18. Disorders of the pancreas

Question 1

What is the difference between diagnosis and etiology?

Answer 1

Diagnosis refers to identifying a disease or condition, while etiology refers to identifying the cause of the disease or condition.

Question 2

What tests are needed for a patient with AP?

Answer 2

• Measurements of inflammatory markers (CRP, WBC), liver enzymes, TG, cholesterol and calcium
• Pancreatic imaging
• Determining BISAP score
• Genetic testing following second episode of AP

Question 3

What is the BISAP score used for severity prediction in acute pancreatitis?

Answer 3

Bedside Index for Severity in Acute Pancreatitis score, which includes
- serum urea level,
- impaired mental state,
- SIRS criteria,
- age > 60,
- presence of hydrothorax.

Question 4

What is the mortality rate for patients with a BISAP score less than 2?

Answer 4

Less than 2%.

Question 5

What are the recommended measurements when diagnosing AP?

Answer 5

Inflammatory markers (CRP, WBC, PCT), liver enzymes, triglyceride, cholesterol, and calcium.

Question 6

What are some common mistakes when using early CT scans in acute pancreatitis?

Answer 6

• Early CT scans (in the first 72-96 hours) may be false negative or underscore acute pancreatitis,
• mCTSI may misdiagnose severity due to subjective components of criteria,
• there may be confusion between “walled-off necrosis” and pseudocysts.

Question 7

Why is fluid resuscitation important in acute pancreatitis?

Answer 7

Patients with AP are hypovolemic due to vomiting, decreased oral fluid intake, sweating, and loss of fluid into a third water-space.

Question 8

What are the three steps recommended for fluid resuscitation therapy?

Answer 8

• Start with rapid 5-10ml/bodykg/h infusion,
• Ringer lactate (2500-3000ml) is the optimal choice for securing daily fluid intake,
• Monitor the efficacy of fluid resuscitation (electrolytes, BUN, hematocrit), physical parameters (pulse, MAP, urine)!

Question 9

What happens to CRP and WBC levels in the first 3 days of acute pancreatitis?

Answer 9

CRP and WBC levels rise due to the sterile inflammation in the first 3 days of acute pancreatitis.

Question 10

What are the common mistakes in initiating AB therapy for acute pancreatitis?

Answer 10

1) Initiating AB therapy as a response to rising CRP and WBC in the first days of admission.
2) Indicating prophylactic antibiotics for necrosis.

Question 11

What is the only parameter really correlating with infection?

Answer 11

PCT (specifically bacterial infection)

Question 12

What are some common mistakes in feeding patients with acute pancreatitis?

Answer 12

Lack of feeding, fear of gastric feeding, and postponing re-feeding until the normalization of laboratory studies.

Question 13

Is enteral nutrition recommended for acute pancreatitis?

Answer 13

Yes, enteral nutrition is recommended and very rarely contraindicated in acute pancreatitis.

Question 14

What is the optimal timing of ERCP in acute biliary pancreatitis (ABP)?

Answer 14

Urgent ERCP (<24h) is recommended ONLY if ABP is associated with acute cholangitis.

Question 15

What should be done if biliary stones or obstruction cannot be confirmed with conventional imaging?

Answer 15

Non-invasive methods such as MRCP or EUS should be used.

Question 16

What are some common mistakes associated with performing ERCP and EST?

Answer 16

Performing ERCP and EST without proper indication, such as confirmed bile duct stone, obstruction, or cholangitis.

Question 17

What is the recommended first choice for imaging if cholangitis and obstruction are not confirmed?

Answer 17

MRCP or EUS should be the first choice.

Question 18

When should cholecystectomy be performed in mild acute biliary pancreatitis?

Answer 18

In mild acute biliary pancreatitis, an early cholecystectomy performed immediately after the acute episode (without discharge) seems to be safe and is therefore recommended.

Question 19

When should cholecystectomy be performed in severe acute biliary pancreatitis?

Answer 19

A delayed cholecystectomy is recommended in the case of peripancreatic fluid collections to provide sufficient time for reabsorption, or if they persist, cholecystectomy seems to be safe 6 weeks later.

Question 20

What are some common mistakes in the timing of cholecystectomy for acute pancreatitis?

Answer 20

• Ignoring step-up approach and initiating an invasive treatment with surgery.
• Early (within 4 weeks) surgery, which may be associated with a high rate of complications, such as bleeding, infection, loss of pancreatic parenchyma
• Discharge without cholecystectomy following mild ABP.

Question 21

What is a common mistake in the categorization of acute pancreatitis as “severe”?

Answer 21

AP is often categorized to be “severe” even if persistent organ failure did not occur.

Question 22

What is required to diagnose diabetes as a complication?

Answer 22

Knowledge of pre-existing diseases, initial HgbA1c levels, and continuous blood glucose monitoring.