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Acute Pancreatitis - High-Yield Questions (LQ)

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ETIOLOGY & PATHOPHYSIOLOGY

Gallstones (40-70%) and alcohol abuse (25-35%). Gallstones are the leading cause in women; alcohol is more common in men (though this demographic is changing).

• Swanson's Family Medicine Review; Yamada's Textbook of Gastroenterology

• Current Surgical Therapy 14e; Sleisenger & Fordtran's GI and Liver Disease

>1000 mg/dL with no other clear cause. Note: serum triglycerides can be secondarily elevated by pancreatitis itself, so persistent elevation after resolution supports this diagnosis.

• Rosen's Emergency Medicine

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DIAGNOSIS

1. Acute-onset epigastric pain, often radiating to the back
2. Serum lipase or amylase > 3x upper limit of normal
3. Imaging (CT/MRI/US) showing pancreatic inflammation

• Current Surgical Therapy 14e; Sabiston Textbook of Surgery

Lipase is preferred - it is more sensitive and specific for AP than amylase, has a longer elevation window (stays elevated for 7-14 days vs. amylase 3-5 days), and is not elevated by salivary gland disease or macroamylasemia.

Abdominal ultrasound - performed to evaluate for a biliary (gallstone) etiology. CT is reserved for: diagnostic uncertainty, atypical presentations, hemodynamically unstable patients (to rule out other diagnoses), or to assess for complications (necrosis).

• Rosen's Emergency Medicine

• Diagnostic uncertainty (atypical symptoms or non-elevated enzymes)
• Hemodynamically unstable patients (to rule out mesenteric ischemia, perforation)
• Suspected pancreatic necrosis or failure to improve after 48-72 hours
• Recurrent AP (CT in all cases)
• Current Surgical Therapy 14e

• Grey-Turner's sign: reddish-brown/ecchymotic discoloration of the flanks - retroperitoneal hemorrhage
• Cullen's sign: bluish periumbilical ecchymosis - hemoperitoneum

Both are rare but indicate severe necrotizing pancreatitis with hemorrhage into surrounding spaces. They appear late in the disease course.

• Tintinalli's Emergency Medicine; Yamada's Textbook of Gastroenterology; Bailey & Love's Surgery

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SEVERITY SCORING

• PPV: ~50%, NPV: ~90% (mainly used to rule OUT severe pancreatitis)
• Sabiston Textbook of Surgery

• Sabiston Textbook of Surgery

• B - BUN >25 mg/dL
• I - Impaired mental status (GCS <15)
• S - SIRS criteria (≥2 present)
• A - Age >60 years
• P - Pleural effusion on imaging

• Sabiston Textbook of Surgery

≥8. Advantage: can be used at admission and repeated serially. Disadvantage: complex, not specific for AP, age-dependent.

• Sabiston Textbook of Surgery

CRP ≥150 mg/mL, but peaks at 48-72 hours after onset - cannot be used reliably at admission. Sensitivity decreases if measured <48 hours.

• Sabiston Textbook of Surgery

• Sabiston Textbook of Surgery

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SEVERITY CLASSIFICATION (2012 Atlanta)

• Current Surgical Therapy 14e

SIRS lasting >48 hours carries a 25% mortality vs. 8% for SIRS that resolves within 48 hours. SIRS is currently the recommended system for evaluating severity at presentation and at 48 hours.

• Current Surgical Therapy 14e

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COMPLICATIONS

• Current Surgical Therapy 14e; Sleisenger & Fordtran's

Gas bubbles within a peripancreatic collection on CT - pathognomonic for infected necrosis.

• Current Surgical Therapy 14e

• ARDS / pleural effusion (most common pulmonary complication)
• Acute kidney injury / renal failure
• Shock / hypotension
• DIC
• Hyperglycemia
• Hypocalcemia (saponification of fat - calcium binds to fatty acids released by lipase)
• Hemorrhage (erosion into vessels)

Pancreatic lipase causes fat saponification - free fatty acids released by lipolysis bind calcium, depositing calcium soaps in peripancreatic fat, leading to hypocalcemia. This is a poor prognostic sign.

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MANAGEMENT

Lactated Ringer's (LR) is preferred over normal saline (NS reduces inflammatory cascade). Goal-directed resuscitation starting at 5-10 mL/kg/hour. Most patients need 2500-4000 mL in the first 24 hours.

• Avoid over-resuscitation (risk: ARDS, abdominal compartment syndrome)
• Avoid under-resuscitation (risk: end-organ damage, pancreatic necrosis)

• Current Surgical Therapy 14e

Early oral feeding within 24 hours of admission is recommended, even if lipase has not normalized.

• Mild-moderate AP: low-fat or normal solid diet (skip liquid/soft diet step)
• Severe AP / intolerant: nasogastric or nasojejunal feeds once hemodynamically stable
• Parenteral nutrition: reserved for those who don't tolerate enteral feeding within 5-7 days (associated with increased infected necrosis and MOF compared to enteral feeds)

• Current Surgical Therapy 14e

NOT for prophylaxis. Antibiotics should be used only for confirmed or suspected infected pancreatic necrosis or in septic patients with no other source.

