PANCE Blueprint GI and Nutrition (10%)

Acute and chronic pancreatitis

Patient will present with → severe epigastric pain radiating to the back.  The pain typically lessens when the patient leans forward or lies in the fetal position. The patient has diminished bowel sounds on physical exam

Acute Pancreatitis - epigastric abdominal pain with radiation to the back and elevated lipase - pain lessons when patient leans forward

  • Etiology: Most common causes are ETOH and gallstones
  • Cullen's sign (bruising near umbilicus) is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus
  • Grey Turner's sign (flank bruising) refers to bruising of the flanks, the part of the body between the last rib and the top of the hip

Ranson’s criteria for poor prognosis

Ranson's criteria: The Ranson criteria form a clinical prediction rule for predicting the severity of acute pancreatitis.  Three or more means more severe course:

At admit:

  • Age > 55
  • Leukocyte: >16,000
  • Glucose: >200
  • LDH: >350
  • AST: >250

At 48 hrs:

  • Arterial PO2: <60
  • HCO3: <20
  • Calcium: <8.0
  • BUN: Increase by 1.8+
  • Hematocrit: decrease by >10%
  • Fluid sequestration >6L

Chronic Pancreatitis

Clinical features are the same as those of acute pancreatitis, with the addition of fat malabsorption and steatorrhea late in the disease. Fecal fat will be elevated if malabsorption is present.

The classic triad (look for this on your exam) of pancreatic calcification, steatorrhea, and diabetes mellitus occurs in only 20% of patients

  • Permanent and progressive damage to the pancreas
  • Epigastric abdominal pain, weight loss, diarrhea, and pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)
  • ERCP is the most sensitive for chronic pancreatitis

Will have prandial epigastric pain, labs will show increased serum lipase (more sensitive and specific than amylase, but only with elevations of threefold or greater)

  • Abdominal CT is the diagnostic test of choice
  • Sentinel loops on X-Ray
    • look for diminished bowel sounds as part of exam question
  • ERCP is the most sensitive for chronic pancreatitis

The mainstay of treatment for acute pancreatitis is supportive therapy: NPO, IV fluids (best), analgesics, bowel rest

  • Antibiotics
  • ERCP if biliary sepsis is suspected
  • Complication: pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)
  • Patients with mild pancreatitis can progress to severe pancreatitis over the initial 48 hours, often due to inadequate fluid replacement
  • Referral to tertiary center is needed if acute pancreatitis is severe or evolving/worsening

The only definitive treatment for chronic pancreatitis is to address the underlying cause, which is most commonly alcohol, low fat diet

Sentinel Loop-one or two dilated loops of small bowel which may indicate the presence of an irritative process in the region, e.g., inflammation

Sentinel Loop-one or two dilated loops of small bowel which may indicate the presence of an irritative process in the region, e.g., inflammation

