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USMLE – Acute Pancreatitis

Pathophysiology
1. Inflammation of pancreas with proteolysis
2. Most common causes in USA – alcoholism and cholelithiasis

Signs and Symptoms
1. Severe, constant epigastric pain radiating to back (usually acute onset, worse in supine position, relieved by sitting with knees drawn up)
2. Nausea and vomiting
3. Abdominal distention and bloating
4. Decreased bowel sounds
5. Fever
6. Tachycardia
7. Hypotension
8. Oliguria
9. Abdominal tenderness
10. Palpable upper abdominal mass (owing to pseudocyst)
11. Pancreatic ascites
12. Pleural effusions (more common on the left)
13. Positive Cullen’s sign (blue discoloration around umbilicus) and Turner’s sign (flank discoloration)

Characteristic Test Findings
1. Increased amylase and lipase
2. Leukocytosis
3. Decreased hemoglobin
4. Hyperglycemia
5. Increased triglycerides
6. Increased trypsinogen
7. Hypocalcemia
8. Increased bilirubin and transaminases
9. Increased LDH
10. Decreased albumin
11. Decreased PO2
12. Localized ileus with “sentinel loop”
13. Colon cutoff sign (dilated transverse colon)
14. Calicifications, edematous borders, hemorrhage, and necrosis on CT scan

Associated Conditions
1. Hypertriglyceridemia
2. Hypercalcemia
3. Infectious diseases (mumps, coxsackie, echovirus, CMV)
4. Drugs (azathioprine, sulfonamides, furosemide, oral contraceptives)
5. Trauma
6. Cystic fibrosis
7. Pancreas divisum
8. SLE and AIDS
9. Pancreatic carcinoma
10. Obesity
11. Diabetes mellitus
12. Purtscher’s retinopathy (sudden blindness)

Biochemistry
Likely related to proteolytic enzymes (trypsinogen, chymotrypsinogen, phospholipase – activated in pancreas instead of gut lumen by trauma, viruses, and toxins

Treatment
1. Nothing by mouth
2. Vigorous fluid resuscitation (often 5-10 L)
3. Analgesics
4. Nasogastric tube suction
5. Carbapenems class antibiotics in infected pancreatitis
6. Surgical debridement in necrotizing pancreatitis
7. Octreotide in pancreatic ascites
8. Prognosis determined by Ranson’s criteria (presence of six criteria = 50% mortality, over 7 = 90% mortality)

Tips for the USMLE
Amylase is also increased in salivary gland disease, gut infarction, gut perforation, renal failure, diabetic ketoacidosis, postoperative, carcinoma of the lung, esophagus, and breast. Increased serum triglycerides will cause a falsely low level of amylase. Serum lipase is a more sensitive and specific test for pancreatitis than amylase. Serum amylase is usually increased at least 3 times normal in first 24-48 hours. Ranson’s criteria defines prognosis.

Lillian Thompson By Lillian Thompson

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