Snapshot A 50-year-old man presents to the emergency room with acute onset epigastric pain. His past medical history includes hyperlipidemia, hypertriglyceridemia, diabetes, and alcohol abuse. His last drink was this morning and he drinks 20 beers a day. He denies any fevers or chills but reports nausea and 2 episodes of nonbloody, nonbilious vomiting. Physical exam is notable for tenderness to palpation of the epigastrium. There is no muscle spasm with percussion of the cheeks. Laboratory evaluation shows significantly elevated amylase and lipase. He is started on aggressive fluid resuscitation. Introduction Clinical definition acute inflammation of pancreas and surrounding tissue, often by autodigestion with pancreatic enzyme leakage ETIOLOGY Pathogenesis inflammation is caused by leakage of pancreatic enzymes into pancreatic tissue causes autodigestion of pancreas and surrounding tissue Epidemiology Risk factors gallstones (more common) heavy alcohol use (more common) electrolyte abnormalities ↑ serum calcium ↑ triglycerides trauma drugs thiazides sulfa drugs NRTIs protease inhibitors statins valproic acid many others viral infections mumps autoimmune disease endoscopic retrograde cholangiopancreatography (ERCP) scorpion sting 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 periumbilical ecchymosis Cullen sign seen in acute pancreatitis hemorrhagic pancreatitis hemorrhage 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 indistinct margins (due to inflammation) necrosis peripancreatic fluid pseudocyst abscess CT-guided fine-needle aspiration indications infected necrosis for Gram stain and culture to guide antibiotic selection Studies Diagnostic testing studies ↑ amylase ↑ lipase ↓ calcium Differential Peptic ulcer disease distinguishing factor also presents with epigastric pain but will not have elevations in pancreatic enzymes DIAGNOSIS 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 Treatment Management approach remove all offending agents when possible treatment will be guided by etiology of pancreatitis First-line supportive care fluid resuscitation electrolyte repletion analgesia bowel rest but feed as soon as tolerated nasogastric decompression intravenous antibiotics Other treatments endoscopic retrograde cholangiopancreatography (ERCP) with eventual cholecystectomy indication gallstone pancreatitis with cholangitis common bile duct obstruction surgical debridement indication symptomatic necrotizing pancreatitis Complications Pancreatic pseudocyst Fistula formation Pancreatic abscess Hemorrhagic pancreatitis Pleural effusions (often on the left) Chronic pancreatitis Disseminated intravascular coagulation (DIC) Prognosis Ranson criteria predict mortality Ranson CriteriaClinical SignsOn AdmissionWithin 48 hoursGlucose > 200 mg/dLAge > 55 yearsLDH > 350 IU/LWBC > 16,000/mLAST > 250 IU/dLCalcium < 8.0 mg/dLHematocrit ↓ by >10%PaO2 < 60 mmHgBase deficit > 4 mEq/LBUN ↑ by 5 mg/dLSequestered fluid > 6 LMortality3-4 signs20% mortality5-6 signs40% mortality7+ signs100% mortality Clinical Signs On Admission Within 48 hours Glucose > 200 mg/dL Age > 55years 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 On Admission Within 48 hours 3-4 signs 20% mortality 5-6 signs 40% mortality 7+ signs 100% mortality
