Acute Pancreatitis Dx
Requires 2 of 3: Epigastric pain radiating to back, Lipase > 3x ULN, or CT findings
Charcot Triad
Fever, Jaundice, RUQ Pain = Acute Ascending Cholangitis
Reynolds Pentad
Charcot + Altered Mental Status & Hypotension → Emergent ERCP decompression
Autonomic Innervation
Foregut (T5–T9 Celiac); Midgut (T10–T11 SMG); Hindgut (T12–L2 IMG)
Biliary Pathology Spectrum & Master Differentiation
Distinguishing biliary disease based on clinical triad, ultrasound, and lab markers:
| Condition | Pathophysiology | Clinical Presentation | Gold-Standard Diagnostics & Management |
|---|---|---|---|
| Biliary Colic | Transient cystic duct stone impaction without inflammation | Post-prandial RUQ/epigastric pain resolving within 4–6 hours; normal labs | RUQ Ultrasound: gallstones; elective cholecystectomy |
| Acute Cholecystitis | Persistent cystic duct obstruction → chemical/bacterial inflammation | Positive Murphy sign, fever, leukocytosis, pain > 6 hours | RUQ Ultrasound: gallstones, pericholecystic fluid, wall thickening > 4 mm; HIDA scan if US equivocal. Lap chole within 72h |
| Choledocholithiasis | Stone impacted in Common Bile Duct (CBD) | Biliary pain, elevated direct bilirubin & Alk Phos ± pancreatitis | MRCP / ERCP for stone extraction |
| Acute Ascending Cholangitis | Bacterial infection of obstructed biliary tree (usually E. coli, Klebsiella) | Charcot triad (Fever, RUQ pain, Jaundice) or Reynolds pentad (+ Shock, AMS) | Emergent ERCP decompression + IV broad-spectrum antibiotics (pip/tazo) |
Acute Pancreatitis: Etiology, Severity & Resuscitation
Autodigestion of pancreatic parenchyma by prematurely activated digestive enzymes:
Top Etiologies (I GET SMASHED)
Gallstones (40–50%) and Alcohol abuse (30–35%) account for > 80% of cases. Other causes: Hypertriglyceridemia (> 1000 mg/dL), post-ERCP, hypercalcemia, medications (didanosine, azathioprine, valproate).
Fluid Resuscitation Protocol
Aggressive early goal-directed hydration with Lactated Ringer's solution (200–500 mL/hr or 20 mL/kg bolus) during the first 24 hours. Decreases SIRS and organ failure.
Physical Exam Signs of Retroperitoneal Hemorrhage
Cullen sign (periumbilical ecchymosis) and Grey-Turner sign (flank ecchymosis) signify severe necrotizing pancreatitis.
COMLEX / OMM Integration
NBOME High-Yield Correlate
GI Ganglion Release & Chapman Points
- Celiac Ganglion: Palpated on the linea alba midway between xiphoid process and umbilicus. Inhibitory pressure normalizes stomach, gallbladder, and pancreatic sympathetics (T5–T9).
- Gallbladder Chapman Point:
- Pancreas Chapman Point:
- Gallbladder Chapman Point:
Right 6th intercostal space at sternal border anteriorly.- Pancreas Chapman Point:
Right 7th intercostal space at sternal border anteriorly.
Board Traps & Common Distractors
- Trap: Ordering routine prophylactic antibiotics in mild or moderate acute pancreatitis. Prophylactic antibiotics are NOT recommended unless infected pancreatic necrosis is documented (gas on CT or FNA).
- Trap: Confusing Amylase with Lipase. Serum lipase is significantly more sensitive and specific, and remains elevated longer (8–14 days vs 3–5 days for amylase).