15. Surgical aspects of acute pancreatitis (symptoms, diganosis, treatment)

Question 1

Most common causes

Answer 1

1. Biliary pancreatitis; e.g., gallstones
2. Alcohol-induced
3. Idiopathic

Question 2

Other causes

Answer 2

• Severe hypertriglyceridemia (> 1,000 mg/dl)
• hypercalcemia
• Post-ERCP
• Certain drugs
• Scorpion stings
• mumps
• Trauma (especially in children)
• Autoimmune and rheumatological disorders

Question 3

Symptoms; pain

Answer 3

Constant, severe epigastric pain

• radiates towards back, worse after meals
• nausea + vomiting

Question 4

Symptoms; General physical examination

Answer 4

Signs of shock

Question 5

Symptoms; Abdominal examination

Answer 5

• Abdominal tenderness
• distention
• guarding

Question 6

Diagnosis

Answer 6

Based on clinical presentation, pancreatic enzyme serum elevation or characteristic findings on imaging

Question 7

Lab - confirmational tests

Answer 7

↑ Serum pancreatic enzymes

Lipase: if ≥ 3 x the upper reference range → highly indicative of acute pancreatitis

Amylase

Does not show severity

Question 8

Lab - tests to assess severity

Answer 8

Hct

↑ Hct (due to hemoconcentration) indicates third space fluid loss and inadequate fluid resuscitation

↓ Hct indicates the rarer acute hemorrhagic pancreatitis

Question 9

Imaging

Answer 9

1. US
2. CT-scan (uncommon)
3. MRCP/ERCP (if billiary/pancreatic duct obstruction is suspected)
4. X-ray

Question 10

PANCREAS mnemonic in treatment

Answer 10

Perfusion (fluid replacement) 
Analgesia 
Nutrition
Clinical (observation)
Radiology (imaging)
ERC (endoscopic stone extraction)
Antibiotics
Surgery (surgical intervention, if necessary)

Question 11

Surgical considerations

Answer 11

1. In case of suspicion/detection of infected, necrotized pancreatitis
2. If no infection: in case of ongoing organ failure several weeks after onset

Question 12

Surgical techniques

Answer 12

• Percutaneous (retroperitoneal) catheter drainage
• Minimal necrosectomy
• Open necrosectomy

Question 13

Surgery indications

Answer 13

• Abdominal compartment syndrome
• Ongoing acute bleeding
• Bowel ischemia
• Ongoing leakage or obstruction due to mass effect (compression)