ASGE Adult and Pediatric Gastroenterology and Endoscopy Board Preparatory and Review Course

Kwon_PANCREATITIS
Pdf Summary
This document provides a summary of the ASGE Adult & Pediatric Gastroenterology & Endoscopy Board Preparatory and Review Course on Acute and Chronic Pancreatitis, Peripancreatic Fluid Collections, and Exocrine Insufficiency presented by Richard Kwon, MD, MS, a Clinical Associate Professor at the University of Michigan.<br /><br />Acute Pancreatitis is the leading GI cause for admission, with 80% of cases being mild and recovering in less than 5 days. The remaining 20% are moderate or severe, characterized by local complications such as fluid collections and transient organ failure. Severe disease is defined as persistent organ failure for more than 3 days, with a median mortality rate of 5%.<br /><br />The etiologies of acute pancreatitis include gallstones, alcohol (which account for 80% of cases), trauma, steroids, infections (such as mumps and viruses like CMV and EBV), autoimmune disorders, scorpion sting, hypercalcemia, hypertriglyceridemia, ERCP, and certain drugs.<br /><br />Diagnosis of acute pancreatitis requires the presence of at least two out of three criteria: abdominal pain, elevated pancreatic enzymes, and radiologic evidence. Amylase is less specific than lipase but peaks and falls early. The degree of amylase elevation does not correlate with the severity of pancreatitis.<br /><br />Imaging tests such as ultrasound and computed tomography (CT) can help confirm diagnosis, detect complications, and identify gallstones, sludge, and pancreatic duct stones or strictures. Ultrasound is more sensitive for CBD stones. Other imaging findings in acute pancreatitis include Grey-Turner sign (flank discoloration) and Cullen's sign (periumbilical ecchymosis).<br /><br />Pancreatic fluid collections in acute pancreatitis are classified into four categories: acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection, and walled-off necrosis. Different imaging modalities can help differentiate between pseudocyst and necrosis.<br /><br />Prognosis and predicting mortality in acute pancreatitis can be assessed using scoring systems such as Ranson, APACHE II, CT severity index, and BISAP. Features associated with severe acute pancreatitis include elevated BUN, HCT, and serum creatinine, pleural effusions, multiple co-morbidities, age over 70 years, and BMI over 30.<br /><br />Therapeutic approaches for acute pancreatitis include supportive measures such as aggressive fluid replacement, pain management, NPO status, acid suppression, antiemetics, and antibiotics in case of infection. Urgent ERCP may be required for biliary pancreatitis with jaundice or cholangitis.<br /><br />Chronic pancreatitis is managed with a multidisciplinary approach. Surgical interventions may be necessary for intractable pain, biliary obstruction, duodenal obstruction, or other complications. Total pancreatectomy with islet cell transplantation is an option for end-stage disease, while endoscopic therapy can be performed for strictures, stones, or drainage.<br /><br />Pancreatic exocrine insufficiency (PEI) in chronic pancreatitis can be treated with pancreatic enzyme replacement therapy (PERT). Nutritional support should be provided, with enteral feeding preferred over parenteral. Management of endocrine insufficiency, pain, and other complications should also be addressed.<br /><br />Hereditary pancreatitis is an autosomal dominant disorder with recurrent attacks of acute pancreatitis starting in adolescence. It is associated with an increased risk of pancreatic cancer. Treatment includes steroids and rituximab. ERCP may be used for diagnostic purposes or to treat jaundice.<br /><br />Autoimmune pancreatitis is treated with steroids as first-line therapy. ERCP may be necessary for symptomatic jaundice but is not necessary for mild cases. Recurrence is more likely in cases with high serum IgG4 levels before treatment or persistently high levels after steroid treatment.<br /><br />This summary provides a comprehensive overview of the content covered in the ASGE course on acute and chronic pancreatitis, peripancreatic fluid collections, and exocrine insufficiency.
Keywords
ASGE Adult & Pediatric Gastroenterology & Endoscopy Board Preparatory and Review Course
Acute Pancreatitis
Chronic Pancreatitis
Peripancreatic Fluid Collections
Exocrine Insufficiency
Richard Kwon
University of Michigan
Gallstones
Amylase
CT severity index