Pancreatitis

Question 1

What is the general pathophysiology of acute pancreatitis?

Answer 1

Inflammation of the pancreas from inappropriately activated digestive enzymes, leading to autodigestion.

Question 2

What are the two subtypes of acute pancreatitis?

Answer 2

1) Interstitial Edematous (~85%): Enlarged pancreas with inflammatory edema.
2) Necrotizing (~15%): More severe, areas of pancreatic necrosis.

Question 3

What are the most common causes (etiologies) of acute pancreatitis?

Answer 3

• Gallstones
• Ethanol (alcohol use)
• Hypertriglyceridemia
• Tumors (obstructing outflow)
• Hypercalcemia
• Post-instrumentation (ERCP)
• Trauma
• Infections (mumps, Mycoplasma, Coxsackie, HIV)
• Drugs
• Hereditary (SPINK mutations)

Question 4

A 33-year-old man presents to the emergency department with a 2-day history of severe upper abdominal pain that radiates to his back, as well as nausea and vomiting. The pain began after a large, fatty meal and persisted for several hours. Past medical history is unremarkable. The patient drinks alcohol occasionally on weekends. BMI is 31 kg/m?.
Temperature is 38.9°C (°F), blood pressure is 103/75 mmHg, pulse is 80/min, and respiratory rate is 18/min. On physical examination, the patient appears in distress, and jaundiced, and his abdomen is tender to palpation in the epigastrium. Laboratory results are shown below. CT scan of the abdomen is significant for peripancreatic fat stranding, pancreatic edema, peripancreatic necrosis and common bile duct dilation. The patient is provided with intravenous fluids, analgesia, bowel rest, and broad-spectrum IV antibiotics. Which of the following is the best next step in management?
A) Admission to the intensive care unit for supportive care and observation
B) Admission for urgent cholecystectomy
C) Admission for urgent endoscopic retrograde cholangiopancreatography (ERCP)
D) Admission for open necrosectomy
E) Admission to the intensive care unit for supportive care and early enteral feeding

Answer 4

The management of acute pancreatitis involves a careful assessment of its severity and addressing the underlying cause.
In addition to aggressive hydration, pain management, and nutritional support, urgent ERCP is in the management of gallstone pancreatitis with concurrent cholangitis. This patient presents with severe upper abdominal pain and CT findings of pancreatic edema, and peripancreatic necrosis consistent with the diagnosis of acute necrotizing pancreatitis.
The most likely underlying etiology is gallstone pancreatitis with concurrent cholangitis. In addition to supportive management and IV antibiotics, the most appropriate next step is admission to the hospital for urgent endoscopic retrograde cholangiopancreatography (ERCP). In cases of mild to moderate acute pancreatitis, the initial management includes aggressive fluid resuscitation, analgesia, and antiemetics. Another crucial aspect of care is early oral feeding as it helps to maintain the integrity of the gut mucosa and reduces bacterial translocation and infections. In the case of severe acute pancreatitis, management includes ICU admission for close monitoring and immediate medical support. Aggressive fluid resuscitation, pain control, and antiemetics should be started immediately. Enteral feeding can be attempted after 48 hours of treatment, especially if the patient shows improvement. If oral intake is not possible, a feeding tube can be used. A repeat abdominal CT can be considered after 72 hours, as complications such as necrosis may not be visible on the initial CT scan. Specific treatments depend on the underlying cause. For example, antibiotics are required for infectious necrosis. In scenarios where a stone in the common bile duct (CBD) is suspected, endoscopic retrograde cholangiopancreatography (ERCP) can be performed both as a diagnostic and therapeutic tool. If gallstones are identified, cholecystectomy should be performed during the same hospital stay to prevent recurrence of pancreatitis. Lastly, specific etiologies of pancreatitis, such as toxic, infectious, or medication-related, should be addressed by removing or mitigating the causative agent.

