What questions should be asked to a patient with a history of intraductal papillary mucinous neoplasm (IPMN) and recurrent pancreatitis when they present to the emergency department (ED)?

Initial ED Assessment for IPMN Patient with Recurrent Pancreatitis

When evaluating a patient with known IPMN and recurrent pancreatitis in the ED, your primary focus should be determining if this represents acute pancreatitis from ductal obstruction, progression to high-grade dysplasia or invasive carcinoma, or an alternative acute process.

Critical Historical Questions

Current Episode Characterization

• Onset and character of abdominal pain: Ask specifically about epigastric pain radiating to the back, which is typical of pancreatitis secondary to IPMN-related ductal obstruction 1, 2
• Duration and severity compared to prior episodes: IPMN can cause recurrent pancreatitis over many years (documented cases spanning 22 years), so establish if this episode differs in intensity or character 1
• Associated symptoms: Query about jaundice (which may indicate main duct obstruction or malignant transformation), weight loss (concerning for malignancy), nausea, vomiting, and fever 3

IPMN-Specific History

• Type of IPMN previously diagnosed: Main duct, branch duct, or mixed type—main duct IPMN carries higher malignancy risk and more commonly causes recurrent pancreatitis 2, 4
• Most recent surveillance imaging and findings: When was the last MRI or EUS performed, and were there any worrisome features such as mural nodules >5mm, main pancreatic duct diameter >10mm, or cyst size ≥40mm 3
• Grade of dysplasia if known: High-grade dysplasia requires different management than low-grade 3
• Previous interventions: Has the patient undergone pancreatic duct stenting, which can reduce recurrent pancreatitis frequency 2

Red Flag Symptoms for Malignant Transformation

• New-onset jaundice: This is an absolute indication for surgery in IPMN and suggests either main duct obstruction or invasive carcinoma 3
• Unintentional weight loss: Present in 35% of patients with malignant transformation 5
• Change in pain pattern: New, persistent pain rather than episodic may indicate progression 3

Pancreatitis Severity Assessment

Systemic Complications

• Respiratory symptoms: Tachypnea, dyspnea, or hypoxia suggesting ARDS or pleural effusion 3
• Hemodynamic status: Assess for signs of shock, as severe acute pancreatitis can cause systemic inflammatory response 3
• Urine output: Oliguria may indicate acute kidney injury from hypovolemia 3

Organ Failure Indicators

• Mental status changes: Confusion or altered consciousness suggests severe disease 3
• Abdominal distension: May indicate intra-abdominal hypertension or fluid collections 3

Additional Risk Factors

Gallstone-Related Questions

• History of gallstones or cholecystectomy: Even with known IPMN, concurrent gallstone pancreatitis must be excluded 3
• Prior ERCP or biliary interventions: Determine if cholangitis or common bile duct obstruction is present, which would require urgent ERCP 3

Comorbidities Affecting Management

• Age and functional status: Surgical candidacy must be assessed, as this affects whether aggressive workup for malignancy is appropriate 3
• Immunosuppression: Patients with organ transplants have the same IPMN management but may have different infection risks 3
• Family history of pancreatic cancer: While management is similar to sporadic cases, this information is relevant for long-term surveillance 3

Medication and Substance History

• Alcohol consumption: Quantify current and past use, as this may contribute to pancreatitis independent of IPMN 3
• Recent medication changes: Certain drugs can precipitate pancreatitis 3
• Anticoagulation status: Important for procedural planning if intervention is needed 3

Complications of Chronic IPMN

• Previous fistula formation: Pancreatoduodenal or other fistulae can develop from chronic inflammation and may paradoxically reduce pancreatitis frequency by providing drainage 2
• History of pancreatic collections or pseudocysts: These may become infected in the acute setting 3
• Diabetes mellitus: Can develop from chronic pancreatic damage and affects perioperative risk 3

Screening for Synchronous Malignancies

• Symptoms of colorectal cancer: Patients with IPMN have higher incidence of additional primary malignancies, particularly colorectal cancer 2
• Recent cancer screening: Document when last colonoscopy was performed 2

Common Pitfalls to Avoid

• Assuming all episodes are "just pancreatitis": Each presentation requires reassessment for malignant transformation, especially if the patient has main duct involvement or previously identified high-risk features 3
• Missing cholangitis: This requires urgent ERCP within 24 hours and can be fatal if untreated 3
• Overlooking alternative diagnoses: Perforated viscus, mesenteric ischemia, or other acute abdominal processes must be considered 3