Diagnosis of Acute Pancreatitis Using a Clinical Risk Score

Mark H. Ebell

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Point-of-Care Guides

Diagnosis of Acute Pancreatitis Using a Clinical Risk Score

Mark H. Ebell, MD, MS

American Family Physician. 2025;112(3):322-323.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

CLINICAL QUESTION

Which patients with acute abdominal pain and elevated lipase levels have acute pancreatitis?

EVIDENCE SUMMARY

Typical symptoms of acute pancreatitis include upper abdominal pain that radiates to the back and nausea and vomiting. Signs may include abdominal tenderness to palpation, guarding, and distension with hypoactive bowel sounds¹; however, individual signs and symptoms have not been well studied for their accuracy.

The diagnostic accuracy of individual laboratory tests for the diagnosis of acute pancreatitis is well studied.² A Cochrane review of 10 studies with 5,096 participants evaluated the accuracy of serum amylase, serum lipase, and urinary trypsinogen.³ Table 1 summarizes these results.³ All tests had similar accuracy; however, other studies have found that approximately one-half of patients with a serum lipase level above three times the upper limit of normal (ULN) do not have acute pancreatitis.^4,5 Other conditions, such as small bowel obstruction, gastroenteritis, biliary tract disease, hepatitis, kidney failure, and alcohol intoxication, can also cause significant elevation in serum lipase levels.⁴

LR– = negative likelihood ratio; LR+ = positive likelihood ratio; ULN = upper limit of normal.
*—Assumes 23% prevalence of acute pancreatitis in patients with acute abdominal pain.
Information from reference 3.

A simple risk score for the diagnosis of acute pancreatitis was developed from a 2018 study that included 318 patients with serum lipase levels three times the ULN and used the serum lipase levels and elements from the patients' history (acute pancreatitis, cholelithiasis, recent abdominal surgery, epigastric pain, pain severity and whether it is worsening, and pain for 5 or more days) extracted from electronic health records⁵ (Table 2). Ultimately, 182 (57%) patients were diagnosed with acute pancreatitis based on expert review of hospital records, including imaging and laboratory studies, as the reference standard. However, retrospective data abstraction from a health record can be subject to a range of reporting biases. For example, was a sign or symptom not present or simply not recorded? Therefore, it is especially important that this risk score be prospectively validated in a new population.

ULN = upper limit of normal
*—Each episode of acute pancreatitis is 1 point (up to a maximum of 4 points).
Adapted from Jin DX, Lacson R, Eskian M, et al. Prospective validation of a prediction model for the diagnosis of acute pancreatitis. *JAMA Netw Open*. 2024;7(6):e2419014.

MARK H. EBELL MD, MS, Department of Family Medicine, Michigan State University, East Lansing

Address correspondence to Mark H. Ebell MD, MS, at ebell@msu.edu.

Author disclosure: No relevant financial relationships.

1.Walkowska J, Zielinska N, Tubbs RS, et al. Diagnosis and treatment of acute pancreatitis. Diagnostics (Basel). 2022;12(8):1974.
2.Kemppainen EA, Hedström JI, Puolakkainen PA, et al. Rapid measurement of urinary trypsinogen-2 as a screening test for acute pancreatitis. N Engl J Med. 1997;336(25):1788-1793.
3.Rompianesi G, Hann A, Komolafe O, et al. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis. Cochrane Database Syst Rev. 2017(4):CD012010.
4.Jin DX, Lacson R, Eskian M, et al. Prospective validation of a prediction model for the diagnosis of acute pancreatitis. JAMA Netw Open. 2024;7(6):e2419014.
5.Jin DX, Lacson R, Cochon LR, et al. A clinical model for the early diagnosis of acute pancreatitis in the emergency department. Pancreas. 2018;47(7):871-879.
6.Banks PA, Bollen TL, Dervenis C, et al.; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision-making at the point of care.

This series is coordinated by Mark H. Ebell, MD, MS, deputy editor for evidence-based medicine.

A collection of Point-of-Care Guides published in AFP is available at https://www.aafp.org/afp/poc.

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[afp20250900p322-b1] 1.Walkowska J, Zielinska N, Tubbs RS, et al. Diagnosis and treatment of acute pancreatitis. Diagnostics (Basel). 2022;12(8):1974.

[afp20250900p322-b2] 2.Kemppainen EA, Hedström JI, Puolakkainen PA, et al. Rapid measurement of urinary trypsinogen-2 as a screening test for acute pancreatitis. N Engl J Med. 1997;336(25):1788-1793.

[afp20250900p322-b3] 3.Rompianesi G, Hann A, Komolafe O, et al. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis. Cochrane Database Syst Rev. 2017(4):CD012010.

[afp20250900p322-b4] 4.Jin DX, Lacson R, Eskian M, et al. Prospective validation of a prediction model for the diagnosis of acute pancreatitis. JAMA Netw Open. 2024;7(6):e2419014.

[afp20250900p322-b5] 5.Jin DX, Lacson R, Cochon LR, et al. A clinical model for the early diagnosis of acute pancreatitis in the emergency department. Pancreas. 2018;47(7):871-879.

[afp20250900p322-b6] 6.Banks PA, Bollen TL, Dervenis C, et al.; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111.

Test	Sensitivity (%)	Specificity (%)	LR+	LR−	Probability of acute pancreatitis^*

					Positive test result (%)	Negative test result (%)
Serum amylase > three times the ULN	72	93	10.3	0.30	74	8
Serum lipase > three times the ULN	79	89	7.2	0.24	68	7
Urine trypsinogen-2 > 50 ng/mL	72	90	7.2	0.31	67	8

Predictor	Points
Number of prior episodes of acute pancreatitis^*	0–4
History of cholelithiasis	2
Abdominal surgery in past 2 months	−2
Epigastric pain	2
Worsening pain severity	1
Duration of pain ≥ 5 days	−1
Pain severity on 10-point scale
Mild (0–3)	0
Moderate (4–6)	2
Severe (7–10)	3
Serum lipase level
≥ 3 to < 10 times the ULN	0
≥ 10 to < 20 times the ULN	1
≥ 20 times the ULN	2
Total	__________
Total points	Acute pancreatitis/total	Likelihood ratio

Low risk: < 5	23/171 (13%)	0.19
Moderate risk: 5 to 7	45/82 (55%)	1.49
High risk: ≥ 8	89/96 (93%)	15.6

Single cutoff
Low risk: < 6	29/194 (15%)	0.22
High risk: ≥ 6	128/155 (83%)	5.8

Diagnosis of Acute Pancreatitis Using a Clinical Risk Score

CLINICAL QUESTION

EVIDENCE SUMMARY

TABLE 1. Accuracy of Individual Blood and Urine Tests for the Diagnosis of Acute Pancreatitis in Patients Presenting With Acute Abdominal Pain

TABLE 2. Validated Risk Score for the Diagnosis of Acute Pancreatitis in Patients Admitted With Acute Abdominal Pain

Diagnosis of Acute Pancreatitis Using a Clinical Risk Score

CLINICAL QUESTION

EVIDENCE SUMMARY

TABLE 1. Accuracy of Individual Blood and Urine Tests for the Diagnosis of Acute Pancreatitis in Patients Presenting With Acute Abdominal Pain

TABLE 2. Validated Risk Score for the Diagnosis of Acute Pancreatitis in Patients Admitted With Acute Abdominal Pain

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