Pancreatitis

Question 1

What are the classic symptoms of acute pancreatitis?

Answer 1

Epigastric abdominal pain radiating to the back, nausea, vomiting, anorexia, fever, tachycardia.

Question 2

What is the most likely cause of acute pancreatitis in this patient?

Answer 2

Cholelithiasis (gallstones).

Question 3

What are the Atlanta criteria for diagnosing acute pancreatitis?

Answer 3

1. Severe epigastric pain radiating to the back, 2. Lipase or amylase >3x upper limit of normal, 3. Imaging findings (enlarged pancreas, sentinel loops, colon cutoff sign).

Question 4

What laboratory findings support acute pancreatitis?

Answer 4

Elevated lipase and amylase (3x normal), leukocytosis, elevated ALT/AST, hyperglycemia.

Question 5

What imaging findings are associated with acute pancreatitis?

Answer 5

Sentinel loops (dilated small bowel), colon cutoff sign, pancreatic enlargement.

Question 6

What conditions are in the differential diagnosis for epigastric pain?

Answer 6

Gastroenteritis, acute gastritis, acute cholecystitis, peptic ulcer disease, perforated ulcer, pancreatitis, appendicitis, small bowel obstruction, mesenteric ischemia, ruptured AAA, referred MI pain.

Question 7

How does acute cholecystitis differ from pancreatitis?

Answer 7

Cholecystitis presents with RUQ pain, Murphy’s sign, fever; pancreatitis presents with epigastric pain radiating to the back.

Question 8

What is the significance of a sentinel loop on imaging?

Answer 8

It indicates localized ileus due to nearby inflammation, commonly seen in acute pancreatitis.

Question 9

What is the significance of the colon cutoff sign?

Answer 9

Abrupt termination of gas at the splenic flexure, suggesting inflammation near the pancreas (e.g., pancreatitis).

Question 10

What are the risk factors for acute pancreatitis?

Answer 10

Gallstones, alcohol use, hypertriglyceridemia, medications, infections, trauma.

Question 11

What are the complications of acute pancreatitis?

Answer 11

Necrosis, pseudocysts, abscess, hemorrhage, systemic inflammatory response syndrome (SIRS), multi-organ failure.

Question 12

What are the vital sign abnormalities in acute pancreatitis?

Answer 12

Tachycardia, possible fever, normal to slightly elevated blood pressure initially.

Question 13

What additional tests should be considered in acute pancreatitis?

Answer 13

Abdominal ultrasound (to check for gallstones), CT scan (to assess for complications).

Question 14

What is the initial management of acute pancreatitis?

Answer 14

NPO (bowel rest), IV fluids, pain control, electrolyte management, consider antibiotics if infection suspected.

Question 15

What are the most common causes of acute pancreatitis?

Answer 15

Gallstones and alcohol use.

Question 17

What nonsurgical conditions can mimic an acute abdomen?

Answer 17

Gastroenteritis, acute adrenal insufficiency, sickle cell crisis, diabetic ketoacidosis, acute porphyria, pelvic inflammatory disease, kidney stones, and pyelonephritis.

Question 18

What is the significance of bruising around the umbilicus, flank, and inguinal ligament?

Answer 18

They are signs of retroperitoneal hemorrhage in association with acute hemorrhagic pancreatitis where methemalbumin formed from digested blood tracks subcutaneously to different parts of the abdominal wall. Grey Turner’s sign refers to a blue-black discoloration in the flanks. Cullen’s sign is a blue-red discoloration at the umbilicus, and Fox’s sign is bruising over the inguinal ligament.

Question 19

What are the signs, symptoms, and findings of acute pancreatitis?

Answer 19

Epigastric pain radiating to the back, worsened with food, nausea/vomiting (90% of cases), anorexia, or decreased oral intake. Physical exam frequently reveals fever, tachycardia, epigastric tenderness with localized guarding, and hypoactive bowel sounds secondary to reactive ileus.

Question 20

What structures are in the retroperitoneum?

Answer 20

One can remember these structures with the following mnemonic, ‘SAD PUCKER’: suprarenal (adrenal) glands, aorta/IVC, duodenum (2nd and 3rd part), pancreas (except tail), ureters, colon (ascending and descending), kidneys, esophagus and rectum.

Question 21

What is the pathophysiology of pancreatitis?

