Study guide
3.8 Acute Pancreatitis
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
3.8 Acute Pancreatitis
Key Takeaways Explain This Topic AI
Acute pancreatitis, chronic pancreatitis, cystic fibrosis, pancreatic neuroendocrine tumors and pancreatic infections are enumerated under pancreatic disease.
Diagnosis requires two of three: characteristic abdominal pain, lipase or amylase at least three times the upper limit of normal, or characteristic cross-sectional imaging.
Enzyme elevation does not correlate with severity, so the degree of lipase elevation should not drive prognosis or management.
Early enteral nutrition is preferred to prolonged bowel rest and parenteral nutrition, and prophylactic antibiotics are not indicated in sterile necrosis.
Cholecystectomy during the same admission is recommended after mild gallstone pancreatitis because delay carries a high recurrence rate.
Last updated: August 2026
Pancreatic and biliary disorders frequently appear on the ABIM examination as acute emergencies, complex diagnostic algorithms, or chronic malabsorptive syndromes. Precision regarding fluid management, intervention timing, and autoimmune diagnostic markers is essential.
- 1. Acute Pancreatitis
- Revised Atlanta Diagnostic Criteria
Diagnosis requires at least 2 of the following 3 criteria :
Characteristic Abdominal Pain: Acute onset of severe, persistent epigastric pain often radiating straight through to the back, partially relieved by sitting forward.
Serum Lipase or Amylase Elevation: ≥ 3 × the upper limit of normal (ULN) \ge 3\times\text{ the upper limit of normal (ULN)} ≥ 3 × the upper limit of normal (ULN) . ( Lipase is preferred over amylase due to higher sensitivity, specificity, and prolonged elevation up to 8–14 days).
Characteristic Imaging Findings: Contrast-enhanced computed tomography (CECT), MRI, or transabdominal ultrasound demonstrating peripancreatic inflammation.
Note
If a patient presents with classic epigastric pain and lipase ≥ 3 × ULN \ge 3\times\text{ ULN} ≥ 3 × ULN , diagnostic CT imaging is NOT required on admission and should be avoided to prevent unnecessary contrast-induced nephrotoxicity. CT is indicated only when the diagnosis is uncertain or if clinical deterioration occurs after 48–72 hours.
Common Etiologies
Gallstones (40–45%): Most common cause. Gallstone transiently impacts the ampulla of Vater. Check RUQ ultrasound and liver function tests (ALT > 150 U/L >150\text{ U/L} > 150 U/L has a 95% positive predictive value for biliary etiology).
Alcohol (30–35%): Second most common cause (usually requires ≥ 4 − 5 drinks/day \ge 4-5\text{ drinks/day} ≥ 4 − 5 drinks/day over ≥ 5 \ge 5 ≥ 5 years).
Hypertriglyceridemia (2–5%): Typically occurs when serum Triglycerides > 1 , 000 mg/dL > 1,000\text{ mg/dL} > 1 , 000 mg/dL . Managed with IV regular insulin infusion (activates lipoprotein lipase, accelerating triglyceride clearance) plus 5% dextrose infusion to maintain euglycemia; therapeutic plasma exchange (plasmapheresis) for severe cases.
Post-ERCP Pancreatitis (3–5%): Prevent with rectal Indomethacin (100 mg PR immediately post-procedure) and temporary pancreatic duct stenting in high-risk patients.
Medications: Azathioprine, 6-MP, didanosine, valproic acid, thiazides, furosemide, DPP-4 inhibitors.
Autoimmune Pancreatitis (AIP): Type 1 (IgG4-related systemic disease, "sausage-shaped" pancreas, elevated serum IgG4); Type 2 (duct-centric, associated with IBD). Both exhibit dramatic response to oral corticosteroids .
Severity Stratification & Early Resuscitation
Severity Classification:
Mild: No organ failure, no local or systemic complications.
Moderately Severe: Transient organ failure ( < 48 hours <48\text{ hours} < 48 hours ) or local/systemic complications.
Severe: Persistent organ failure ( > 48 hours >48\text{ hours} > 48 hours ) involving cardiovascular (shock), pulmonary ( PaO 2 / FiO 2 ≤ 300 \text{PaO}_2/\text{FiO}_2 \le 300 PaO 2 / FiO 2 ≤ 300 ), or renal ( Cr ≥ 1.9 mg/dL \text{Cr} \ge 1.9\text{ mg/dL} Cr ≥ 1.9 mg/dL ) systems.
