Chapter 54: Pancreas- Acute Pancreatitis

Question 1

What is it?

Answer 1

Inflammation of the pancreas

Question 2

What are the most common etiologies in the United States?

Answer 2

1. Alcohol abuse (50%)
2. Gallstones (30%)
3. Idiopathic (10%)

Question 3

What is the acronym to remember all causes of pancreatitis?

Answer 3

“I GET SMASHED”:

• *I**diopathic/incineration
• *G**allstones
• *E**thanol
• *T**rauma
• *S**corpion bite
• *M**umps (viruses)
• *A**utoimmune
• *S**teroids
• *H**yperlipidemia/Hypercalcemia
• *E**RCP/end stage renal disease
• *D**rugs
• Methyldopa
• Metronidazole
• Estrogen
• Didanosine
• Valproate
• Isoniazid
• Pentamidine
• Sulfonamides

Question 4

What are the symptoms?

Answer 4

Epigastric pain (frequently radiates to back); nausea and vomiting

Question 5

What are the signs of pancreatitis?

Answer 5

• Epigastric tenderness
• Diffuse abdominal tenderness
• Decreased bowel sounds (adynamic ileus)
• Fever
• Dehydration/shock

Question 6

What lab tests should be ordered?

Answer 6

Amylase/lipase

Question 7

What are the associated diagnostic findings?

Answer 7

• Lab
  
  • ​High amylase
  • high lipase
  • high WBC
• AXR
  
  • ​Sentinel loop
  • colon cutoff
  • possibly gallstones (only 10% visible on xray)
• U/S
  
  • ​Phlegmon
  • cholelithiasis
• CT diagnositc
  
  • Phlegmon
  • pancreatic necrosis

Question 8

What is the most common sign of pancreatitis on AXR?

Answer 8

Sentinel loop(s)

Question 9

What is the treatment?

Answer 9

1. NPO
2. IVF
3. NGT if vomiting
4. Postpyloric tube feeds
5. H2 blocker/PPI
6. Analgesia (Meperdine not morphine)
7. Correction of coags/electrolytes

± Alcohol withdrawal prophylaxis

“Tincture of time”

Question 10

What are the possible complications?

Answer 10

• Pseudocyst
• Abscess/infection
• Pancreatic necrosis
• Splenic/mesenteric/portal vessel rupture or thrombosis
• Pancreatic ascites/pancreatic pleural effusion
• Diabetes
• ARDS/sepsis/MOF
• Coagulopathy/DIC
• Encephalopathy
• Severe hypocalcemia

Question 11

What is the prognosis?

Answer 11

Based on Ranson’s criteria

Question 12

Are postpyloric tube feeds safe in acute pancreatitis?

Answer 12

YES

Question 13

What are Ranson’s criteria at presentation?

Answer 13

1. Age >55
2. WBC >16,000
3. Glucose >200
4. AST >250
5. LDH >350

Alphabetically and numerically: A before L and 250 before 350
Therefore, AST >250 and LDH >350

Question 14

What are Ranson’s criteria during the intial 48 hrs?

Answer 14

1. Base deficit >4
2. BUN increase >5 mg/dL
3. Fluid sequestration >6 L
4. Serum Ca2+ <8
5. Hct decrease >10%
6. PO2 (ABG) <60 mm Hg

(Amylase value is NOT one of Ranson’s criteria!)

Question 15

What is the mortality per positive criteria:

0 to 2?

Answer 15

<5%

Question 16

What is the mortality per positive criteria:

3 to 4?

Answer 16

≈15%

Question 17

What is the mortality per positive criteria:

5 to 6?

Answer 17

≈40%

Question 18

What is the mortality per positive criteria:

7 to 8?

Answer 18

≈100%

Question 19

What is the etiology of hypocalcemia with pancreatitis?

Answer 19

Fat saponification: fat necrosis binds to calcium

Question 20

What complication is associated with splenic vein thrombosis?

Answer 20

Gastric varices (treatment with splenectomy)

Question 21

Can TPN with lipids be given to a patient with pancreatitis?

Answer 21

Yes, if the patient does not suffer from hyperlipidemia (triglycerides >300)

Question 22

What is the least common cause of acute pancreatitis (and possibly
the most commonly asked cause on rounds!)

Answer 22

Scorpion bite (found on the island of Trinidad)