Episode two follows three threads that all trace to the same parenchymal loss the framework episode set up. The acini die and enzyme replacement stands in, but only if dosed with the meal and released at the right duodenal pH, so a proton pump inhibitor enters when the coating fails. The islets die and produce a diabetes defined not by insulin lack but by lost glucagon, which makes hypoglycemia the dominant management feature and steers drug choice away from sulfonylureas. The structural disruption produces complications whose management is read directly off the anatomy, drain the symptomatic pseudocyst, recognize disconnected duct as the exception, and take the spleen out when left-sided portal hypertension bleeds. Mechanism first, management second, throughout. Topics covered Exocrine reserve and the ten-percent threshold Enzyme replacement dosing with meals Structured workup for inadequate response Pancreatogenic diabetes and lost glucagon Drug choices: metformin over sulfonylureas Pseudocyst and disconnected duct syndrome Distal bile duct stricture from head fibrosis Splenic vein thrombosis and left-sided portal hypertension Pancreatic ascites and pseudoaneurysm Key decisions Steatorrhea and fat-soluble vitamin deficiency appear only after exocrine output drops below about ten percent of normal, so clinical insufficiency means roughly ninety percent of acinar capacity is already lost. Start enzyme replacement at forty to fifty thousand lipase units with each main meal and half that with snacks, taken with the meal, titrating up to about ninety thousand per meal by clinical response. When response is inadequate, escalate the dose, then add a proton pump inhibitor because acidic duodenal pH prevents the enteric coating from releasing enzyme, then verify adherence and exclude bacterial overgrowth, bile acid malabsorption, celiac, and mucosal disease. Pancreatogenic diabetes loses glucagon alongside insulin, making hypoglycemia brittle, so insulin titration stays conservative, sulfonylureas are avoided, and metformin remains a reasonable adjunct. Drain a pseudocyst for symptoms, infection, or rapid enlargement rather than size, using an endoscopic-ultrasound-guided cyst-gastrostomy with a lumen-apposing metal stent, and recognize disconnected duct syndrome as the exception needing permanent drainage or resection. Splenectomy is curative when isolated fundal gastric varices from splenic vein thrombosis bleed, because removing the high-flow inlet decompresses the left-sided portal hypertension. Embolize a suspected pseudoaneurysm before any necrosectomy or cyst drainage, because manipulating a collection that hides it risks catastrophic hemorrhage. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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