Pancreatitis & Pancreatic Cancer for the USMLE Step 2

• Pancreatitis is inflammation of the pancreas and can be classified into:
• Acute pancreatitis: A reversible condition with acute inflammation.
• Chronic pancreatitis: Irreversible damage, fibrosis, and progressive loss of pancreatic function.

• Most common causes:
• Gallstones: Biliary obstruction.
• Alcohol abuse: Direct toxicity to pancreatic acinar cells.
• Other causes include hypertriglyceridemia, hypercalcemia, medications (e.g., thiazides), and post-ERCP.

• Severe epigastric pain: Often radiating to the back.
• Nausea and vomiting.
• Physical exam findings may include Cullen’s sign (periumbilical bruising) or Grey Turner’s sign (flank bruising), indicating hemorrhagic pancreatitis.

• Requires 2 of 3 criteria:
• Characteristic abdominal pain.
• Serum lipase or amylase >3 times normal (lipase is more specific).
• Imaging (CT or ultrasound) showing pancreatic inflammation or necrosis.
• CT abdomen with contrast: Used to assess severity and detect complications.

• Local: Pancreatic necrosis, abscesses, and pseudocysts.
• Systemic: Acute respiratory distress syndrome (ARDS), shock, and multi-organ failure.

• Supportive care:
• Aggressive IV fluids (lactated Ringer’s).
• Pain management with opioids.
• NPO (nothing by mouth) to rest the pancreas.
• Antibiotics: Only indicated for infected necrosis.
• ERCP: For biliary pancreatitis due to gallstones.

• Causes include:
• Alcohol abuse: Most common cause.
• Cystic fibrosis: In children.
• Chronic inflammation leads to fibrosis, ductal obstruction, and progressive pancreatic insufficiency.

• Chronic epigastric pain: Often radiates to the back and worsens with eating.
• Pancreatic insufficiency: Steatorrhea (fat malabsorption) and diabetes mellitus.

• CT scan: Shows pancreatic calcifications, ductal dilation, or atrophy.
• Fecal elastase: Used to assess pancreatic exocrine function.

• Pancreatic enzyme replacement: Treats malabsorption.
• Pain management: NSAIDs, opioids for refractory pain.
• Surgery for complications or intractable pain.

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• Pancreatic adenocarcinoma is the most common type of pancreatic cancer, often presenting late with poor prognosis.

• Smoking and chronic pancreatitis are major risk factors.
• Other factors: Diabetes mellitus, obesity, and genetic conditions (e.g., BRCA1/BRCA2 mutations, Lynch syndrome).

• Painless jaundice: Commonly due to obstruction of the common bile duct by tumors in the pancreatic head.
• Weight loss, anorexia, and fatigue.
• Abdominal pain: Often radiating to the back.
• New-onset diabetes in older adults can suggest pancreatic cancer.

• CT scan with contrast: First-line imaging to detect pancreatic masses and assess for metastasis.
• Endoscopic ultrasound (EUS): Used for biopsy and staging.
• CA 19-9: A tumor marker used for monitoring but not specific for diagnosis.

• Pancreaticoduodenectomy (Whipple procedure): The only curative option for tumors in the pancreatic head that are resectable.
• Surgery is only feasible in 20% of cases due to late diagnosis.

• Gemcitabine-based regimens are commonly used.
• FOLFIRINOX: A combination regimen for advanced disease in patients with good performance status.

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• Biliary stenting: For patients with obstructive jaundice and non-resectable tumors.
• Pain management: Typically requires opioids.

• Acute pancreatitis is most commonly caused by gallstones and alcohol abuse, presenting with epigastric pain and elevated lipase levels.
• Chronic pancreatitis leads to irreversible damage, causing steatorrhea, diabetes, and chronic pain.
• Pancreatic adenocarcinoma often presents with painless jaundice, weight loss, and abdominal pain, typically diagnosed late.
• CT scan is the primary diagnostic tool for both pancreatitis and pancreatic cancer.
• Whipple procedure is the only curative treatment for pancreatic cancer, but most patients are not candidates due to advanced disease at diagnosis.