Acute pancreatitis

Question 1

What is the mortality rate of severe pancreatitis?

Answer 1

up to 10% to 30%

Question 2

mortality in pancreatitis has a bimodal distribution.

describe it and what is the most common cause of death?

Answer 2

EARLY PHASE - multiorgan dysfunction syndrome (most common). LATE PHASE - SEPTIC COMPLICATIONS
The most common cause of death is multiorgan dysfunction syndrome.
in the first 2 weeks (early phase), the multiorgan dysfunction syndrome is the final result of
an intense inflammatory cascade triggered initially by pancreatic inflammation.
Mortality after 2 weeks (late period), is often caused by septic complications.

Question 3

which pprotease is responsible for cell death (and which cell) in acute pancreatitis?

Answer 3

The cytosolic cathepsin B induces apoptosis or necrosis, leading to acinar cell death.

Question 4

what is the most common cause of pancreatitis?

how many cases in the U.S?

Answer 4

Gallstone pancreatitis.

40% of U.S. cases.

Question 5

what is the incidence for a patient with gallstones to develop pancreatitis?

Answer 5

3 - 8 %

Question 6

what are the two theories of pancreatitis mechanism?

Answer 6

Obstructive theory, pancreatic injury is the result of
excessive pressure inside the pancreatic duct. This increased intraductal pressure is the result of continuous secretion of pancreatic juice in the presence of pancreatic duct obstruction.
Reflux, theory proposes that stones become impacted in the ampulla of Vater and form a common channel that allows bile salt reflux into the pancreas. Animal models have shown that bile salts cause direct acinar cell necrosis because they increase the concentration
of calcium in the cytoplasm; however, this has never been proven in humans

Question 7

what are the factors that contribute to ethanol-induced pancreatitis?

Answer 7

heavy ethanol abuse (>100 g/day for at least 5 years), smoking, and genetic predisposition.

Question 8

what is the second most common cause

of pancreatitis worldwide. What percentage of cases?

Answer 8

Excessive ethanol consumption.

35% of cases

Question 9

what type of anatomic obstruction can cause abnormal flow of pancreatic juice into the duodenum and pancreatic injury?

Answer 9

pancreatic tumors, parasites, and congenital defects

Question 10

name an anatomic variation that can cause pancreatitis (controversial). what percentage of the population has this variation? what is the treatment?

Answer 10

Pancreas divisum. annular pancreas (less common).
present in 10% of the population.
5% to 10% lifetime risk for pancratitis
ERCP with minor papillotomy and stenting may be beneficial for such patients.

Question 11

which parasite can cause pancreatitis?

Answer 11

Ascaris lumbricoides

Question 12

What is the most common complication after ERCP. percentage?

Answer 12

Pancreatitis. up to 5% of patients!

90-95% mild pancreatitis

Question 13

Up to 2% of acute pancreatitis cases are caused by medications. What are the most common agents?

Answer 13

sulfonamides, metronidazole, erythromycin,

tetracyclines, thiazides, furosemide, statins, acetaminophen and more…

Question 14

Which metabolic factors can cause pancreatitis?

Answer 14

Hypertriglyceridemia and hypercalcemia

Question 15

level of triglyceride that can cause pancreatitits?

Answer 15

> 1000 mg/dL - suspected

>2000 mg/dL - confirms the diagnosis

Question 16

what are the cardinal symptoms of acute pancreatitis?

Answer 16

epigastric or periumbilical CONSTANT pain that radiates to the back. Up to 90% of patients have nausea or vomiting that typically does not relieve the pain

Question 17

describe two rare findings of pancreatitis?

what causes them?

Answer 17

flank and periumbilical ecchymosis (Grey Turner and Cullen signs, respectively). Both are indicative
of retroperitoneal bleeding associated with severe pancreatitis.

Question 18

possible physical examination findings of the lung on acute pancreatitis

Answer 18

Dullness to percussion and decreased breathing sounds in the left or, less commonly, in the right hemithorax suggest pleural effusion secondary to AP.

Question 19

which of the two - amylase or lipase is more indicative for acute pancreatitis 24 - 48 hours after the onset and why?

Answer 19

lipase levels is a more sensitive indicator to
establish the diagnosis. Lipase is also a more specific marker of AP.
The serum half-life of amylase is shorter than that of lipase.

