amylase more than 3 folds of normal limit, only 60 cases are diagnosed as case of acute pancreatitis by multi-detector computed tomography. Among 77 patients with elevated serum lipase more than 3 folds of normal limit, only 65 cases are diagnosed as case of acute pancreatitis by multi-detector computed tomography. The sensitivity, specificity, positive predictive and negative predictive value calculated for Serum Amylase as 75% (CI 64.06% - 84.01%), 55% (CI 31.53% - 76.94%), 86.96% (CI 76.68% - 93.86%) and 35.48% (CI 19.23% - 54.63%). The sensitivity, specificity, positive predictive and negative predictive value calculated for Serum Lipase as 81.25% (CI 70.97 - 89.11%), 40% (CI 19.12% - 63.95%), 84.42% (74.36% - 91.68%) and 34.78% (16.38% - 57.27%).

 

Transabdominal USG

Multi-Detector

Computed Tomography

Total

Acute Pancreatitis Present

Acute Pancreatitis Absent

Acute Pancreatitis Present

60

00

60

Acute Pancreatitis Absent

20

20

40

Total

80

20

100

Table 7: Cross Tabulation between

Transabdominal USG and MDCT Finding

 

All the (Table No. 7), 60 patients diagnosed as acute pancreatitis by trans–abdominal ultrasonography also diagnosed by Multi-Detector Computed Tomography as acute pancreatitis. The sensitivity, specificity, positive predictive and negative predictive value calculated of trans-abdominal ultrasonography was 75% (CI 64.06% - 84.01%), 100% (CI 83.16% - 100%), 100% (CI 94.04% - 100%) and 50% (33.80% - 66.20%).

 

 

 

DISCUSSION

Acute pancreatitis is one of the commonly encountered aetiologies in the emergency setting and its incidence is rising. Kinney TP et al(9) found gallstones and alcohol abuse as commonest cause in 80% of cases. Other causes are neoplasm, infection, drugs, traumatic and iatrogenic (endoscopy, postoperative).(10,11) In our study, most common causative factors were alcohol abuse and gall stone induced. Alcohol alone 60%, gall stone induced 17% and both together 10%. Pain is the cardinal symptom.(12) accompanied by nausea and vomiting. In our study, most of the patients presented with abdominal pain accompanied by nausea and vomiting.

Chang JWY et al(13) reported a sensitivity and specificity of amylase at 3-fold above normal limit were 63.6% and 99.4% respectively, while sensitivity and specificity of lipase at 3-fold above normal limit were 95.5% and 99.2% respectively. They concluded both are good markers, but lipase was slightly better than amylase. In our study, the sensitivity and specificity of Serum Amylase was 75% (CI 64.06% - 84.01%), 55% (CI 31.53% - 76.94%) and for Serum Lipase was 81.25% (CI 70.97 - 89.11%), 40% (CI 19.12% - 63.95%). Finstad et al(14) reported pancreatic abnormalities by USG in 45 of 48 patients (91.7%). The classic finding of decreased gland echogenicity is present in only 44% of patients. In our study, 60 of 100 patients (60%) had abnormal pancreatic features and in the remaining 40 patients, pancreas was normal or poorly visualized due to obesity or excessive bowel gas shadow.

CONCLUSION

In our study, Alcohol and gallstone are the commonest causes of acute pancreatitis. Raised serum lipase levels were found more than amylase level. USG had similar sensitivity, but higher specificity value than serum markers (Amylase and lipase).

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