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Mastering Pancreatic Disease for the MRSA exam

Updated: Aug 9

Pancreatic disorders frequently appear in the MSRA due to their acute presentations, life-threatening complications, and clear management guidelines. This guide focuses on what doctors need to know about acute pancreatitis, chronic pancreatitis, necrotising pancreatitis, and associated concepts such as gallstone disease, ERCP, and pancreatic cancer.



🔥 Section 1: Acute Pancreatitis – Clinical Recognition &


Classification


📌 Diagnostic Criteria (Revised Atlanta Criteria)

Acute pancreatitis is diagnosed when 2 of the following 3 are present:

  1. Severe epigastric pain (often radiating to the back)

  2. Serum amylase or lipase ≥3 times upper limit of normal (ULN)

  3. Imaging evidence (CT, MRI, or US showing pancreatic inflammation)


🧪 Investigations

  • Serum lipase is preferred over amylase (more specific, remains elevated longer)

  • Contrast-enhanced CT is used after 72 hours if:

    • Diagnosis is unclear

    • Deterioration despite initial treatment

    • Suspected complications (e.g. necrosis, collections)



🚨 Section 2: Aetiology of Acute Pancreatitis


Common Causes — “GET SMASHED” Mnemonic

  • G: Gallstones (most common in the UK)

  • E: Ethanol (alcohol misuse)

  • T: Trauma

  • S: Steroids

  • M: Mumps or other viral infections

  • A: Autoimmune

  • S: Scorpion sting (non-UK)

  • H: Hyperlipidaemia / hypercalcaemia

  • E: ERCP

  • D: Drugs (e.g., azathioprine, valproate, thiazides, tetracyclines)



🧭 Section 3: Management of Acute Pancreatitis


Initial (Supportive) Management

  • A–E approach: Oxygen, fluids, analgesia, NPO (nil by mouth)

  • Monitor vitals and urine output

  • Early enteral feeding when tolerated

  • Identify and treat underlying cause (e.g., gallstones, alcohol)



🧠 Section 4: Gallstone Pancreatitis – Key Diagnostic


Clues

  • ALT >150 IU/L within 48 hours is highly specific for a biliary cause

  • Dilated common bile duct (CBD) on ultrasound

  • No alcohol history

  • Postprandial pain is common



🧪 Section 5: Role of ERCP


What is ERCP?

Endoscopic Retrograde Cholangiopancreatography is both diagnostic and therapeutic — allowing stone removal, stent placement, and sphincterotomy.


When is ERCP Used in Acute Pancreatitis?

  • Gallstone pancreatitis + cholangitis → ERCP urgently (within 24–48 hrs)

  • Obstructive jaundice but no cholangitis → ERCP within 72 hrs

  • Mild cases with no obstruction or jaundice → ERCP not needed

MRCP is used for diagnosis, ERCP for intervention.


🩺 Section 6: Chronic Pancreatitis


Definition

Chronic inflammation of the pancreas causing irreversible damage, fibrosis, and loss of exocrine and endocrine function.

Clinical Features

  • Recurrent epigastric pain (often post-meal, radiates to back)

  • Steatorrhoea (due to fat malabsorption)

  • Diabetes mellitus (endocrine failure)

  • Weight loss, vitamin deficiencies


Diagnosis

  • CT pancreas: Calcifications, ductal changes

  • Faecal elastase-1: Low levels indicate exocrine insufficiency

  • Blood glucose/HbA1c: To assess endocrine failure


Causes (TIGAR-O classification):

  • Toxic-metabolic: Alcohol, smoking, hypercalcaemia, hyperlipidaemia

  • Idiopathic

  • Genetic: PRSS1, SPINK1, CFTR mutations

  • Autoimmune: IgG4-related

  • Recurrent acute pancreatitis

  • Obstructive: Tumours, pancreas divisum



⚠️ Section 7: Acute on Chronic Pancreatitis

This occurs when a patient with established chronic pancreatitis has an acute flare, usually due to alcohol, stones, or dietary indiscretion.

Features:

  • Lipase may be mildly elevated or normal (due to destroyed acinar cells)

  • Similar treatment to acute pancreatitis: fluids, analgesia, NPO, and rule out complications



☠️ Section 8: Necrotising Pancreatitis


What is it?

Necrosis of pancreatic tissue due to severe inflammation and loss of perfusion.


Diagnosis

  • Non-enhancing areas on contrast-enhanced CT (performed after 72 hrs)

  • Gas bubbles on CT = infected necrosis


Management

  • Sterile necrosis: Supportive care only

  • Infected necrosis: “Step-up approach”

    1. IV antibiotics

    2. Minimally invasive drainage (percutaneous or endoscopic)

    3. Surgical necrosectomy (only if necessary)



🛑 Section 9: Pancreatic Cancer Clues

  • Painless progressive jaundice → suggests tumour in the pancreatic head

  • Dull epigastric/back pain, weight loss, new-onset diabetes → consider body/tail tumours

  • Courvoisier’s sign: Painless jaundice + palpable gallbladder = likely malignancy

  • Tumour marker: CA 19-9 (used for monitoring, not diagnosis)



🧠 Summary Cheat Sheet

Condition

Key Features

First-Line Test

Acute pancreatitis

Sudden pain, lipase ↑

Lipase ≥3× ULN

Gallstone pancreatitis

ALT >150, stones on US

US abdomen

Chronic pancreatitis

Steatorrhoea, diabetes, pain

Faecal elastase-1, CT

Necrotising pancreatitis

Non-enhancing pancreas ± gas

Contrast CT after 72 hrs

Pancreatic cancer

Jaundice, weight loss, new diabetes

CT with contrast


👩‍⚕️ Final Words

For the MSRA, pancreas-related questions often test your:

  • Clinical judgment (e.g., when to image, when to intervene)

  • Ability to recognize red flags (e.g., cholangitis, necrosis)

  • Familiarity with timing-sensitive decisions (like ERCP)


📚 References

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