353.1 🎓 醫孞生版

353.1.0.1 📌 䞀頁重點

353.1.0.1.1 Acute Pancreatitis (AP)
353.1.0.1.1.1 Etiology — “I GET SMASHED”
  • Idiopathic
  • Gallstones (50%, women)
  • Ethanol (alcohol — 25-30%, men)
  • Trauma
  • Steroids
  • Mumps + other viruses
  • Autoimmune (IgG4-related, Type 2)
  • Scorpion bites (Tityus trinitatis)
  • Hyperlipidemia (TG > 1000), Hypercalcemia
  • ERCP (post-procedure)
  • Drugs (DDI):
    • Anti-HIV (didanosine, pentamidine)
    • Diuretics (furosemide, thiazides)
    • Antiretrovirals
    • GLP-1 agonists (rare, controversial)
    • Estrogen
    • Valproate
    • Azathioprine, 6-MP
    • Statins
    • Sulfonamides
    • Mesalamine

353.1.1 Other Less Common

  • Hypercalcemia (hyperparathyroidism)
  • Pancreatic cancer
  • Pancreas divisum
  • Sphincter of Oddi dysfunction
  • Cystic fibrosis (CFTR)
  • Hereditary (PRSS1, SPINK1, CTRC, CASR mutations)
353.1.1.0.0.1 Pathophysiology
  • Premature trypsinogen activation
  • Pancreatic autodigestion
  • Inflammatory cascade
  • Possible necrosis + organ failure
353.1.1.0.0.2 Clinical Presentation
  • Severe epigastric pain (radiating to back; relieved by leaning forward)
  • Nausea + vomiting
  • Anorexia
  • Abdominal tenderness
  • Fever (severe)
  • Tachycardia
  • Hypotension (severe)
  • Cullen sign (periumbilical ecchymosis) — late, necrotizing
  • Grey-Turner sign (flank ecchymosis) — late, necrotizing
353.1.1.0.0.3 Diagnosis (2 of 3 Criteria)
  1. Abdominal pain consistent with AP
  2. Serum lipase or amylase > 3x ULN
  3. Characteristic imaging findings

353.1.2 Labs

  • Lipase (more specific than amylase)
  • Amylase
  • LFT, BMP
  • CBC
  • Triglycerides (severe — TG > 1000)
  • Calcium, glucose
  • Coagulation
  • CRP (severity marker)

353.1.3 Imaging

  • CT abdomen (with contrast):
    • Pancreatic edema → fluid collection → necrosis
    • Stranding
    • Pseudocyst
    • Walled-off necrosis
  • US: gallstones, cholecystitis
  • MRCP / EUS: anatomic details
  • ERCP: therapeutic (extraction)
353.1.3.0.0.1 Severity Classification (Atlanta Revised 2012)

Mild AP: - No organ failure - No local complications - Resolves usually in 1 week

Moderately Severe AP: - Transient organ failure (< 48 h) OR - Local complications (fluid collections, pseudocyst, necrosis)

Severe AP: - Persistent organ failure (> 48 h) - Often necrotizing - High mortality

Marshall Scoring for organ failure: - Respiratory, renal, cardiovascular - Each scored 0-4 - Total > 2 = organ failure

353.1.3.0.0.2 Severity Predictors (Early)
  • BISAP score (BUN, Impaired mental, SIRS, Age > 60, Pleural effusion)
  • APACHE II
  • Persistent SIRS
  • Hemoconcentration (Hct > 44)
  • CRP > 150 at 48 h
353.1.3.0.0.3 Treatment

Initial Resuscitation: - Aggressive IV fluids (lactated Ringer’s preferred over NS — PAMPHLET trial) - Avoid over-resuscitation (controversial; WATERFALL trial — moderate) - Goal-directed: UO, HR, BP, Hct - Analgesia (IV opioids) - Anti-emetics

Specific Treatments: - Gallstone AP: ERCP within 24-72 h if obstructive/cholangitis; otherwise after stabilization; cholecystectomy before discharge for mild - Hypertriglyceridemic AP: insulin infusion ± heparin ± apheresis - Hypercalcemia: IV fluids + calcitonin + bisphosphonate - Drug-induced: discontinue offending agent

Nutrition: - Early oral feeding as tolerated (preferred — improves outcomes vs NPO) - NJ tube for severe / unable to tolerate - TPN only if enteral failed - Low-fat initially

Antibiotics: - NOT routine - Reserved for proven infected necrosis (procalcitonin, culture, gas on imaging) - Carbapenem if needed

Cholecystectomy: - After gallstone AP recovery - Same admission for mild - Reduces recurrence

353.1.3.0.0.4 Local Complications

Pancreatic Fluid Collections: - Acute fluid collection (early, < 4 weeks) - Pseudocyst (4+ weeks, walled with non-epithelial wall) - Acute necrotic collection (early, with necrosis) - Walled-off necrosis (WON) (4+ weeks, with necrosis)

