353.4 📋 章末速蚘 Summary

353.4.1 🔑 䞀句話瞜結

Acute pancreatitis (AP) = acute inflammation; “I GET SMASHED” etiology mnemonic — gallstones (50% women) + alcohol (25-30% men) + hypertriglyceridemia (TG > 1000) + ERCP + drugs + idiopathic main causesdiagnosis (2 of 3)abdominal pain + lipase/amylase > 3x ULN + imaging consistentseverity (Atlanta Revised 2012)mild (no OF) / moderate (transient OF or local complications) / severe (persistent OF > 48 h)severity markersBISAP score, CRP > 150 at 48 h, hemoconcentration, persistent SIRStreatmentaggressive IV LR (lactated Ringer’s preferred — PAMPHLET trial) but not over-resuscitate (WATERFALL 2022 — moderate sufficient) + analgesia (IV opioids) + early oral feeding > NJ tube > TPN + ERCP within 24-72 h for gallstone with cholangitis or persistent obstruction + cholecystectomy before discharge for mild gallstone AP + antibiotics ONLY for infected necrosis (procalcitonin, culture, gas on imaging)local complicationsacute fluid collection → pseudocyst (4+ weeks, non-epithelial) vs acute necrotic collection → walled-off necrosis (WON 4+ weeks); step-up approach (PANTER trial) percutaneous → endoscopic → surgical; endoscopic transmural drainage with LAMS preferred for WONchronic pancreatitis (CP)irreversible parenchymal damage; alcohol most common (50%+) + smoking independent + hereditary (PRSS1, SPINK1, CFTR, CASR) + CF + autoimmune; clinical = chronic pain + exocrine insufficiency (steatorrhea + ADEK deficiency) + endocrine insufficiency (Type 3c diabetes — brittle, often insulin-requiring); diagnosis = imaging (CT, MRCP, EUS) + fecal elastase + secretin-MRCP; treatment = alcohol + smoking cessation + PERT (pancreatic enzyme replacement therapy) + insulin + analgesia (multimodal, avoid chronic opioids) + endoscopic (stent, ESWL) for ductal + surgery (Beger, Frey, Whipple, TPIAT)autoimmune pancreatitis (AIP)Type 1 IgG4-related (multi-system, sausage-shaped pancreas, elderly males) + Type 2 idiopathic duct-centric (younger, IBD association) — both steroid-responsive。

353.4.2 💊 治療粟芁

  • AP IV fluidslactated Ringer’s preferred (PAMPHLET) but moderate rate (WATERFALL — avoid over-resuscitation); goal-directed (UO, HR, BP, Hct < 44)
  • AP analgesiaIV opioids (morphine, hydromorphone, fentanyl)
  • AP nutritionearly oral feeding as tolerated > nasojejunal (NJ) tube > TPN (improves outcomes)
  • gallstone APERCP within 24-72 h for cholangitis/persistent obstruction; cholecystectomy before discharge for mild
  • hypertriglyceridemia AP (TG > 1000)insulin infusion ± heparin ± apheresis + lipid-lowering
  • antibiotics for APonly for confirmed infected necrosis; carbapenem if needed
  • necrotizing pancreatitis drainagestep-up approach (PANTER trial) — percutaneous → endoscopic → surgical; endoscopic transmural with lumen-apposing metal stents (LAMS) preferred for WON
  • CPalcohol + smoking cessation foundational + PERT (pancrelipase 25,000-75,000 units lipase per meal) + ADEK vitamins + insulin for Type 3c DM + multimodal analgesia (avoid chronic opioids if possible) + endoscopic (stent, ESWL for ductal stones) + TPIAT (total pancreatectomy with islet auto-transplant) for refractory pain
  • autoimmune pancreatitissteroids (prednisone 30-40 mg taper) + rituximab + MMF for refractory; IgG4-RD systemic management

353.4.3 🎯 盧醫垫的考前提醒

  1. AP “I GET SMASHED” mnemonicIdiopathic, Gallstones (50% women), Ethanol (25-30% men), Trauma, Steroids, Mumps + viruses, Autoimmune, Scorpion bite, Hyperlipidemia/Hypercalcemia, ERCP, Drugs
  2. AP diagnosis 2 of 3abdominal pain + lipase > 3x ULN (more specific than amylase) + imaging consistent
  3. Atlanta Revised 2012 severitymild (no OF), moderate (transient OF < 48 h or local complications), severe (persistent OF > 48 h — high mortality)
  4. PAMPHLET (2022) + WATERFALL (2022)lactated Ringer’s preferred over NS + moderate fluid resuscitation sufficient (avoid over-resuscitation → volume overload)
  5. AP nutrition paradigm shiftearly oral feeding as tolerated improves outcomes over NPO + NJ tube + TPN ; “rest the pancreas” outdated
  6. antibiotics in AP only for infected necrosis (procalcitonin elevated, positive culture, gas on imaging); routine antibiotics not beneficial; carbapenem for infected
  7. necrotizing pancreatitis step-up approach (PANTER trial)percutaneous drainage → endoscopic transmural → surgical necrosectomy; endoscopic transmural with lumen-apposing metal stents (LAMS) preferred for WON
  8. chronic pancreatitis (CP)alcohol > 50% + smoking independent + synergy; PERT for exocrine + Type 3c diabetes (brittle, often insulin-requiring) for endocrine; alcohol + smoking cessation foundational
  9. autoimmune pancreatitis Type 1 (IgG4-related)multi-system (Riedel thyroiditis, retroperitoneal fibrosis, sialadenitis, Mikulicz, aortitis) + elderly males + sausage-shaped pancreas on imaging + IgG4 elevated; steroid-responsive
  10. autoimmune pancreatitis Type 2 (idiopathic duct-centric)younger + IBD association + granulocytic epithelial lesions; steroid-responsive; differentiates from Type 1 by absence of IgG4 + extra-pancreatic findings