QUESTIONS 1 of 10 1 2 3 4 5 6 7 8 9 10 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.GI.17.4694) A 45-year-old man with a history of biliary colic presents with one-day of intractable nausea, vomiting, and abdominal pain radiating to the back. Temperature is 99.7 deg F (37.6 deg C), blood pressure is 102/78 mmHg, pulse is 112/min, and respirations are 22/min. On abdominal exam, he has involuntary guarding and tenderness to palpation in the right upper quadrant and epigastric regions. Laboratory studies show white blood cell count 18,200/uL, alkaline phosphatase 650 U/L, total bilirubin 2.5 mg/dL, amylase 500 U/L, and lipase 1160 U/L. Which of the patient's laboratory findings is associated with increased mortality? QID: 107797 Type & Select Correct Answer 1 White blood cell count 29% (2/7) 2 Alkaline phosphatase 0% (0/7) 3 Total bilirubin 0% (0/7) 4 Amylase 0% (0/7) 5 Lipase 71% (5/7) M 6 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (M2.GI.16.4692) A 39-year-old male presents to the emergency department with acute abdominal pain and anorexia for two days. The patient has an extensive history of alcoholism with a hospitalization four months ago after being brought in by the police department for intoxication. On physical exam vital signs are T 99.0 F, BP 100/68 mmHg, HR 135 bpm, RR 20 rpm, and O2 Sat 100%. Abdominal exam is notable for exquisite tenderness to palpation over the epigastrium and the following finding (Figure A). Therapy for this patient should consist of which of the following? QID: 107669 FIGURES: A Type & Select Correct Answer 1 Endoscopic retrograde cholangiopancreatography (ERCP) 0% (0/9) 2 IV fluid hydration, analgesia, and intensive care management 67% (6/9) 3 Treat with chlordiazepoxide and intensive care management 11% (1/9) 4 Esophagogastroduodenoscopy (EGD) with variceal banding 0% (0/9) 5 Percutaneous transhepatic cholangiography (PTC) 22% (2/9) M 5 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (M2.GI.15.14) A 37-year-old woman with a past medical history diabetes, high cholesterol, hypertension and anxiety complains of rapid-onset, mid-epigastric pain with radiation to the back. She states that she has had a few of these episodes in the past, but this is the worst so far. Her pain is somewhat relieved by sitting forward. Physical examination notes epigastric tenderness without guarding or rebound. Figure A is also noticed on physical examination. Laboratory studies show elevated amylase and lipase. She denies use of alcohol, tobacco, and illicit drugs. A RUQ ultrasound was performed and found to be negative and total and direct bilirubin are normal. Urine toxicology returns negative results and her blood alcohol level is determined to be 0. What is the most likely cause of her current symptoms? QID: 104556 FIGURES: A Type & Select Correct Answer 1 Alcoholism 6% (5/86) 2 Scorpion sting 5% (4/86) 3 Biliary tract obstruction 13% (11/86) 4 Hypertriglyceridemia 73% (63/86) 5 Hypercalcemia 2% (2/86) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M2.HE.15.4672) A 45-year-old homeless man presents to the emergency department acutely intoxicated. He has a history of belligerence and substance abuse and was found today in a local park outdoors in Arizona. His temperature is 97.7°F (36.5°C), blood pressure is 100/66 mmHg, pulse is 130/min, respirations are 26/min, and oxygen saturation is 98% on room air. The patient is responsive to sternal rub and cries out in pain with palpation of his epigastric region. Lower extremity petechiae are noted. Laboratory studies are ordered as seen below.Hemoglobin: 10 g/dLHematocrit: 31%Leukocyte count: 6,520/mm^3 with normal differentialPlatelet count: 51,000/mm^3 Serum:Na+: 130 mEq/LCl-: 101 mEq/LK+: 3.3 mEq/LHCO3-: 25 mEq/LBUN: 20 mg/dLGlucose: 66 mg/dLCreatinine: 1.7 mg/dLCa2+: 9.2 mg/dLINR: 2.5A peripheral smear is ordered as seen in Figure A. The patient is given 2 liters of fluids, and his pulse is subsequently 80/min with a blood pressure of 125/81 mmHg. Which of the following is the most likely diagnosis? QID: 107183 FIGURES: A Type & Select Correct Answer 1 Cirrhosis 0% (0/25) 2 Immune thrombocytopenic purpura 32% (8/25) 3 Pancreatitis 40% (10/25) 4 Rattlesnake bite 20% (5/25) 5 Septic shock 4% (1/25) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
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