Pancreatitis

Question 1

What are the Atlanta Symposium (1992) criteria for acute pancreatitis?

Answer 1

At least 2 of the following:
- Typical pancreatic type pain.
- Radiographic findings of pancreatitis
- Elevated blood chemistries (amylase and/or lipase)
(Pain, radiographic, chemistries)

Question 2

What is pain from pancreatitis like?

Answer 2

Severe, steady pain in bandlike pattern - often radiating to the back.
(hurts a lot, pain lasts for days)
- note that 5-10% of acute pancreatitis is painless.

Question 3

Is vomiting a common presenting sign in pancreatitis?

Answer 3

Yes. 90% vomit.

Question 4

What are the 2 main etiologies of acute pancreatitis?

Answer 4

Alcohol

Biliary

Question 5

Where must a stone be to cause pancreatitis?

Answer 5

In the duodenal papilla.

a stone in the common bile duct will just cause cholangitis

Question 6

What test is pretty good at telling you if pancreatitis is from a biliary cause?

Answer 6

Elevated ALT (>150)

Question 7

What are a few mechanisms that may contribute to acute alcoholic pancreatitis?

Answer 7

Abnormal blood flow / secretion.
Toxic metabolites, mitochondrial damage, lysosome instability (ROS, etc.).
Sensitization to CCK (Zymogens and cytokines).
Sphincter of Oddi spasms.
(and increased triglycerides?)

Question 8

What mainly catalyzes the damage in acute pancreatitis?

Answer 8

Premature / intracellular activation of trypsin.

It activates other enzymes -> autodigestion.

Question 9

How does high Ca++ predispose to acute pancreatitis?

Answer 9

High Ca++ leads to trypsin activation (maybe)

Question 10

What are the 3 mainstays of acute pancreatitis treatment?

Answer 10

Bowel rest, IV fluids, and pain control.

Question 11

How can enteral feeding be done in severe acute pancreatitis?

Answer 11

Feeding beyond the ligament of Treitz.

Question 12

What are 2 types of acute pancreatitis with different severity levels? How can these be distinguished with imaging?

Answer 12

Interstitial - look “patchy” on CT

Necrotizing - worse - big dark areas of pancreas on CT.

Question 13

What is Cullen’s sign?

Answer 13

Blood near umbilicus

Question 14

What is Grey Turner’s sign?

Answer 14

Retroperitoneal blood.

Question 15

What should you rule out if you see acute pancreatitis in someone over 50?

Answer 15

Pancreatic cancer.

Question 16

What are the 2 “mortality peaks” from acute pancreatitis?

Answer 16

Necrotizing/severe pancreatitis causes mortality earlier.

Infection of necrotizing pancreatitis can cause mortality later on.

Question 17

What are 5 diagnostic signs of chronic pancreatitis?

Answer 17

Calcifications
Pancreatic duct stones
Dilate irregular pancreatic duct without mass.
Dilate side branches.
Atrophy without a mass.

Question 18

What’s one of the earliest ways to detect chronic pancreatitis? (before structural damage)

Answer 18

Secretin stimulation test - test duodenal bicarb levels after secretin stimulation.

Question 19

What can biopsy and endoscopic ultrasound show you when there’s chronic pancreatitis?

Answer 19

Fibrosis (maybe other things as well…)

Question 20

3 possible etiologies of chronic pancreatitis?

Answer 20

Ductal obstruction -> trypsin activation in ducts.
Toxic / metabolic (EtOH, smoking, etc.) -> oxidative stress... fibrosis.
Necrosis fibrosis (after acute inflammatory attacks) - a messed up healing process, "like a keloid scar"

Question 21

What are two modalities for seeing duct abnormalities?

Answer 21

MRCP (MRI) - can see earlier changes?

ERCP

Question 22

3 main consequences of chronic pancreatitis?

3 other consequences?

Answer 22

Pain
Steatorrhea
Diabetes
(billiary obstruction, B12 def, cancer)

Question 23

Is CP pain serious stuff?

Answer 23

Yeah.

Question 24

Review: How much pancreas function do you have to lose to get steatorrhea?

Answer 24

about 90% - it’s a late sign.

Question 25

How does diabetes of chronic pancreatitis (“Type 3 diabetes”?) differ from T2D?

Answer 25

It’s very sensitive to insulin - it’s caused by a lack of insulin production, not insulin resistance.
(but you can still use metformin..)

Question 26

3 treatments for chronic pancreatitis?

Answer 26

Enzymes (replace what’s not being made).
Duct decompression by surgery.
ERCP (endoscopy… to remove blockages?).