Pancreatic Patient

Question 1

Differentials to consider for RUQ/Epigastric Pain

Answer 1

1. Gallbladder Disease
2. Hepatits
3. Pancreatitis
4. PUD

Question 2

Describe the process that occurs in acute pancreatitis

Answer 2

Activation of digestive enzymes, kinases, and inflammatory markers leads to auto digestion of the pancreas.
Results in SAPONIFICATION that leads to hypocalcemia

Question 3

2 most common causes of acute pancreatitis

Answer 3

Biliary Tract stones

Heavy alcohol use

Question 4

Other less common causes of acute pancreatitis

Answer 4

Trauma
Medications
Infectious agents (mumps, CMV)
Autoimmune issues

Question 5

What is a common chief complaint from patient’s presenting with acute pancreatitis?

Answer 5

Constant, boring pain that goes straight through them to their back.

Question 6

PE findings of acute pancreatitis

Answer 6

Cullen/Gray Turner Sign (ecchymosis)
Chvostek and Trousseau signs (hypocalcemia)
ARDS

Question 7

Diagnostic criteria for acute pancreatitis

Answer 7

2/3

1. Epigastric pain
2. 3xULN for Lipase (and amylase)
3. CT changes

Question 8

What would be seen on a CMP in a patient with acute pancreatitis?

Answer 8

Hyperglycemia
Hyperbilirubinemia
Increased BUN
Elevated Creatinine
Elevated ALT 
Hypocalcemia
"Harry Herbert's manBUN Created ALTernative Calcium"

Question 9

What are the 2 XR signs indicative of acute pancreatitis?

Answer 9

Sentinal Loop- air-filled SI in LLQ

Colon cutoff sign- gas filled Transverse colon

Question 10

What is the first line treatment for acute pancreatitis

Answer 10

Fluid Resuscitation

Question 11

Complications associated with acute pancreatitis

Answer 11

1. 3rd spacing fluid leaks
2. Pre-renal azotemia (most common form of kidney failure in hospitalized patients)
3. Pleural Effusion
   * Dry intravascularly but edema everywhere else; why you need to treat fluids first
4. Pseudocysts
5. ARDS

Question 12

Ranson Critera for acute pancreatitis severity upon admission

Answer 12

"GA-LAW": 3 or more= severe course with necrosis in 60-80% of patients 
Glucose>100 
Age>55
LDH>350
AST>250
WBC>16,000

Question 13

Ranson Criteria for acute pancreatitis severity 48hrs after admission

Answer 13

"C & HOBBS"
Calcium <8
Hct drop >10%
O2 (PaO2) <60mmHg
Base deficit >4
BUN increase >5
Sequestration of fluid >6L

Question 14

BISAP score for acute pancreatitis at or within 24 hrs of admission

Answer 14

Bun>25mg/dL
Impaired Mental status
SIRS: >2 of 4 
Age >60 
Pleural Effusion

Question 15

APACHE II score

Answer 15

Just know higher the score the higher the mortality rate

Question 16

What is a sign of infected pancreatic necrosis and what are common organisms to cause it?

Answer 16

Emphysematous Pancreatitis

1. C. Perfringens
2. E. Aerogenes
3. E. Faecalis
   * Don’t think we need to memorize those but good to know

Question 17

Describe Chvostek Sign

Answer 17

twitching of facial muscles due to hypocalcemia

Question 18

Describe Trousseau sign related to hypocalcemia

Answer 18

hand postures when BP cuff is pumped up

Question 19

Which is a better prognostic indicator of pancreas function, Lipase or Amylase

Answer 19

Lipase: more specific to pancreatitis

Question 20

What is the most frequent cause of chronic pancreatitis?

Answer 20

Alcoholism

Question 21

PE findings of chronic pancreatitis

Answer 21

epigastric pain
steatorrhea 
WL
Fatigue 
Pain

Question 22

Diagnostic labs for chronic pancreatitis

Answer 22

Lipase/Amylase
Steatorrhea
DECREASED FECAL ELASTASE < 100 mcg

Question 23

What is usually seen on XR in chronic pancreatitis patients

Answer 23

Pancreaticolithiasis

Question 24

What can be seen on CT that would probe workup for possible pancreatic cancer?

Answer 24

tumefactive chronic pancreatitis (chronic pancreatitis with a mass and/or obstructive jaundice)

Question 25

TIGAR-O Chronic Pancreatitis

Answer 25

Toxic-Metabolic: EtOH
Idiopathic
Genetic: CF
Autoimmune- Celiac/IgG4 disease
Recurrent- 36% of recurrent acute pancreatitis pt's
Obstructive

Question 26

What is the main cause of death in those with chronic pancreatitis?

Answer 26

Cancer

Question 27

3 treatments for chronic pancreatitis

Answer 27

1. supportive
2. Pain control
3. Pancreatic enzyme supplementation

Question 28

Pancreatic function tests

Answer 28

Fecal Elastase is most indicative

Low in insufficiency

Question 29

What endocrine related disorder do close to 80% of chronic pancreatitis pt’s develop?

Answer 29

DM

Question 30

67 y/o patient presents with weight loss and new onset DM. What is in your differential?

Answer 30

Pancreatic Cancer

• > 65
• New onset DM
• Painless Jaundice

Question 31

Trousseau sign of Malignancy

Answer 31

aka Migratory Thromboplebitis
- repeated attacks of multiple venous thrombosis at different sites. Due to overproduction of coagulation factors from cancer cells

Question 32

Courvoisier Sign

Answer 32

enlarged, palpable gallbladder in patients with obstructive jaundice

Question 33

MEN Type 1 can be diagnosed by which findings

Answer 33

2/3:

1. Hypercalcemia with increased PTH (Parathyroid)
2. Gastrinoma (ZES) or Insulinoma that leads to hypoglycemia
3. Acromegaly or Cushing Disease

Andre the Giant

Question 34

MEN type 2A

Answer 34

Thyroid- elevated calcitonin (hypocalcemia)
Adrenal- elevated catecholamines
PT- Hypercalcemia with increased PTH

Question 35

MEN Type 2B

Answer 35

Marfanoid type with neuromas of lips and tongue

*Not HY