Pancreatitis

Question 1

Acute pancreatitis etiology

Answer 1

Mechanical: gallstone, sludge, tumour
Toxic: alcohol
Metabolic: hyperlipidemia, hypercalcemia
Drugs: Azathioprine/6-MP, estrogen, didanosine (antiretroviral)
Infection: virus (mumps), bacteria, parasite
Trauma/post-procedure: ERCP
Congenital/genetic: pancreas divisum, CFTR, familial
Vascular: ischemia, vasculitis

Question 2

Acute pancreatitis pathophys

Answer 2

Inappropriate activation of digestive enzymes –> inflammation and autodigestion
Peri-pancreatic edema (necrosis if severe)
Pseudocyst complications

Question 3

Chronic pancreatitis etiology

Answer 3

Mechanical: tumour, gallstone, trauma
Toxic: alcohol (75%)
Congenital/genetic: cystic fibrosis, trypsin, protease inhibitor mutations
Autoimmune (rare)
Idiopathic

Question 4

Chronic pancreatitis pathophys

Answer 4

Reduced bicarb secretion (CFTR) coupled with increased pancreatic protein secretion –> plugs in ducts –> nidus for calcification –> stone formation, scarring, obstruction
Intraparenchymal activation of enzymes

Question 5

Causes of infectious pancreatitis

Answer 5

Acute pancreatitis
Causes:
- viral: mumps, viral hepatitis (HBV), herpes, coxsackievirus, varicella
- parasites: ascariasis
- fungal: aspergillus
- bacterial: mycoplasma, salmonella,legionella

Question 6

Alcoholic pancreatitis pathophysiology

Answer 6

Only a small number of alcoholics develop chronic pancreatitis - other ppting factors as well

Theory: increased protein secretion from acinar cells, decreased fluid and bicarb secretion from ductal epithelial cells - viscous debris results in obstruction, upstream acinar atrophy and fibrosis

Theory: persistent demands of metabolizing alcohol –> oxidative stress - CYP450 2E1 induced to meet metabolic demands

Question 7

Obstructive pancreatitis pathophysiology

Answer 7

Periductal fibrosis, ductal dilatation
Mostly focal
Diffuse changes may occur if the main pancreatic duct is obstructed

Chronic obstructive pancreatitis: could be due to ampullary stenosis, inflammatory/neoplastic, surgical ductal ligation, fibrosis due to a pseudocyst or complications from acute pancreatitis

Question 8

Most common causes of acute pancreatitis

Answer 8

gallstone, alcohol ~75%

Question 9

Acute pancreatitis clinical presentation

Answer 9

Pain - epigastric - steady, not colic, may radiate to the back
may be associated with recent alcohol excess
nausea, vomiting, restlessness

Question 10

Acute pancreatitis PE findings

Answer 10

Tender epigastrium, guarding, splinting
fever, tachycardia, signs of shock
abdominal distention
Cullen’s - Grey-Turner’s sign (central, costovertebral signs of hemorrhage)
s/c nodular fat necrosis (panniculitis), thrombophlebitis
underlying disease: parotid enlargement, xanthomas, hepatomegaly

Question 11

Acute pancreatitis labs

Answer 11

pancreatic amylase/lipase - elevated for 3-5 days
liver enzymes +/- bili
CBC
electrolytes, ca, phos, creatinine
lipid profile
blood cultures if febrile
Ranson criteria - for prognosis based on symptoms seen within 48 hours

Question 12

Acute pancreatitis imaging

Answer 12

X-ray: may see calcifications (chronic pancreatitis)
US: not a good view
CT: necrosis vs edema, caution with dye toxicity
MRI/MRCP (MRI of the bile duct) - good
Endoscopic US best for gallstones

Question 13

Acute pancreatitis treatment

Answer 13

no specific therapy (stop alcohol)
correct underlying cause, address inflammation
supportive - iv fluid, npo

in moderate to severe (pancreatic necrosis):
needle biopsy/antibiotics if infection suspected
surgery for severe/infected cases

Question 14

Management of acute pancreatitis related to gallstone

Answer 14

ERCP if continued biliary obstruction
Cholecystectomy after pancreatitis has settled
Recurrence without cholecystectomy - 25-30% within 6-18 wks

Question 15

Chronic pancreatitis history

Answer 15

Epigastric pain, initially episodic then more continuous
Exocrine insufficiency - steatorrhea (>90% function lost), protein maldigestion (late stage)
Endocrine insufficiency - DM (late), insulin-requiring, brittle

Question 16

Chronic pancreatitis PE findings

Answer 16

tender epigastrium
fat/protein malnutrition - weight loss, thin, minimal cutaneous fat, muscle wasting, vitamin deficiency ADEK
Mass effect from pseudocyst - early satiety, pain, palpable mass

Question 17

Chronic pancreatitis lab

Answer 17

Amylase/lipase normal
no diagnostic lab tests
Steatorrhea

Question 18

Chronic pancreatitis imaging

Answer 18

X-ray: calcifications - 30%
US, CT, MRI: calcifications, ductal dilation, pseudocyst
ERCP/MRCP/endoscopic US: beading duct and ectatic branches (chain of lakes), ductal calculi

Question 19

Chronic pancreatitis tx

Answer 19

stop alcohol!
enzyme supplement
analgesia - often narcotics
celiac plexus block
ERCP-pancreatic stent
partial pancreatectomy