Ch. 17 Severe Epigastric Pain with Nausea and Vomiting

Question 1

How do you diagnose acute pancreatitis?

Answer 1

Acute pancreatitis is considered a clinical dx. Two of the following three required:

1. Sudden, severe, persistent epigastric pain radiating to the back
2. Elevated lipase or amylase to 3x greater than the upper limit of normal
3. Characteristic findings on imaging (i.e., enlarged pancreas, sentinel loops, colon cutoff sign, etc…)

Question 2

What is the significance of bruising around the umbilicus and flank?

Answer 2

Grey Turner’s Sign refers to a blue-black discoloration in the flanks. It is considered a sign of retroperitoneal hemorrhage due to acute pancreatitis.

Cullen’s Sign is a blue-red discoloration at the umbilicus, and the appearance is a result of digested blood products in the retroperitoneum, forming methemalbumin, that then travel towards the anterior abdominal wall.

Question 3

Retroperitoneal organs

Answer 3

Question 4

Most common cause of acute pancreatitis vs. chronic pancreatitis

Radiologic differences

Answer 4

Acute: Gallstone (40%), alcohol (30%)

• Dilated loops of bowel near pancreas (sentinel loop)

Chronic: Alcohol (90%), anatomic defects (pancreas divisum)

• Pancreatic calcifications

Question 5

How many phases are there in acute pancreatitis?

Answer 5

1. Premature activation of trypsin within the pancreatic acinar cells
2. Intrapancreatic inflammation
3. Extrapancreatic inflammation (affecting multiple organ systems)

Question 6

What is the mechanism for hypotension in pancreatitis?

Answer 6

Inflammation and cytokine storm –> endothelial injury and increased permeability in the peripancreatic vasculature –> fluid leaking into retroperitoneal space

Cytokine storm –> massive vasodilation (which along with a shrunken intravascular volume –> severe hypotension)

Question 7

What is the diagnostic imaging of choice on admission for acute pancreatitis?

Answer 7

RUQ U/S since the most common cause of acute pancreatitis is gallstones (this is the first etiology that should be ruled out)

Question 8

Mgmt:

What is the initial treatment for acute pancreatitis?

Answer 8

Supportive –> managed conservatively with vigorous IV fluid hydration, NPO, analgesics, nasogastric decompression only if vomiting

Majority of pt’s symptoms resolve within 3-5 days with this mgmt

Question 9

1. What should you suspect if a patient with severe acute pancreatitis, develops a fever and leukocytosis 3 weeks into hospitalization?
2. What should you suspect if a patient with a recent hospitalization for pancreatitis comes in 4 weeks later with persistent abdominal pain, a palpable epigastric mass, and persistently elevated serum amylase?

Answer 9

1. Pancreatic abscess
   
   1. Order a CT scan with contrast looking for necrotic tissue (areas that do not enhance) or a pancreatic abscess
2. ​Pancreatic pseudocyst
   
   1. ​Order a CT scan
   2. Majority of pts: resolves spontaneously in 6 weeks with supportive tx only

Question 10

What kind of nutritional support is necessary?

Answer 10

ENTERAL (not parenteral) is preferred –> feeding tube placed past the ligament of Treitz to avoid activation of the pancreas