Master the board step 3

Surgery
Acute Pancreatitis
Suspect this in the alcoholic who develops an acute (over several hours) upper
abdominal pain, radiating to the back, with nausea and vomiting. Acute
pancreatitis may be
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edematous,
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hemorrhagic, or
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suppurative (pancreatic abscess).
Late complications include pancreatic pseudocyst and chronic pancreatitis.
Diagnostic Testing
Diagnose with a serum or urinary amylase or lipase (serum from 12 to 48
hours, urinary from 3rd to 6th days). Perform a CT if diagnosis is uncertain.
Basic Science Correlate
Pancreatitis can lead to low calcium levels due to the presence of insoluble
calcium salts in the pancreas. The free fatty acids avidly chelate the salts,
resulting in calcium deposition in the retroperitoneum.
Warning signs for
hemorrhagic pancreatitis
are the following:
• Lower hematocrit that
continues to fall the day
after presentation
• Very high WBC
(> 18,000), glucose, BUN
• Very low calcium
Treatment
Treat with NPO, NG suction, and IV fluids.
Complications can include the following:
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Abscess: Often appears 10 days after onset with persistent fevers and high
WBC count. Surgical drainage is the treatment.
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Pseudocyst: Appears 5 weeks after initial symptoms, when a collection of
pancreatic juice causes anorexia, pain, and a palpable mass.
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If painless: Do not drain.
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If painful and > 6 cm and > 6 weeks: Perform surgical internal drainage
or endoscopic drainage. If infected, percutaneous external drainage is
performed.
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Chronic damage: Causes diabetes and steatorrhea. Treat with insulin and
pancreatic enzyme supplements.
Amylase = highest sensitivity
Lipase = highest specificity
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