Answer 21

It occurs as a result of inappropriate activation of pancreatic enzymes leading to peripancreatic inflammation. Intraparenchymal extravasation of enzymes causes autodigestion of pancreatic parenchyma but primarily damages the peripancreatic tissues and vasculature. The inflammatory response is out of proportion to the insult and, with time, potentiates further damage leading to fluid sequestration, fat necrosis, vasculitis, and hemorrhage.

Question 22

What are the etiologies for pancreatitis?

Answer 22

5 ‘GET SMASHED’ will help you remember the causes of acute pancreatitis: G – gallstones (40%), E – ethanol (30%), T – tumors, S – scorpion stings, M – mycoplasma or mumps, A – autoimmune (Lupus or polyarteritis nodosa), S – surgery or trauma, H – hyperlipidemia/hypercalcemia, E – ERCP or embolic/ischemic, D – drugs or toxins.

Question 23

What medications can cause pancreatitis?

Answer 23

Medications that can cause pancreatitis include: Cardiovascular disease: Furosemide, thiazides; Inflammatory bowel disease: Sulfasalazine, 5-ASA; Immunosuppression: Azathioprine; Seizures: Valproic acid; Diabetes: Exenatide; HIV: Didanosine, pentamidine.

Question 24

What are the 4 ‘F’s’ for gallbladder disease?

Answer 24

Female, fat, forty, and fertile.

Question 25

What is the first step in the evaluation for gallstones?

Answer 25

An abdominal ultrasound is the first step in the evaluation for gallstones.

Question 26

How do gallstones cause acute pancreatitis?

Answer 26

Gallstones cause acute pancreatitis by passing from the gallbladder into the common bile duct, causing transient impaction at the ampulla, which raises pancreatic duct pressure.

Question 27

In patients with gallstone pancreatitis, how often does the gallstone remain impacted in the distal common duct?

Answer 27

In the majority of cases, the stone remains impacted briefly, only transiently obstructing the ampulla of Vater before passing into the duodenum.

Question 28

What are the differences between acute and chronic pancreatitis?

Answer 28

Acute pancreatitis has a severe and sudden onset, usually caused by gallstones (40%) or alcohol (30%), presenting with epigastric pain radiating to the back, nausea, vomiting, and anorexia. Chronic pancreatitis involves recurrent episodes, is mainly caused by alcohol (90%) and anatomic defects (e.g., pancreas divisum), and presents with recurrent epigastric pain, weight loss, diabetes, and steatorrhea.

Question 29

How is the severity of pancreatitis classified?

Answer 29

The severity is classified as mild (80-90% of cases, resolves in 2-5 days), moderately severe (with transient organ failure or complications), and severe (persistent organ failure lasting more than 48 hours).

Question 30

What organ systems can be affected by acute pancreatitis?

Answer 30

Cardiac, pulmonary, renal, and gastrointestinal systems can be affected.

Question 31

How is organ failure defined in acute pancreatitis?

Answer 31

Organ failure is defined by: systolic blood pressure < 90 mmHg, PaO2 ≤ 60 mmHg, creatinine >2.0 mg/L after rehydration, gastrointestinal bleeding >500 cc/24 hours, disseminated intravascular coagulation, and metabolic disturbances (calcium <7.5 mg/dl).

Question 32

What is the mechanism of hypotension in pancreatitis?

Answer 32

Hypotension in pancreatitis is caused by inflammation and cytokine storm, leading to endothelial injury, increased vascular permeability, fluid leakage (third spacing), and massive vasodilation with reduced intravascular volume.

Question 33

What are the main pulmonary complications of acute pancreatitis?

Answer 33

Main pulmonary complications include pleural effusions (majority on the left side) and acute respiratory distress syndrome (ARDS), caused by cytokine-mediated vasodilation and pancreatic enzyme (e.g., phospholipase A2) mediated lung injury.

Question 34

Which medications are used for cardiovascular disease?

Answer 34

Furosemide, thiazides.

Question 35

Which medications are used for inflammatory bowel disease?

Answer 35

Sulfasalazine, 5-ASA.

Question 36

Which medications are used for immunosuppression?

Answer 36

Azathioprine.

Question 37

Which medications are used for seizures?

Answer 37

Valproic acid.

Question 38

Which medications are used for diabetes?

Answer 38

Exenatide.

Question 39

Which medications are used for human immunodeficiency virus (HIV)?

Answer 39

Didanosine, pentamidine.