Question 5

A 48-year-old man presents to the emergency department for evaluation of severe upper abdominal pain that radiates to the back for the past 8 hours. He rates the pain as 10/10 and states that it worsens when he is lying flat and improves with leaning forward. Past medical history is significant for hypertension controlled with amlodipine. The patient reports drinking 4-5 beers every weekend. BMI is 34 kg/m?. Temperature is 37.8°C (100°F), blood pressure is 140/85 mmHg, pulse is 110/min, and respiratory rate is 18/min. On physical examination, multiple eruptive xanthomas are seen over his arms and legs. His abdomen is distended with tenderness and guarding in the epigastric region and associated hepatomegaly. Laboratory evaluation is significant for serum amylase of 800 U/L, serum lipase of 650 U/L, alanine transaminase (ALT) of 90 U/L and aspartate aminotransferase (AST) of 80 U/L. Which of the following is the most likely underlying etiology of this patient’s condition?
A) Idiopathic
B) Alcohol use
C) Hypertriglyceridemia
D) Gallstones
E) Medication side effects

Answer 5

Hypertriglyceridemia, particularly when triglyceride levels exceed 1000 mg/dL, can lead to acute pancreatitis. Patients may present with epigastric pain and elevated lipase and amylase along with the presence of findings suggestive of hypertriglyceridemia such as eruptive xanthomas. This patient presents with severe, constant, epigastric pain radiating to the back, which worsens when lying flat and improves when leaning forward. This is a classic presentation of acute pancreatitis. This patient also has evidence of elevated pancreatic enzymes, consistent with the diagnosis of acute pancreatitis. The presence of eruptive xanthomas and hepatomegaly are suggestive of hypertriglyceridemia as the primary underlying etiology. Eruptive xanthomas are caused by the precipitation of chylomicrons and very low-density lipoproteins (VLDL) and are often associated with severe hypertriglyceridemia. When triglyceride levels exceed 1000 mg/dL, they can precipitate in pancreatic vasculature and cause pancreatitis. Physical examination findings in acute pancreatitis can vary depending on the severity of the condition. In mild cases, the patient may appear uncomfortable with tenderness in the upper abdomen, and abdominal distention with decreased bowel sounds due to ileus. In severe cases, patients may appear ill, with signs of systemic inflammation such as fever, tachycardia, and hypotension. Rarely, Cullen sign (periumbilical bruising) or Grey Turner sign (flank bruising) can be seen, both indicating associated retroperitoneal hemorrhage. Lastly, physical findings suggesting a specific etiology may be observed, such as xanthomas in hypertriglyceridemia or jaundice in biliary pancreatitis.

Question 6

What are the most common medications that can cause pancreatitis?

Answer 6

Use the mnemonic “PILLS HIT the Pancreas”

Question 7

Do dodium-glucose cotransporter-2 inhibitors increase the risk of pancreatitis?

Answer 7

Sodium-glucose cotransporter-2 inhibitors, such as empagliflozin, are associated with an increased risk of pancreatitis.

Question 8

What are the key clinical features of acute pancreatitis?

Answer 8

Severe epigastric pain radiating to the back, nausea, vomiting, fever, tachypnea, tachycardia.

Question 9

What are the rare associated clinical signs of acute pancreatitis?

Answer 9

Grey Turner sign (flank hemorrhage), Cullen sign (blue discoloration at the umbilicus).

Question 10

What respiratory condition is known to evolve as sequalla from pancreatitis?

Answer 10

ARDS

Question 11

What are the diagnostic criteria for acute pancreatitis?

Answer 11

Diagnosis is made if 2 out of 3 criteria are met: 1) Epigastric pain, 2) Amylase/Lipase >3x upper limit, 3) Imaging findings (CT/MRI) showing edema or necrosis.

Question 12

What is the initial management of acute pancreatitis?

Answer 12

Aggressive IV fluid resuscitation (lactated Ringer’s), pain control (morphine, fentanyl), electrolyte correction, NPO.