Question 20

acute pancreatitis - lab results?

Answer 20

Typically hyperglycemic,
Leukocytosis
Liver enzyme elevation.

The elevation of alanine aminotransferase levels in the serum in the context of AP confirmed by high pancreatic enzyme levels has a positive predictive value of 95% in the diagnosis of acute biliary pancreatitis.

Combined with the presence of gallstones on ultrasound have an even higher sensitivity (97%) and specificity (100%) for diagnosing acute biliary pancreatitis.

Question 21

Which findings can be found on simple abdominal radiograph of acute pancreatitis?
why should it be performed?

Answer 21

Althoughnot useful for diagnosis, they can help rule out other conditions, such as perforated ulcer disease. Nonspecific findings:
air-fluid levels suggestive of ileus, cutoff colon sign as
a result of colonic spasm at the splenic flexure, and widening of the duodenal C loop caused by severe pancreatic head edema.

Question 22

the rule of US in acute pancreatitis

Answer 22

this test should always be ordered in patients with AP because of its high sensitivity (95%) in diagnosing gallstones.

The usefulness for diagnosis is limited by intra-abdominal fat and increased intestinal gas as a result of ileus.

Question 23

What is the best modality for evaluation of the pancreatitis?

Answer 23

Contrast-enhanced computed tomography.

Noncontrast CT scanning may also be of value in the setting of renal failure by identifying fluid collections or extraluminal air

Question 24

which phase of CT is the most valuable to evaluate pancreatitis?

Answer 24

portal venous phase
(65 to 70 seconds after injection of contrast material), which allows evaluation of the viability of the pancreatic parenchyma, amount of peripancreatic inflammation, and presence of intra-abdominal free air or fluid collections.

Question 25

MRCP is not indicated in acute pancreatitis, what is its important role?
which additional act can improve its findings?

Answer 25

evaluation unexplained or recurrent pancreatitis.
it allows complete visualization of the biliary and pancreatic duct anatomy.

intravenous (IV) administration of secretin increases pancreatic duct secretion, which causes a transient distention of the pancreatic duct.

Question 26

secretin MRCP is useful to demontrate…

Answer 26

pancreas divisum, intraductal papillary mucinous neoplasm (IPMN), or a small tumor in the pancreatic duct.

Question 27

evaluation method of persistent choledocholithiasis in AP?

Answer 27

Endoscopic ultrasound (EUS).

EUS has been proven to be sensitive for identifying choledocholithiasis; it allows examination of the biliary tree and pancreas with no risk of worsening of the pancreatitis.

Question 28

when ERCP is indicated for acute pancreatitis?

Answer 28

1. severe acute biliary pancreatitis
2. patients who develop cholangitis
3. persistent bile duct obstruction demonstrated by other imaging modalities, such as EUS.
4. older patients with poor performance status or severe comorbidities that preclude surgery, ERCP with sphincterotomy is a safe alternative to prevent recurrent biliary pancreatitis

Routine ERCP for suspected gallstone pancreatitis reveals no evidence of persistent obstruction in most cases and may actually worsen symptoms because of manipulation of the gland.

Question 29

describe the Ranson criteria,
What are the disadvantages of this criteria?
what is its main use and why?

Answer 29

predicts the severity of the disease on the basis of 11 parameters obtained at the time of admission or 48 hours later.

mortality rate correlates with number of positive parameters.
Severe pancreatitis is diagnosed if three or more of the Ranson criteria are fulfilled.

The main disadvantage is that it does not
predict the severity of disease at the time of the admission because six parameters are assessed only after 48 hours of admission.

mainly used to rule out severe pancreatitis or to predict the risk of mortality.
Low positive predictive value (50%) and high
negative predictive value (90%).

Question 30

signs that can indicate severe pancreatitis?

Answer 30

local pancreatic complications (necrosis, abscess, or pseudocyst)
any evidence of organ failure.