Early Predictors of Severity: Admission Hematocrit > 44 % >44\% > 44% , rising BUN at 24 hours ( > 20 mg/dL >20\text{ mg/dL} > 20 mg/dL ), and BISAP score ≥ 3 \ge 3 ≥ 3 .
Goal-Directed Fluid Resuscitation:
Fluid of Choice: Lactated Ringer's (LR) solution (preferred over normal saline; LR reduces systemic acidosis and decreases SIRS incidence).
Administration Rate: Moderate goal-directed rate of 200 − 250 mL/hour 200-250\text{ mL/hour} 200 − 250 mL/hour (or 5 − 10 mL/kg/hr 5-10\text{ mL/kg/hr} 5 − 10 mL/kg/hr initially if hypovolemic), titrated to clinical targets: urine output > 0.5 − 1.0 mL/kg/hour >0.5-1.0\text{ mL/kg/hour} > 0.5 − 1.0 mL/kg/hour , normalization of BUN and creatinine, and MAP ≥ 65 mmHg \ge 65\text{ mmHg} ≥ 65 mmHg .
Avoid Fluid Overload: Aggressive fluid loading ( > 3.5 − 4.0 L >3.5-4.0\text{ L} > 3.5 − 4.0 L in first 24h) increases pulmonary edema, abdominal compartment syndrome, and mortality.
Early Nutrition: Initiate early oral feeding with a low-fat solid or liquid diet as soon as abdominal pain improves, ileus resolves, and nausea subsides (typically within 24–48 hours). If oral intake is not tolerated, enteral tube feeding (nasogastric or nasojejunal) is superior to total parenteral nutrition (TPN).
Prophylactic Antibiotics: Routine prophylactic antibiotics are NOT recommended for mild, severe, or sterile necrotizing pancreatitis.
Loading diagram... Acute Pancreatitis & Biliary Disease Management Flowchart
Atlanta Classification of Local Pancreatic Complications
Timing & Pathologic Subtype < 4 Weeks Duration < 4\text{ Weeks Duration} < 4 Weeks Duration (No Defined Fibrous Capsule) > 4 Weeks Duration > 4\text{ Weeks Duration} > 4 Weeks Duration (Mature Fibrous Capsule Formed)
Interstitial Edematous Pancreatitis (Fluid Only) Acute Peripancreatic Fluid Collection (APFC): Homogeneous fluid adjacent to pancreas; no capsule. Resolves spontaneously in > 80 % >80\% > 80% . Pancreatic Pseudocyst: Well-circumscribed, encapsulated, homogeneous fluid collection without solid debris. Asymptomatic pseudocysts require NO intervention regardless of size. Drain endoscopically (cystogastrostomy) only if symptomatic (pain, gastric outlet obstruction) or infected.
Necrotizing Pancreatitis (Fluid + Non-Viable Solid Debris) Acute Necrotic Collection (ANC): Heterogeneous collection containing both liquid and solid necrotic pancreatic parenchyma; no capsule. Walled-Off Pancreatic Necrosis (WOPN): Mature, encapsulated collection of fluid and solid tissue necrosis.
The "Step-Up Approach" for Infected Pancreatic Necrosis
Clinical Suspicion: Suspected when a patient develops recurrent fever, leukocytosis, and clinical deterioration 7 to 14+ days after admission. CECT demonstrates gas bubbles within the necrotic retroperitoneal bed.
Algorithmic Step-Up Protocol:
Systemic Antibiotics: Initiate IV broad-spectrum antibiotics with proven pancreatic tissue penetration: IV Carbapenem (Meropenem 1 g IV q8h) .
Delayed Intervention: Postpone invasive intervention for ≥ 4 weeks \ge 4\text{ weeks} ≥ 4 weeks to allow encapsulation into mature WOPN.
Minimally Invasive Drainage: If sepsis persists, perform CT-guided Percutaneous Catheter Drainage or Endoscopic Transluminal Transgastric Drainage .
Minimally Invasive Necrosectomy: If no improvement after drainage, perform Video-Assisted Retroperitoneal Debridement (VARD) or endoscopic necrosectomy.