Question 13

When is nutritional support indicated in acute pancreatitis?

Answer 13

If NPO for >7 days, provide nasojejunal (NJ) tube feeding.

Question 14

When is CT imaging indicated in acute pancreatitis?

Answer 14

CT is reserved for evaluating complications such as necrosis, pseudocyst formation, or if the patient deteriorates after 72 hours.

Question 15

When are antibiotics indicated in acute pancreatitis?

Answer 15

Only if there is evidence of infected necrosis or extra-pancreatic infections. Routine prophylactic antibiotics are NOT recommended.

Question 16

What are the systemic complications of acute pancreatitis?

Answer 16

ARDS, DIC, sepsis.

Question 17

What index is commonly used to assess the severity & mortality risk at admission and 48 hours?

Answer 17

• Use “GALAW” at admission: Glucose > 200mg/dL, AST > 250 IU/L, LDH > 350 IU/L, Age > 55 years, and White blood cell count > 16,000/mm^3
• Use “HBCPBS” at 48 hours: Hypocalcemia (serum calcium < 8 mg/dL), Base deficit > 4 mEq/L,
  Hypoxemia (PaO, < 60 mmHg)

Fall in hematocrit ≥ 10% during first 48 hours
Estimated fluid sequestration > 6 L
BUN increased by ≥ 5 mg/dL despite IV fluid hydration

Question 18

How is pancreatic necrosis diagnosed and treated?

Answer 18

Diagnosed with CT or CT-guided FNA. Treated with broad-spectrum antibiotics +/- necrosectomy for severe cases.

Question 19

What is a pancreatic pseudocyst?

Answer 19

Encapsulated collection of pancreatic fluid with a well-defined wall, usually occurring 3-4 weeks after acute pancreatitis.

Question 20

When should a pancreatic pseudocyst be treated?

Answer 20

Monitor if asymptomatic. If symptomatic or enlarging, treat with endoscopic or surgical drainage.

Question 21

What is abdominal compartment syndrome in pancreatitis?

Answer 21

Intra-abdominal pressure >20 mmHg causing organ failure. Screen using bladder pressure. Requires surgical decompression.

Question 22

What is the general pathophysiology of chronic pancreatitis?

Answer 22

Progressive fibrosis and inflammation of the pancreas, leading to structural damage and impaired exocrine and endocrine function.

Question 23

What are the major risk factors for chronic pancreatitis?

Answer 23

Chronic alcoholism, cystic fibrosis, malignancy, pancreatic stones/obstructions.

Question 24

What are the key clinical features of chronic pancreatitis?

Answer 24

Chronic, recurrent epigastric pain, nausea, vomiting, weight loss, malabsorption.

Question 25

What imaging and diagnostic tests are used in chronic pancreatitis?

Answer 25

CT or plain films showing pancreatic calcifications. MRCP or ERCP if unclear. Secretin stimulation test and fecal elastase for exocrine function.

Question 26

What are the key components of chronic pancreatitis management?

Answer 26

Small volume meals, quit alcohol/tobacco, pain control (NSAIDs, opioids), pancreatic enzyme supplementation (lipase), PPIs, surgery (if refractory).

Question 27

A 48-year-old woman presents to the primary care clinic for routine follow-up. The patient developed chronic pancreatitis 5 years ago. The patient previously had heavy alcohol use but has been in recovery for the past year. She smokes 1 pack of cigarettes per day. Current medications include naproxen (as needed) and pancreatic enzyme replacement therapy. Laboratory studies today are notable for fasting blood glucose of 190 mg/dL and hemoglobin A1c of 8.5%. Which of the following is the best next step in management? A) Glipizide B) Sitagliptin C) Empagliflozin D) Low glycemic diet E) Insulin

