Snapshot A 15-year-old boy with severe nodulocystic acne presents to the emergency room for sudden onset epigastric pain radiating to the back, as well as nausea and vomiting. An abdominal computed tomography shows findings concerning for pancreatitis. On further chart review, the physician discovers that he has been taking isotretinoin, and the dermatologist had been monitoring his triglycerides as they were mildly elevated at the last clinical visit. However, the patient reports that he had not only doubled his dose in the last week in an attempt to speed up the process but also had been eating burgers and fries for every meal. Laboratory results show significantly elevated levels of triglycerides in the blood. Introduction Clinical definition acute inflammation of pancreas and surrounding tissue, often by autodigestion with pancreatic enzyme leakage Epidemiology risk factors gallstones (more common) heavy alcohol use (more common) electrolyte abnormalities ↑ serum calcium ↑ triglycerides trauma drugs thiazides sulfa drugs NRTIs protease inhibitors viral infections mumps autoimmune disease endoscopic retrograde cholangiopancreatography (ERCP) scorpion sting Pathogenesis inflammation is caused by leakage of pancreatic enzymes into pancreatic tissue causes autodigestion of pancreas and surrounding tissue Prognosis Ranson criteria predict mortality Ranson Criteria / Clinical Signs On Admission Within 48 hours Glucose > 200 mg/dL Age > 55 years LDH > 350 IU/L WBC > 16,000/mL AST > 250 IU/dL Calcium < 8.0 mg/dL Hematocrit ↓ by >10% PaO2 < 60 mmHg Base deficit > 4 mEq/L BUN ↑ by 5 mg/dL Sequestered fluid > 6 L Ranson Criteria / Mortality 3-4 signs 20% mortality 5-6 signs 40% mortality 7+ signs 100% mortality Presentation Symptoms sudden onset epigastric pain radiating to the back nausea and vomiting systemic inflammation fever chills Physical exam inspection flank ecchymosis Grey Turner sign tetany hypocalcemia secondary to free digested fats binding ionized calcium periumbilical ecchymosis Cullen sign palpation epigastric tenderness Imaging Abdominal radiograph findings sentinel loop isolated and dilated loop of bowel seen in inflammatory conditions Abdominal ultrasound indication all patients to assess for gallstones findings enlarged pancreas abscess gallstones Computed tomography (CT) of abdomen and pelvis with contrast indications diagnosis uncertain failure to improve clinically presence of Grey Turner or Cullen sign, as this may indicate hemorrhagic pancreatitis findings enlarged pancreas necrosis peripancreatic fluid pseudocyst abscess CT-guided fine needle aspiration indications infected necrosis for Gram stain and culture to guide antibiotic selection Studies Serum labs ↑ amylase ↑ lipase ↓ calcium Diagnostic criteria diagnosis by 2 or more of the following acute-onset epigastric pain ↑ serum amylase or lipase to 3x upper limit of normal imaging suggestive of pancreatitis Differential Peptic ulcer disease distinguishing factor also presents with epigastric pain but will not have elevations in pancreatic enzymes Treatment Management approach remove all offending agents when possible treatment will be guided by etiology of pancreatitis Conservative supportive care fluid resuscitation electrolyte repletion analgesia bowel rest but feed as soon as tolerated nasogastric decompression Medical intravenous antibiotics Surgery endoscopic retrograde cholangiopancreatography (ERCP) with eventual cholecystectomy indication gallstone pancreatitis surgical debridement indication symptomatic necrotizing pancreatitis Complications Pancreatic pseudocyst Fistula formation Pancreatic abscess Hemorrhagic pancreatitis Pleural effusions (often on the left) Chronic pancreatitis