Gastroenterology - Acute Pancreatitis

Front 1

What is pancreatitis?

Back 1

Pancreatitis is inflammation of the pancreas that results from auto-digestion of the pancreatic parenchyma by enzymes produced by the pancreas itself.

Front 2

Which cells produce pancreatic enzymes?

Back 2

Acinar cells

Front 3

Under physiologic conditions, what defence mechanisms are in place to protect the pancreas against the activation of its own enzymes and autolysis?

Back 3

1) Pancreatic enzymes are secreted in a pro-enzyme form and become activated by a series of reactions only once they reach the duodenum.

2) The pancreas produces a trypsin inhibitor protein that binds to an inactivates trypsin.

Front 4

Given these defence mechanisms, how does pancreatitis develop?

Back 4

1) Failure of defence mechanisms

2) Overwhelming of defence mechanisms by inflammatory insult

Front 5

Name 5 common causes of pancreatitis.

Back 5

1) Biliary tree pathology

2) ETOH abuse

3) Medications

4) Infections

5) Neoplasia

6) Dyslipidemia

Front 6

What is the most common cause of acute pancreatitis?

Back 6

Biliary tree pathology (cholelithiasis, choledocholithiasis, biliary sludge, microlithiasis)

Front 7

What is the second most common cause of acute pancreatitis?

Back 7

ETOH abuse

Front 8

Any new medication may be the cause of the pancreatitis. Name 3 classes of drugs that are commonly associated with pancreatitis.

Back 8

NSAIDs

Diuretics (HCT, furosemide)

Corticosteroids

Sulfonamides

Front 9

What is the cardinal sign of acute pancreatitis?

Back 9

Epigastric pain that increases over hours with radiation to the back

Front 10

Name two common associated symptoms of acute pancreatitis.

Back 10

Nausea and vomiting

Front 11

Name three severe complication of pancreatitis.

Back 11

Hemorrhage

Sepsis/SIRS

ARDS

Front 12

The classic pain of pancreatitis is epigastric, radiating to the back. What other important conditions must be on your differential?

Back 12

CVS: AAA, MI

GI: PUD, cholecystitis, bowel ischemia, bowel obstruction/perforation

GU: nephrolithiasis, pyelonephritis

Front 13

Give an overview of the history you would take for a patient with suspected pancreatitis.

Back 13

1) Characterize the pain: OPQRST plus associated symptoms

2) Previous history of pancreatitis?

3) Ask questions to determine the etiology: Gall bladder trouble? ETOH abuse? New medications?

Front 14

Name 3 extra-abdominal signs of acute pancreatitis that may be present on physical examination.

Back 14

Fever, tachycardia, tachypnea

Also watch for signs of sepsis/SIRS

Front 15

What are the signs of acute pancreatitis you may find on abdominal examination?

Back 15

I: Icterus/jaundice from biliary pathology, Grey-Turner sign, Cullen sign

A: absent/diminished bowel sounds

P: /

P: epigastric tenderness

Front 16

What is the Grey-Turner sign?

Back 16

Reddish brown discoloration of the flanks as a result of retroperitoneal bleeding

Front 17

What is the Cullen sign?

Back 17

Bluish discoloration around the umbilicus that indicates hemoperitoneum, often from a ruptured splenic artery

Front 18

A patient you suspect has acute pancreatitis shows signs of an acute abdomen/peritonitis on physical examination.

How should this direct your thinking?

Back 18

Think of alternative diagnoses and perform imaging studies to investigate them (e.g. CT abdo)

Front 19

How is the diagnosis of acute pancreatitis made?

Back 19

Clinical diagnosis, though laboratory investigations and imaging may provide useful information

Front 20

What laboratory tests should you order to investigate pancreatitis?

Back 20

CBC, electrolytes, BUN/creatinine, LFTs, AMYLASE and LIPASE, toxicology screen, lipid profile

Front 21

What imaging modality is most commonly used in the investigation of pancreatitis?

Back 21

CT abdomen to rule out alternative diagnoses

Front 22

What is the first step in the management of acute pancreatitis?

Back 22

ABCs, including volume resuscitation with IV fluids

Front 23

What are the three pillars of treatment for acute pancreatitis?

Back 23

Volume resuscitation (IV fluids)

Pain control (high-dose narcotics)

Bowel rest

Front 24

Describe the dietary/nutritional management of a patient with acute pancreatitis.

Back 24

There is no clear consensus at present.

Most physicians order bowel rest followed by a clear liquid diet once the patient is hemodynamically stable and pain free.

This can be advanced to low-fat diet as symptoms allow.

Front 25

Name two surgical procedures that may be employed in the treatment of acute pancreatitis.

Back 25

Sneaky question, as these procedures don’t treat the pancreatitis but rather the underlying cause:

ERCP with endoscopic sphincterotomy

Cholecystectomy

Front 26

Are antibiotics indicated for the treatment of acute pancreatitis?

Back 26

Only in the case of significant pancreatic necrosis or worsening systemic manifestations (e.g. sepsis)