Teaching Pearls:

• Common causes of pancreatitis:
  • gallstones, alcohol, hypertriglyceridemia, hypercalcemia, medications, infectious, trauma, scorpion bites, autoimmune, idiopathic, etc
• Not recommended to trend lipases
  • Although on certain occasions, decrease in lipase may help suggest a certain etiology.
  • Fast decrease in lipase level can be associated with passed gallstone.
• Normal CBD normal is <6mm. Can widen in non-pathologic conditions including age and post-cholecystectomy.
• LFT Abnormalities
  • Hepatocellular – defined by severe elevation in AST and ALT in proportion to Alk phos
  • Cholestatic – defined by severe elevation in alkaline phosphatase compared to AST and ALT
  • Both can have elevated bilirubin levels
• Causes of cholestatic jaundice includes:
  • Primary biliary cirrhosis, primary sclerosing cholangitis, large bile duct obstruction, infiltrative liver disease, malignancy (pancreatic carcinoma, ampullary carcinoma, cholangiocarcinoma), cholangitis, extrahepatic pancreatic mass, choledocholithiasis.
• MRCP is good for detecting proximal bile duct lesions, but sensitivity worsens distally.
• EUS has good sensitivity for distal bile duct lesions and obstructions.
• Autoimmune Pancreatitis
  • Can manifest by a pancreatic mass that is often confused with pancreatic carcinoma.
  • Recurrent pancreatitis is common and occurs more frequently in focal disease.
  • May lead to pancreatic duct strictures.
  • Most common presentation is obstructive jaundice.
  • A pancreatic biopsy is usually required to establish the diagnosis.
  • Important to check IgG4 levels and CA 19-9.
    • Higher levels of IgG4 levels decreases sensitivity, but increases specificity of autoimmune pancreatitis.