353.3 🏥 內科專科考前版

353.3.1 Mechanistic Deep Dive

353.3.1.1 Premature Trypsinogen Activation

  • Trypsin activates other proenzymes
  • Self-perpetuating autodigestion
  • Severity related to extent

353.3.1.2 Hypertriglyceridemia-Induced AP

  • TG > 1000-2000 mg/dL
  • Fatty acid lipotoxicity
  • More severe course
  • Treat with insulin infusion ± apheresis

353.3.1.3 Smoking + Pancreatitis

  • Independent risk factor
  • Synergistic with alcohol
  • Important counseling target

353.3.2 Recent Trials & Updates

353.3.2.1 PAMPHLET (2022)

  • Aggressive LR vs NS for AP
  • LR slightly better

353.3.2.2 WATERFALL (2022)

  • Aggressive vs moderate fluid resuscitation
  • Moderate sufficient; aggressive ↑ volume overload

353.3.2.3 PANTER (2010)

  • Step-up vs primary surgery for necrotizing pancreatitis
  • Step-up better outcomes

353.3.2.4 TPIAT (Total Pancreatectomy + Islet Auto-Transplant)

  • For severe refractory CP pain
  • ↓ Pain + ↑ QoL
  • Maintain endocrine function (partial)

353.3.3 High-Yield Specialist Points

353.3.3.1 Post-ERCP Pancreatitis Prevention

  • Rectal NSAIDs (indomethacin 100 mg) — preventive
  • Hydration

353.3.3.2 Drug-Induced AP Workup

  • High suspicion for new drug starts
  • Time relationship
  • Common: didanosine, pentamidine, valproate, azathioprine, mesalamine, statins, GLP-1 (controversial)

353.3.3.3 Necrotizing Pancreatitis Distinction

  • Infected vs sterile necrosis
  • Procalcitonin marker
  • Gas on imaging = infected
  • Antibiotics + drainage if infected

353.3.3.4 Walled-Off Necrosis Drainage

  • Endoscopic transmural with LAMS (lumen-apposing metal stents) — preferred
  • Multiple endoscopic necrosectomies often needed
  • Outpatient procedures

353.3.3.5 Chronic Pancreatitis Pain Management

  • Multimodal approach
  • Avoid chronic opioids if possible
  • Endoscopic interventions for ductal stenosis
  • Celiac plexus block
  • Surgery (Beger, Frey, Whipple) for refractory

353.3.3.6 TPIAT Indications

  • Severe refractory pain
  • Recurrent acute pancreatitis
  • ↑ Risk pancreatic cancer (hereditary)
  • Centers of excellence

353.3.3.7 Pancreatic Cancer Screening

  • Hereditary pancreatitis
  • BRCA1/2 mutation carriers
  • Lynch syndrome
  • Family clusters
  • Annual MRI / EUS at specialized centers

353.3.3.8 Pediatric Pancreatitis

  • Often hereditary or metabolic
  • Different prevalence of etiologies
  • Specialty referral

353.3.3.10 Pancreatic Cysts

  • IPMN (intraductal papillary mucinous neoplasm)
  • Mucinous cystic neoplasm
  • Serous cystadenoma
  • Pseudocyst
  • MRI/MRCP for characterization
  • EUS-FNA selected
  • Surveillance vs surgery

353.3.3.11 Diabetic Type 3c

  • Pancreatic in origin
  • Brittle (loss of glucagon counter-regulation)
  • Insulin + carbohydrate management
  • Frequent monitoring

353.3.4 Pearls

  • AP diagnosis 2 of 3: pain + lipase + imaging
  • Etiology “I GET SMASHED” mnemonic
  • Atlanta 2012 severity: mild, moderate, severe
  • Treatment: aggressive IV LR + analgesia + early oral feeding + ERCP if obstructive
  • Antibiotics only for infected necrosis
  • Step-up approach: percutaneous → endoscopic → surgery
  • CP: alcohol + smoking; PERT + insulin
  • AIP: steroid-responsive (Type 1 IgG4 + Type 2 idiopathic)
  • TPIAT: refractory CP pain