C-reactive protein (CRP) > 150 mg/ml
(peaks 48 to 72 hours after the onset of pancreatitis and correlates with the severity of the disease)

Question 31

Ranson Prognostic Criteria for Gallstone Pancreatitis

11 points

Answer 31

At presentation
• Age >70 years
• Blood glucose level >220 mg/dL
• White blood cell count >18,000 cells/mm3
• Lactate dehydrogenase level >400 IU/liter
• Aspartate aminotransferase level >250 IU/liter
After 48 hours of admission
• Hematocrit*: decrease >10%
• Serum calcium level <8 mg/dL
• Base deficit >5 mEq/L
• Blood urea nitrogen level: increase >2 mg/dL
• Fluid requirement >4 liters
• PaO2: Not available

Question 32

Treatment of acute pancreatitis

Answer 32

fluids, O2, analgestics, pulse oximeter:

aggressive fluid resuscitation with isotonic crystalloid solution. may need catheter.

PULSE OXIMETRY because one of the most common
systemic complications of AP is hypoxemia caused by the acute lung injury associated with this disease.

supplementary oxyge - saturation > 95%.
analgesia.

Question 33

which patients with biliary pancreatitis should be operated? which operation?

Answer 33

With the exception of older patients and those with poor performance status, laparoscopic cholecystectomy
is indicated for all patients with mild acute biliary pancreatitis.

Question 34

when patients with biliary pancreatitis should be operated?

Answer 34

Studies have shown that early laparoscopic cholecystectomy, defined as laparoscopic cholecystectomy during the initial admission to the hospital, is a safe procedure that decreases recurrence of the disease.
For patients with severe pancreatitis, early surgery may increase the morbidity and length of stay

Question 35

when should patients with severe biliary pancreatitis should be operated?

Answer 35

conservative treatment for at least 6 weeks before laparoscopic cholecystectomy

Question 36

what is the percentage of acute abdominal fluid during an episode of acute pancreatitis?

Answer 36

30% to 57% of patients.

Question 37

does luid collections due to pancreatitis are surrounded or encased by epithelium or fibrotic capsule?
if not, who does?

Answer 37

no.

pseudocysts and cystic neoplasias of the pancreas do.

Question 38

what is the treatment for fluid collections due to pancreatitis?

Answer 38

supportive because most fluid collections will be spontaneously reabsorbed by the peritoneum.

Question 39

what are the signs of fluid collection infection in pancreatitis?
how can it be confirmed?
what is the treatment?

Answer 39

Fever, elevated, white blood cell count, and abdominal pain suggest infection of this fluid, and percutaneous aspiration is confirmatory. Percutaneous drainage and IV administration of antibiotics should be instituted
if infection is present.

Question 40

how many patients with AP will develop pancreatic necrosis?

Answer 40

Up to 20%

Question 41

It is important to identify and to provide proper treatment for pancreatic necrosis because most
patients who develop multiorgan failure have necrotizing pancreatitis;
how many people who died from AP had pancreatic necrosis?

Answer 41

it has been documented in up to 80% of the autopsies of patients who died after an episode of AP.

Question 42

what is the main complication of pancreatic necrosis? what is the risk for this complication?

Answer 42

Infection.
Therisk is directly related to the amount of necrosis;
pancreatic necrosis involving - risk of infection:
<30% of the gland - risk 22%.
30-50% - 37% risk
>70% of the gland - 46% risk

Question 43

modified Marshall scoring system?

Respiratory

Answer 43

Respiratory (PaO2/FiO2)

0) >400
1) 301-400
2) 201-300
3) 101-200
4) ≤101

Question 44

modified Marshall scoring system?

Renal

Answer 44

creatintine (for non CRF)

0) <1.4
1) 1.4-1.8
2) 1.9-3.6
3) 3.6-4.9
4) >4.9

Question 45

modified Marshall scoring system?

Cardiovascular

Answer 45

(systolic blood pressure, mmHg)

0) >90
1) <90, fluid responsive
2) <90, not fluid responsive
3) <90, pH <7.3
4) <90, pH <7.2

Question 46

CT finding that confirms infected pancreatic necrosis

Answer 46

Evidence of air within the pancreatic necrosis.

rare finding.

Question 47

what is the treatment for infected pancreatic necrosis?

Answer 47

IV antibiotics
Because of their penetration into the pancreas and spectrum coverage, carbapenems are the first option of treatment.
Alternative therapy includes quinolones, metronidazole, third generation cephalosporins, and piperacillin

Question 48

Pancreatic Pseudocysts p 1530

Answer 48

Pancreatic Pseudocysts p 1530