Answer 27

Chronic pancreatitis can result in diabetes mellitus due to decreased insulin production. This should be managed with insulin therapy.This patient has developed diabetes mellitus (type 3c) as a result of chronic pancreatitis, as evidenced by a high fasting blood sugar and hemoglobin A1c. This can occur as a result of islet cell loss during the course of pancreatic inflammation and fibrosis. The duration of chronic pancreatitis appears to be the most important risk factor for the development of endocrine insufficiency. Management of diabetes mellitus related to chronic pancreatitis usually involves insulin. Metformin is sometimes an option for cases with hyperglycemia, but its use is often limited because of gastrointestinal side effects. Because chronic pancreatitis results in the destruction of all types of cells within the pancreas, regulatory hormone production (such as glucagon) is also diminished. This places patients at an increased risk for hypoglycemia, so tight glucose control is typically avoided. Patients with chronic pancreatitis should also have their pain controlled with medications or procedures. Patients with exocrine insufficiency should be started on pancreatic enzyme replacement therapy. Treating the underlying cause of chronic pancreatitis may involve lifestyle modifications for alcohol use disorder, corticosteroids for autoimmune disease, and endoscopic management for ductal obstruction. All patients with chronic pancreatitis should have periodic screening for diabetes mellitus, fat-soluble vitamin deficiencies, and osteoporosis.

Question 28

A 53-year-old woman presents to the emergency department with worsening abdominal pain over the past two days. The patient has had several recurrent episodes of acute pancreatitis and typically drinks a 750 mL bottle of vodka daily. During this past year, the patient has developed mild and constant epigastric pain, oily stools, and she has lost 15 lbs (6.8 kg) unintentionally. The current abdominal pain is significantly worse than what she has been experiencing regularly this past year and interferes with her ability to give a history. Previous abdominal CT imaging showed atrophy of the pancreas and heavy intraductal calcifications. Temperature is 37.0 °C (98.6 °F), pulse is 102/min, respiratory rate is 18/min, and blood pressure is 135/78 mmHg. On physical examination, the patient is thin with sarcopenia and temporal wasting. Bowel sounds are normoactive. There is significant epigastric tenderness to palpation without rebound or guarding. Which of the following is the best next step in management? A) Endoscopic retrograde cholangiopancreatography (ERCP) B) Urgent surgical consultation C) CT abdomen and pelvis D) Broad-spectrum antibiotics E) Pain management

Answer 28

Pain control is an essential part of the management of acute exacerbations of chronic pancreatitis. This patient's history and examination are consistent with an exacerbation of chronic pancreatitis which should be treated with pain management. Heavy alcohol use and previous episodes of recurrent acute pancreatitis (RAP) which can result from chronic alcohol use, are clues to the diagnosis. Chronic pancreatitis is caused by inflammation and fibrosis of the pancreas which leads to epigastric pain that can range from mild to severe. Additionally, destruction of the pancreas results in exocrine and endocrine insufficiency leading to malabsorption, steatorrhea, and weight loss, as well as hyperglycemia from diminished insulin production. On imaging, the pancreas will often appear atrophied with extensive ductal calcifications and ductal dilatation. One of the most important aspects of assessing and managing patients with chronic pancreatitis is pain control. Adequate pain control can be difficult to achieve and multiple different treatments may need to be employed. Medications typically used for chronic pancreatitis include NSAIDs, acetaminophen, opiates, TCAs, SSRIs, pregabalin, and antioxidants. In patients who fail medical therapy, celiac plexus blocks, endoscopic interventions, and surgery may be options.

Question 29

What are the surgical options for refractory chronic pancreatitis?

Answer 29

Pancreaticojejunostomy or pancreatic resection.

Question 30

What are the complications of chronic pancreatitis?

Answer 30

Pancreatic insufficiency (malabsorption, steatorrhea), splenic vein thrombosis, pseudocyst formation, duct stricture, duodenal obstruction, diabetes mellitus (late-stage), pancreatic adenocarcinoma.