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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
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
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Questions (2)
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(M1.GI.13.69) A 29-year-old female is hospitalized 1 day after an endoscopic retrograde cholangiopancreatography (ERCP) because of vomiting, weakness, and severe abdominal pain. Physical examination findings include abdominal tenderness and diminished bowel sounds. A CT scan demonstrates fluid around the pancreas. Serum levels of which of the following are likely to be low in this patient? Tested Concept

QID: 101126
1

Calcium

49%

(71/144)

2

Glucose

10%

(15/144)

3

Amylase

10%

(14/144)

4

Lipase

16%

(23/144)

5

Triglycerides

15%

(21/144)

M 1 E

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