Clinical DSA 1: Pancreas

Question 1

Etiology of acute pancreatitis

Answer 1

Activation of digestive enzymes within the pancreas => autodigestion

Question 2

Causes of acute pancreatitis

Answer 2

Main 2 are cholelithiasis and heavy alcohol use

Others:
Hypertriglyceridemia (lipid panel shows trigs >1000mg/dL)
Trauma: injury or surgery (don’t fuck with the pancreas)
Medications
ERCP (don’t fuck with the pancreas)

Question 3

The following PE findings are associated with what diagnosis?

Epigastric pain that radiates straight through to the back
Cullen sign (periumbilical ecchymosis)
Grey Turner sign (flank ecchymosis)
Pulm stuff (crackles, difficulty breathing, ARDS)
Chovstek/Trousseau Signs (hypocalcemia)

Answer 3

Acute pancreatitis

Question 4

The following lab findings are suggestive of what diagnosis?

Lipase elevated 3x upper limit of normal
CBC: leukocytosis and elevated Hct
CMP: Increased blood glucose, bilirubin, BUN, creatinine, ALT, Alk phos; hypocalcemia
INR: increased
Lipid panel: hypertriglyceridemia (>1000)
CRP: elevated

Answer 4

Acute pancreatitis

Question 5

Diagnostic criteria for acute pancreatitis

Answer 5

At least 2/3 of the following

• Epigastric pain
• Lipase 3x upper normal
• CT changes consistent with pancreatitis

Question 6

First imaging study ordered when suspecting acute pancreatitis

Answer 6

1st: CT abdomen WITHOUT contrast

Many with acute pancreatitis may have kidney disease, which can be exacerbated by IV contrast

Question 7

When working up acute pancreatitis, in what situation should a CT with IV contrast be avoided?

Answer 7

In patients with serum creatinine >1.5 mg/dL

*don’t give IV contrast to pts with bad kidney fx

Question 8

Abdominal x ray findings in acute pancreatitis (2)

Answer 8

Sentinel loop (air filled air segment in SI)

Colon cutoff sign (gas filled segment of transverse colon ending at pancreas)

Question 9

Major complications that may arise from acute pancreatitis

Answer 9

Intravascular volume depletion => pre-renal azotemia (acute tubular necrosis)

ARDS

Question 10

Treatment/Management for acute pancreatitis (severe/unstable)

Answer 10

1st: Aggressive IV fluid resuscitation (can increase pain and lead to ARDS, but absolutely needs to be done), use vasopressors too if not sufficient

• Calcium gluconate for hypocalcemia w/tetany
• FFP for coagulopathy
• Albumin infusions for hypoalbuminemia

Question 11

Treatment/Management for acute pancreatitis (stable)

Answer 11

Treat underlying cause

i.e alcohol cessation, remove gallstones

Question 12

Severe acute pancreatitis prognostic indicators:

APACHE II

Answer 12

used to evaluate ICU patients, not just for pancreatitis

Score >8 = higher mortality

Question 13

Severe acute pancreatitis prognostic indicators:

Bedside Index for Severity in Acute Pancreatitis (BISAP)

Answer 13

B = BUN > 25
I = Impaired mental status
S = SIRS (systemic inflammatory response synd)
A = Age >60
P = Pleural effusion

Question 14

BISAP score interpretation

Answer 14

Scale 0-5

0-1 = <1% chance of mortality
5 = 27% chance of mortality

Question 15

Characterized by irreversible damage to the pancreas

Answer 15

Chronic pancreatitis

Question 16

Causes of chronic pancreatitis (TIGAR-O)

Answer 16

TIGAR-O

Toxic/Metabolic (alcohol)
Idiopathic
Genetic
Autoimmune
Recurrent (develops from recurrent acute pancreatitis)
Obstructive (stone/tumor)

Question 17

The following lab findings are suggestive of what diagnosis?

Lipase/Amylase: normal
Fecal fat: elevated (pancreatic insufficiency)
Fecal chymotrypsin: decreased (pancreatic insufficiency)
Fecal elastase: decreased <100 mcg/g (pancreatic insufficiency)

Answer 17

Chronic pancreatitis

Question 18

Abdominal x ray finding in chronic pancreatitis

Answer 18

Calcifications throughout pancreas

CT may show pancreatic calcifications not seen on x ray, suggestive of pancreatic cancer

Question 19

Treatment/Management for chronic pancreatitis

Answer 19

Supportive

• Pain control
• Pancreatic enzyme supplementation
• Low fat diet with NO alcohol
• Corticosteroids for autoimmune

Question 20

Major complications of chronic pancreatitis (3)

Answer 20

Diabetes mellitus (most will develop)

Pancreatic insufficiency

Pancreatic cancer (most common cause of death)

Question 21

The following patient history is associated with what diagnosis?

Painless jaundice
New onset diabetes mellitus in older person
Trousseau sign of malignancy (migratory thrombophlebitus)
Courvoiser sign (nontender, palpable gallbladder from underlying mass)

Answer 21

Pancreatic cancer (adenocarcinoma)