• Preferred: carbapenems (achieve high concentrations in necrotic pancreatic tissue)
• Infections are often polymicrobial with enteric organisms; E. coli is most common isolate
• Add antifungal coverage empirically

• Current Surgical Therapy 14e

• NOT routine for all gallstone pancreatitis (most stones pass spontaneously)
• Urgent ERCP indicated for acute cholangitis (as soon as possible)
• Choledocholithiasis without cholangitis: wait 24-48 hours; ERCP if obstruction doesn't resolve
• Mild biliary pancreatitis: cholecystectomy during index admission to reduce recurrence, readmission, and mortality

• Current Surgical Therapy 14e

• Infected pancreatic necrosis (main indication)
• Symptomatic walled-off necrosis (WON) not resolving
• Preferred approach: step-up strategy (percutaneous drain first → endoscopic/minimally invasive necrosectomy if needed → open surgery as last resort)
• Intervention for sterile necrosis is avoided unless clinically deteriorating

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QUICK HIGH-YIELD FACTS (Exam Favourites)

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History Taking for Intestinal Volvulus

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1. PATIENT DEMOGRAPHICS (ask first - they guide everything)

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2. PRESENTING COMPLAINT - CARDINAL SYMPTOMS

A. Abdominal Pain

• Onset: Sudden or gradual? (Fulminant = sudden, severe onset; indolent = insidious, slow)
• Character: Colicky (cramping, comes in waves) or constant?
  • Colicky pain = peristalsis fighting obstruction
  • Constant/severe unremitting pain = strangulation / ischaemia (RED FLAG)
• Location: Periumbilical (small bowel) or lower abdomen (large bowel/sigmoid)?
• Radiation: Any radiation to back or pelvis?
• Severity: Scale 0-10. Beware: the patient whose pain is not controlled with IV opiates - suggests ischaemia
• Progression: Has it changed in character? (Colicky pain that becomes constant = evolving strangulation)

B. Abdominal Distension

• When did the abdomen start swelling?
• How rapidly did it develop? (Massive, rapid distension is the hallmark of sigmoid volvulus)
• Is it localised or generalised?
• Any visible movement of the abdomen? (Visible peristalsis = mechanical obstruction)

C. Vomiting

• When did vomiting start relative to pain? (Earlier onset in high/small bowel; later in large bowel)
• Frequency and volume?
• Character of vomitus:
  • Undigested food / bile (early, high obstruction)
  • Green/bilious (mid-small bowel)
  • Faeculent/faecal-smelling (late feature - bacterial overgrowth, low obstruction)
• Bilious vomiting in a neonate = midgut volvulus until proven otherwise (EMERGENCY)

D. Constipation / Change in Bowel Habit

• Last time flatus was passed? (Absolute constipation = no flatus or stool = complete obstruction)
• Last bowel motion?
• Has there been any diarrhoea? (Partial obstruction can cause overflow diarrhoea)
• Note: Some patients may pass stool/flatus early because the bowel distal to the obstruction empties - this does not exclude obstruction

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3. ASSOCIATED SYMPTOMS

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4. ONSET & PROGRESSION PATTERN

• Fulminant - sudden onset, severe pain, early profuse vomiting, rapidly deteriorating course (common in caecal volvulus, midgut volvulus, strangulation)
• Indolent - insidious onset, slow progression, less pain, late vomiting (more common in sigmoid volvulus in elderly)

• "How did it start - suddenly or slowly?"
• "Has it been getting worse continuously or does it come and go?"
• "Have you had similar episodes before that resolved on their own?" (Recurrent episodes suggest intermittent/partial volvulus)

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5. PAST HISTORY - RISK FACTORS

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6. DRUG HISTORY

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7. FAMILY & SOCIAL HISTORY

• Family history of colorectal cancer, IBD, or congenital bowel disorders?
• Dietary history: High-fibre/high-residue diet? Long periods of fasting?
• Mobility and activity level: Bedridden / institutionalised?
• Alcohol use (associated with nutritional deficiencies and dysmotility)
• Occupation and living conditions (care home, prison, psychiatric facility)

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8. SPECIAL POPULATIONS - TARGETED HISTORY

Neonates / Infants (Midgut Volvulus)

• Bilious (green) vomiting - the most important feature; any bilious vomiting in a neonate is a surgical emergency
• Abdominal distension (may be minimal early on)
• Bloody stools (late sign - ischaemia)
• Feeding refusal / lethargy
• Maternal history of polyhydramnios (associated with gut obstruction in utero)
• Antenatal scans showing bowel dilation?

Elderly / Institutionalised (Sigmoid Volvulus)

• History may be unreliable - patient may not communicate symptoms clearly
• Carers' account: Increasing abdominal size, not opening bowels, not eating
• Massive distension is key; pain is unusual - if pain is present, suspect ischaemia
• Background history of repeated similar episodes

Younger Adults (Caecal Volvulus)

• More acute presentation, more pain
• Ask about previous right-sided abdominal surgery
• Pregnancy in women of reproductive age

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9. RED FLAGS - STRANGULATION / ISCHAEMIA

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10. SYSTEMATIC SUMMARY - SUGGESTED SEQUENCE IN CLERKING

1. Chief complaint: pain / distension / vomiting / constipation - which came first?
2. Onset, duration, progression
3. Character and location of pain
4. Vomiting: onset, character (bilious? faeculent?)
5. Bowel habit: last flatus and stool
6. Associated: fever, rectal bleeding, urinary symptoms
7. Previous episodes? Self-resolution?
8. Past surgical history (adhesions, stoma, prior bowel surgery)
9. Medical history: constipation, neurological disorders, psychiatric illness, malrotation
10. Drugs: psychotropics, opioids, laxatives
11. Social: institutionalised? Diet? Mobility? Pregnancy?
12. Family history
13. Review of systems: dehydration, syncope, anorexia

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