PANCE Blueprint GI and Nutrition (8%)

Acute pancreatitis is most commonly caused by gallstones (most common overall) and alcohol (most common in men), diagnosed by 2 of 3 criteria: epigastric pain radiating to the back + lipase ≥3× ULN + characteristic CT findings; Ranson's criteria and BISAP score predict severity; hemorrhagic pancreatitis produces Grey Turner's sign (flank ecchymosis) and Cullen's sign (periumbilical ecchymosis); treatment is aggressive IV fluids, pain control, NPO, and early enteral nutrition for severe cases.

• Gallstones (~40%) and alcohol (~30%)
• Mnemonic: GET SMASHED (Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion sting, Hypercalcemia/Hypertriglyceridemia [TG >1000 mg/dL], ERCP, Drugs [furosemide, thiazides, azathioprine, tetracyclines, estrogen, valproic acid])
• Key differentiator: pancreatitis pain is constant, severe, radiates to back, unlike biliary colic

DX: Diagnosis requires 2 of 3: (1) characteristic pain, (2) lipase ≥ 3× normal (most specific), (3) imaging findings; CT abdomen = best initial imaging if diagnosis unclear or severe

• Labs: ↑ lipase (preferred over amylase); ALT >150 suggests gallstone pancreatitis; may see hypocalcemia in severe disease

• DX:
  • Clinical + elevated lipase and amylase
  • CT is required to differentiate from necrotic pancreatitis
• Signs: Grey Turner's sign (flank bruising), Cullen’s sign (bruising near the umbilicus) - think of "C" looks like an "O"

This 40-year-old woman complained of worsening epigastric pain of five days duration. On examination, she had hypotension, a board-like abdomen, and extensive ecchymosis over her right loin (Grey Turner’s sign)

Acute pancreatitis with Cullen’s sign

Severity assessment: use BISAP or Ranson criteria

Ranson’s criteria for poor prognosis:

TX: Aggressive IV fluids (lactated Ringer’s), NPO, and IV opioids for pain control; early fluids are the most important mortality-reducing step

• Complication: pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)

Chronic Pancreatitis

Chronic pancreatitis is progressive inflammatory fibrosis of the pancreas leading to irreversible exocrine and endocrine dysfunction (most commonly due to chronic alcohol use).

• Chronic epigastric pain radiating to the back + steatorrhea + weight loss = classic triad; pain often worse after meals
• Most common cause: chronic alcohol abuse (~70–80% in Western countries)
  • Other causes → cystic fibrosis, hereditary pancreatitis (PRSS1), hypercalcemia, hypertriglyceridemia
• Pathophysiology: repeated inflammation → fibrosis, ductal obstruction, and pancreatic calcifications → loss of enzyme production
• Exocrine insufficiency occurs first → fat malabsorption (steatorrhea) and fat-soluble vitamin (A, D, E, K) deficiency
• Endocrine failure later → diabetes mellitus (type 3c, brittle DM)

DX: CT scan = best initial test showing pancreatic calcifications; fecal elastase ↓ confirms exocrine insufficiency (functional test)

• Key differentiator: chronic pain + calcifications (vs acute pancreatitis = elevated lipase without calcifications)
• Complications: pseudocysts, pancreatic cancer (increased risk), malnutrition

TX: Pancreatic enzyme replacement (pancrelipase) + alcohol and smoking cessation + pain control (stepwise, avoid opioids if possible)

• Fat-soluble vitamin supplementation, low-fat diet, and insulin for diabetes; consider endoscopic or surgical decompression if refractory pain or obstruction