Pancreas and Biliary Tract
Core concepts
Separate acute from chronic pancreatitis and biliary from pancreatic disease. Acute pancreatitis diagnosis requires two of three: characteristic pain, lipase greater than three times the upper limit, or imaging findings. Severity is assessed with organ failure and local complications; fluid resuscitation and early enteral nutrition matter. Gallstone pancreatitis prompts early cholecystectomy, and cholangitis with obstruction requires urgent ERCP. Chronic pancreatitis presents with calcifications, steatorrhea, and diabetes; fecal elastase is the practical test for exocrine insufficiency.
Biliary disease questions test the difference between choledocholithiasis and cholangitis, and the role of MRCP versus EUS. Primary sclerosing cholangitis shows beading strictures and is associated with ulcerative colitis and cholangiocarcinoma. Autoimmune pancreatitis (IgG4-related) mimics malignancy and responds to steroids.
Traps
Lipase can be elevated without pancreatitis; do not diagnose on a single mildly elevated value. Amylase is less specific than lipase. Do not miss that ascending cholangitis is a clinical diagnosis (fever, jaundice, right upper quadrant pain, often with hypotension and confusion) requiring drainage. Pancreatic head mass with painless jaundice suggests malignancy, not chronic pancreatitis.
Rule of thumb
In gallstone pancreatitis, perform cholecystectomy during the same admission for mild disease to prevent recurrence.