Treatment of Collections: - Asymptomatic small: observation - Symptomatic / infected: drainage (endoscopic, percutaneous, surgical) - Step-up approach (PANTER trial): percutaneous drainage → endoscopic → surgical if needed - Endoscopic transmural drainage (lumen-apposing metal stents) preferred for many WON

Other Complications: - Splenic vein thrombosis → gastric varices (sinistral portal HTN) - Pseudoaneurysm (splenic artery) - Bowel obstruction - Fistula (pancreatic, biliary) - Persistent ductal leak

353.1.3.0.0.5 Outcomes
  • Mild AP: low mortality
  • Severe AP: 20-30% mortality
  • Recurrence common, especially with persistent risk factors
353.1.3.0.1 Chronic Pancreatitis (CP)
353.1.3.0.1.1 Etiology
  • Alcohol (most common — > 50%)
  • Smoking (independent + synergy with alcohol)
  • Hereditary (PRSS1, SPINK1, CTRC, CASR)
  • Cystic fibrosis (CFTR)
  • Autoimmune (IgG4-related Type 1, Type 2)
  • Ductal obstruction (cancer, stone)
  • Hypercalcemia
  • Tropical chronic pancreatitis
  • Idiopathic
353.1.3.0.1.2 Clinical Features

Pain: - Chronic epigastric pain (often radiating to back) - May decrease over years (“burnout”)

Exocrine Insufficiency: - Steatorrhea (> 90% pancreatic function loss) - Weight loss - Fat-soluble vitamin deficiency (ADEK) - Diarrhea

Endocrine Insufficiency: - Pancreatic-related diabetes (Type 3c) - Brittle, prone to hypoglycemia - Often requires insulin

353.1.3.0.1.3 Diagnosis

Imaging: - CT: calcifications, ductal dilation, atrophy - MRCP: ductal anatomy - EUS: detailed parenchymal + ductal - Rosemont criteria (EUS)

Function: - Fecal elastase (< 200 ÎŒg/g — moderate; < 100 — severe) - Secretin-MRCP stimulation - 72-h fecal fat (rarely)

Lab: - CA 19-9 (cancer differential) - Genetic testing (hereditary) - IgG4 (autoimmune pancreatitis)

353.1.3.0.1.4 Treatment

Lifestyle: - Alcohol cessation (critical) - Smoking cessation (independent risk) - Small frequent meals

Pancreatic Enzyme Replacement (PERT): - For exocrine insufficiency - Pancrelipase (Creon, Zenpep, Pancreaze, Ultresa) - With all meals - ADEK vitamin supplementation

Diabetes Management: - Pancreatic diabetes (Type 3c) - Often insulin-requiring - Brittle - Watch for hypoglycemia - Glucagon may be impaired

Pain Management: - Tylenol first - NSAIDs (caution renal) - Pregabalin / gabapentin - Antidepressants (TCAs, SNRIs) - Opioids (cautious; addiction risk) - Celiac plexus block (selected)

Endoscopic Therapy: - ERCP with stent for ductal stenosis - Stone removal - ESWL for large pancreatic duct stones

Surgery: - For intractable pain not relieved - Beger, Frey, Whipple, drainage procedures - Total pancreatectomy with autologous islet transplant (TPIAT) for select

353.1.3.0.2 Autoimmune Pancreatitis (AIP)

353.1.5 Type 2 (Idiopathic Duct-Centric)

  • Younger
  • IBD association
  • Granulocytic epithelial lesions
  • Steroid-responsive

353.1.6 Treatment

  • Steroids (prednisone)
  • Rituximab + MMF for refractory
  • IgG4-RD systemic management
353.1.6.0.1 Pancreatic Pseudocyst

353.1.7 Definition

  • Walled-off fluid collection ≥ 4 weeks post-AP
  • Non-epithelial lining
  • Contains pancreatic secretions

353.1.8 Symptoms

  • Often asymptomatic
  • Pain
  • Bleeding
  • Infection
  • Mass effect (compression)

353.1.9 Treatment

  • Observation if asymptomatic + < 6 cm
  • Drainage if symptomatic / > 6 cm / complications:
    • Endoscopic transmural (preferred)
    • Percutaneous
    • Surgical (less common now)

353.1.9.1 🩺 床邊速查

  • AP diagnosis (2 of 3): pain + lipase > 3x ULN + imaging
  • Etiology “I GET SMASHED”: idiopathic, gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion, hyperlipidemia/Ca, ERCP, drugs
  • Severity (Atlanta 2012): mild, moderate (transient OF), severe (persistent OF > 48 h)
  • Treatment: aggressive IV LR + analgesia + early oral feeding
  • Necrotizing: antibiotics ONLY if infected
  • CP: alcohol + smoking; PERT for exocrine + insulin for endocrine
  • AIP Type 1 (IgG4-related) + Type 2: steroid-responsive