DSA: Approach to the Pancreatic Patient (McGowan)

Question 1

What are the two most common causes of Acute Pancreatitis and what is Saponification?

Answer 1

CC: Gallstones (< 5mm) and Heavy alcohol use

S: “making into soap”
- cations interact with FFA released by action of activated lipase on triglycerides in fat cells (low serum calcium = HYPOCALCEMIA)

Question 2

What does Acute Pancreatitis present clinically, what are 4 signs associated with it, and what are the 3 diagnostic criteria?

What pulmonary issue is Acute Pancreatitis associated with?

Answer 2

P: constant epigastric pain that goes straight through to the back

S: Cullen/Grey Turner Signs, Chvostek and Trousseau Sign (hypocalcemia signs)

DC: epigastric pain, LIPASE (amylase) 3x ULN, and CT changes of pancreatitis (need 2 of 3)

associated with ARDS

Question 3

What are two plain radiograph findings that could point towards Acute Pancreatitis? (SL/CC)

Answer 3

1. Sentinel Loop - segment of air-filled SI (LUQ)

2. Colon Cutoff Sign - gas filled segment of transverse colon abruptly ending at area of pancreatic inflammation

Question 4

What are 3 common prognostic indicators for Severe Acute Pancreatitis? (R/B/A)

Answer 4

Ranson Criteria, BISAP (bedside index), APACHE II

Question 5

What is Rapid-Bolus Intravenous Contrast-enhanced CT and when should it not be used?

Answer 5

• diagnostic use for acute pancreatitis used following aggressive volume resuscitation after 3 days of SAP
• can ID areas and degrees of pancreatic necrosis
• IV contrast can increase complications of pancreatitis and AKI (avoid use when serum creatinine > 1.5 mg/dL)

Question 6

How is Acute Pancreatitis treated (3) and what are complications of disease? (3/PE/EP/P/A)

Answer 6

T: treat the cause, FLUID RESUSCITATION (FIRST thing to do using IV), and early surgical consult for complications (monitor hemodynamics in ICU)

C: 3rd spacing, fluid collections (pleural effusion), emphysematous pancreatitis (gas-forming bacteria), Pseudocysts, ARDS (acute respiratory distress syndrome)

Question 7

What are Cullen and Grey Turner Signs?

Answer 7

C: ecchymosis of UMBILICUS from retroperitoneal bleeding/fluid

GT: ecchymosis of FLANK from retroperitoneal bleeding/fluid

both can be seen in Acute Pancreatitis

Question 8

Ranson Criteria

What does it do, what is difference between admission (GA-LAW) and 48 hours after admission (CHOBBS) criteria?

Answer 8

• Ranson used to assess severity of acute pancreatitis

Admission: Glucose > 200, Age > 55, LDH > 350, AST > 250, WBC > 16000

48 AA: Calcium < 8, Hematocrit drop > 10%, PaO2 < 60 mmHg, Base deficit > 4, BUN inc > 5, fluid sequestration > 6L

Question 9

What is the BISAP score?

Answer 9

• used for Acute Pancreatitis, helps determine mortality rate (Scale of 0-5; range from 1-27%)

B - BUN > 25 mg/dL
I - impaired mental status
S - SIRS: >/= 2 0f 4 present
A - age > 60
P - pleural effusion

Question 10

Acute Pancreatitis

What are 3 examples of Gas-forming GI organisms (CP/EA/EF), what condition can they cause, and how are they treated?

Answer 10

Ex: C. perfringens, Enterobacter aerogenes, Enterococcus faecalis

• cause Emphysematous pancreatitis

T: surgical debridement and antibiotics (Imepenem/Meropenem)

Question 11

What are Chvostek and Trousseau Signs?

Answer 11

C: twitching of muscles innervated by facial nerve when tapped (signify HYPOcalcemia)

T: hand posture changes when sphygmomanometer cuff inflated above systolic BP within 3 min (signify HYPOcalcemia)

can be seen in Acute Pancreatitis

Question 12

Chronic Pancreatitis

What is the most common cause, how does it present, what are 3 common diagnostic findings (FE/DM/Ab), and what does it look like on imaging?

Answer 12

MCC: ALCOHOLISM

P: chronic pain (CARDINAL SYMPTOM), malabsorption –> steatorrhea (exocrine pancreas insufficiency), Diabetes Mellitus (endocrine pancreas insufficiency), fatigue, unintentional weight loss

Dx: dec. fecal elastase (< 100 mcg/g), Glucose/HbA1c (DM after 25 yrs of chronic), elevated IgG4 (AAP)

Imaging: calcifications (XRAY and CT)
- can develop pancreatic cancer

Question 13

Chronic Pancreatitis

What is the TIGAR-O Mneumonic?

Answer 13

• causes of pancreatitis

T - Toxic Metabolite (EtOH 45-80% of cases)
I - idiopathic (early or late onset; smoking inc. risk)
G - genetic (< 30 yo; Cystic Fibrosis - CFTR gene)
A - autoimmune (hypergammaglobulinemia IgG4)
R - develops in 36% of acute pancreatitis patients
O - obstructive (strictures, stone, tumor)

Question 14

Chronic Pancreatitis

How is it treated, what are 3 common complications it causes, and what is its prognosis?

Answer 14

T: supportive, pain control, enzyme supplementation, NO alcohol or opioids, and treat associated DM

C: brittle DM (80% after 25 yrs), pancreatic insufficiency (steatorrhea/malabsorption), pancreatic cancer

P: pancreatic cancer is the MAIN cause of death

Question 15

What are two tests to check for Pancreatic Insufficiency? (FC/FE)

Answer 15

Detection of decreased FECAL CHYMOTRYPSIN and decreased pancreatic FECAL ELASTASE (<100mcg/g)

40% have B12 malabsorption detected through labs, though don’t see as clinical deficiency through

Question 16

Pancreatic Cancer

What is it, what does it cause clinically, what two patient populations is it typically seen in, and what are 3 clinical findings of disease (CS/TS/CA)

Answer 16

• FATAL adenocarcinoma (usually not detected till it has spread)

C: PAINLESS JAUNDICE, N/V, fatigue, WL, steatorrhea
- pain hurts most (lying on back), better with bending

• pts w/painless jaundice or >65 yo w/new onset DM

CF: Courvoisier Sign, Trousseau Sign on Malignancy (migratory thrombophlebitis), CA 19-9 > 100 U/mL

Question 17

MEN Type 1

What is it and how does it affect Parathyroid, Pancreas, and Pituitary?

Answer 17

• AD multiple endocrine neoplasia

Parathyroid: hypercalcemia, inc. intact PTH
Pancreas: Gastrinoma (ZE), Insulinomia (hypoglycemia)
Pituitary: acromegaly, Cushings Disease

MEN1 has two or more of the above