18 - Pancreatitis

Question 1

2 mortality peaks for acute pancreatitis

Answer 1

w/in 1-2 wks from multi organ failure

later (3+wks) from infection

Question 2

what starts the cascade of acute pancreatitis

Answer 2

conversion of typsinogen to trypsin > starts cascade of other enzymes and degrading the pancreas
cause of this first event usually unknown

Question 3

pathophys of acute pancreatitis

Answer 3

initial insult is activation of enzymes
> microcirculatory damage > edema and ischemia
disruption of pancreatic ducts
cytokines from PMNs and macrophages > systemic inflammatory response

Question 4

2 main causes of acute pancreatitis

Answer 4

gallstones (40%) and alcohol abuse (30%)

Question 5

less common causes of acute pancreatitis

Answer 5

hyperTGemia
microlithiasis/biliary sludge
drugs
hypercalcemia

Question 6

dx of acute pancreatitis

Answer 6

need 2 of:
typical sx
amylase/lipase 3x nl limits
CT findings of pancreatitis

Question 7

acute pancreatitis sx and signs

Answer 7

sx: abd pain - epigastric radiating to back, steady, mod-severe; N/V
signs: abd tenderness
Gray Turner’s sign (ecchymoses in flanks)
Cullen’s sign - periumbilical ecchymosis
tachycardia, fever
resp distress, AMS in severe cases

Question 8

which one rises quicker in acute pancreatitis - amylase or lipase?

Answer 8

amylase

Question 9

imaging modality for pancreatitis

Answer 9

CT

Question 10

Ranson’s criteria (not specfics, just general use)

Answer 10

for judging severity of acute pancreatitis

1 set for at admission, and check again at 48 hrs

Question 11

Balthazar grades

Answer 11

CT scoring guide for acute pancreatitis

Question 12

BISAP score

Answer 12

score for acute pancreatitis

BUN >25
Impaired mental status
SIRS (>2 signs)
Age >60
Pleural effusions 

> 3 has likelihood for severe pancreatitis

Question 13

management of acute pancreatitis

Answer 13

NPO (enteral feeding, not TPN)
aggressive IVF resuscitation (lactated ringer’s, maintain good urine output)
pain control (opiates)
*prophylactic abx generally NOT indicated

Question 14

local complications of acute pancreatitis

Answer 14

pseudocysts, walled off necrosis

Question 15

pathophys of chronic pancreatitis

Answer 15

loss of parenchymal cells, chronic inflammation, fibrosis

Question 16

MCC chronic pancreatitis

Answer 16

alcohol abuse

Question 17

presentation of chronic pancreatitis

Answer 17

abd pain
exocrine insufficiency (steatorrhea, wt loss, diarrhea)
endocrine insufficiency - usually later (DM, reduced glucagon)

Question 18

indirect tests for chronic pancreatitis

Answer 18

fecal elastase

fecal fat

Question 19

“gold standard” for chronic pancreatitis dx

Answer 19

ECRP - dialted pancreatic duct, filling defects, dilated side branches

Question 20

mgmt of abd pain in chronic pancreatitis

Answer 20

stop ETOH
want to avoid pain meds if possible - addiction
pancreatic enzymes - non enteric coated

Question 21

chronic pancreatitis and pancreatic adenoCA

Answer 21

4% lifetime risk of CA
inc w/ smoking
difficult to dx in setting of chronic pancreatitis - similar presentation