Question 1
A 36 year old man presents with sudden onset severe epigastric pain following an alcohol binge. Pain is referred to his back. Pain is alleviated when he sits and leans forward. There is also nausea and vomiting. Physical examination revealed upper abdominal tenderness, bluish discoloration around the umbilicus, bowel sounds are absent. What is the most likely diagnosis?
A
Acute pancreatitis
B
Acute appendicitis
Hint:
Usual presentation is periumbilical pain that is later referred to the right lower quadrant. No Cullen’s sign.
C
Acute cholecystitis
Hint:
Presents with right upper quadrant pain that is not relieved sitting and leaning forward. Not associated with Cullen’s sign.
D
Acute gastroenteritis
Hint:
Presents as diarrhea with vomiting, colicky abdominal pain. Pain not relieved by sitting and leaning forward.
Question 1 Explanation: 
Sudden severe epigastric pain (following alcohol binge) that is referred to the back and relieved by sitting and leaning forward with Cullen’s sign (periumbilical ecchymosis) strongly suggest acute pancreatitis.
Question 2
In the previous patient All of the following tests should be ordered next except
A
complete blood count with differential
B
serum amylase and lipase level
C
computed tomography (CT) scan of the abdomen with contrast
D
comprehensive metabolic panel
E
arterial blood gases
Question 2 Explanation: 
The initial laboratory evaluation should include a complete blood count with differential, amylase and lipase levels, metabolic panel (blood urea nitrogen, creatinine, glucose, and calcium levels), liver function tests, and arterial blood gas analysis. Results from these tests should be used to guide further evaluation. CT scan of the abdomen would help in diagnosis of pancreatitis and pseudocyst formation but should be done after the initial laboratory investigations and stabilization of the patie
Question 3
Which of the radiologic imaging techniques is the most sensitive in diagnosis of acute pancreatitis and pancreatic pseudocyst?
A
transabdominal ultrasonography
B
contrast-enhanced CT of the abdomen
C
magnetic resonance cholangiopancreatography
D
plain radiograph (abdominal series)
Question 3 Explanation: 
Contrast-enhanced CT has become the standard imaging technique for detection of acute pancreatitis and pseudocyst formation. Not only does it help in diagnosis, but some studies have shown that a CT severity index is helpful in predicting the severity of acute pancreatitis compared with the Ranson criteria and the APACHE II scale. Transabdominal ultrasonography is a better tool for diagnosis of cholelithiasis. Bowel gas can often limit the accuracy of pancreatic imaging by ultrasonography. Plain radiograph of the abdomen can demonstrate the sentinel loop in two thirds of patients but is not sensitive or specific enough for diagnosis. Magnetic resonance cholangiopancreatography can be used as a noninvasive test to determine which patients will need endoscopic retrograde cholangiopancreatography (ERCP). It is no more sensitive than a CT scan in determining the severity of acute pancreatitis, and it is much more expensive and not always available.
Question 4
What is (are) the essential diagnostic feature(s) of the condition of the patient described here?
A
abrupt onset of epigastric pain with radiation to the back
B
nausea and vomiting
C
elevated serum amylase
D
all of the above
Question 4 Explanation: 
The essential diagnostic features of acute pancreatitis include abrupt onset of epigastric pain with radiation to the back and lower lumbar spine, nausea and vomiting, and elevated serum amylase and lipase levels. Acute pancreatitis is usually caused by gallstones or alcoholism. The essential diagnostic features of pancreatic pseudocyst include an epigastric mass and pain, mild fever and leukocytosis, persistent serum amylase or serum lipase elevation, and demonstration of pseudocyst by CT scan.
Question 5
The treatment of this condition must include all of the following except
A
eliminate oral intake for the first 48 hours
B
aggressive fluid replacement
C
calcium replacement
D
pain control
E
intravenous H2 receptor blockers
Question 5 Explanation: 
The essentials of treatment of severe acute pancreatitis include (1) keeping the patient NPO for the first 48 hours and gastric suction by nasogastric tube if severe gastric distention is present; (2) fluid replacement to replace sequestered fluid in the retroperitoneal space; (3) replacement of calcium and magnesium and other electrolytes (in severe attacks of pancreatitis, both hypocalcemia and hypomagnesemia may occur and need to be treated); (4) oxygen therapy (severe hypoxemia develops in 30% of patients; the onset is often insidious and can result in ARDS); (5) adequate pain relief; (6) nutrition—enteral nutrition when the patient can tolerate oral intake; and (7) antibiotics if pancreatic necrosis and infection are present. Although the use of H2 receptor blockers, anticholinergic drugs, and glucagon is reasonably common, their efficacy has not been demonstrated.
Question 6
In approximately two thirds of patients with this disease, a plain film of the abdomen is abnormal. Which of the following abnormalities is this plain film most likely to show?
A
a “sentinel loop”
B
the “colon cutoff sign”
Hint:
Gas distending the right colon that abruptly stops in the mid or left transverse colon is called the colon cutoff sign. This is caused by colonic spasm adjacent to the pancreatic inflammation but is not as common as the sentinel loop.
C
air under the diaphragm
Hint:
Air under the diaphragm is suggestive of a perforated peptic ulcer.
D
distention in both the small bowel and the large bowel
Hint:
A completely distended small and large bowel suggests a distal bowel obstruction.
E
feces throughout the colon
Hint:
Constipation is not associated with acute pancreatitis.
Question 6 Explanation: 
In approximately two thirds of cases, a plain film of the abdomen is abnormal. The most frequent finding is isolated dilation of a segment of gut (the sentinel loop) consisting of jejunum, transverse colon, or duodenum adjacent to the pancreas.
Question 7
Fullness in the epigastric region and a palpable mass in this patient are most likely due to
A
pancreatic pseudocyst formation
B
palpable gallbladder
Hint:
A palpable gallbladder is seen in obstruction at the ampulla or sphincter of Oddi.
C
enlarged spleen
Hint:
An enlarged spleen is unlikely in this patient given the clinical history, as is an enlarged liver.
D
enlarged liver
Question 7 Explanation: 
The palpable mass in this patient is most likely due to pancreatic pseudocyst formation. These patients are jaundiced and do not present with such acute symptoms and pain.
There are 7 questions to complete.
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