Pancreatitis

Pancreatitis US Medical PG Question 1: A 55-year-old man is brought to the emergency room by his roommate due to an abdominal pain that started 2 hours ago. His pain is dull, aching, and radiates to the back. He admits to binge drinking alcohol for the past 2 days. Past medical history is significant for multiple admissions to the hospital for similar abdominal pain events, hypertension, and hyperlipidemia. He takes chlorthalidone and atorvastatin. He admits to heavy alcohol consumption over the past 10 years. He has smoked a pack of cigarettes a day for the last 20 years. In the emergency department, his temperature is 38.9℃ (102.0℉), pulse rate is 100/min, and respiratory rate is 28/min. On physical examination, he looks generally unwell and diaphoretic. Auscultation of his heart and lungs reveals an elevated heart rate with a regular rhythm. His lungs are clear to auscultation bilaterally. His abdomen is tympanitic with generalized tenderness. Evaluation of lab values reveals a leukocyte count of 28,000/mm3 with 89% of neutrophils. His amylase level is 255 U/L. A CT scan of the abdomen shows the diffuse enlargement of the pancreas. Which pathological process is most likely occurring in this patient’s peripancreatic tissue?

• A. Fat necrosis (Correct Answer)
• B. Caseous necrosis
• C. Fibrinoid necrosis
• D. Coagulative necrosis
• E. Liquefactive necrosis

Pancreatitis Explanation: ***Fat necrosis*** - This patient presents with **acute pancreatitis**, characterized by severe epigastric pain radiating to the back, elevated amylase, and diffuse pancreatic enlargement on CT, all exacerbated by **binge drinking**. - In acute pancreatitis, activated pancreatic enzymes, particularly **lipases**, leak into the peripancreatic fat, causing enzymatic breakdown of fat into fatty acids, which then combine with calcium to form **calcium soaps** (saponification), clinically recognizable as fat necrosis. *Caseous necrosis* - This type of necrosis is typically associated with **tuberculosis** and fungal infections, forming a cheesy, crumbly appearance. - It involves a granulomatous inflammatory response and does not align with the enzyme-driven fat breakdown seen in pancreatitis. *Fibrinoid necrosis* - This is a vascular injury characterized by the deposition of **fibrin-like material** in arterial walls, often seen in immune-mediated vasculitis or severe hypertension. - It is not a primary pathological process in the peripancreatic tissue during acute pancreatitis. *Coagulative necrosis* - This form of necrosis is characteristic of **ischemic injury** in most solid organs (e.g., heart, kidney) where the cellular architecture is preserved for some time. - While pancreatic necrosis can occur, the specific breakdown of peripancreatic fat by lipases leads to fat necrosis, not coagulative necrosis of the fat itself. *Liquefactive necrosis* - This type of necrosis occurs in tissues rich in hydrolytic enzymes and low in structural proteins, such as the **brain after ischemia** or in **abscesses**. - While pancreatic tissue undergoing severe necrosis can exhibit liquefaction, the specific process affecting the surrounding fat in pancreatitis is fat necrosis due to lipase activity.

Pancreatitis US Medical PG Question 2: A 52-year-old woman presents to the urgent care center with several hours of worsening abdominal discomfort with radiation to the back. The patient also complains of malaise, chills, nausea, and vomiting. Social history is notable for alcoholism. On physical exam, she is febrile to 39.5°C (103.1°F), and she is diffusely tender to abdominal palpation. Complete blood count is notable for 13,500 white blood cells, bilirubin 2.1, lipase 842, and amylase 3,210. Given the following options, what is the most likely diagnosis?

• A. Choledocholithiasis
• B. Ascending cholangitis
• C. Gallstone pancreatitis (Correct Answer)
• D. Cholelithiasis
• E. Acute cholecystitis

Pancreatitis Explanation: ***Gallstone pancreatitis*** - The patient presents with classic symptoms of **acute pancreatitis**: severe abdominal pain radiating to the back, nausea, vomiting, and markedly elevated **lipase (842)** and **amylase (3,210)**. - The **key differentiating feature** is the elevated **bilirubin (2.1 mg/dL)**, which indicates biliary obstruction from a gallstone passing through or obstructing the ampulla of Vater. - **Gallstone pancreatitis** is the most common cause of acute pancreatitis in women, and the combination of pancreatitis with hyperbilirubinemia strongly suggests a biliary etiology rather than alcoholic pancreatitis (which typically does not cause elevated bilirubin). - While the patient has a history of alcoholism, the elevated bilirubin makes **gallstone pancreatitis** the most likely diagnosis. *Choledocholithiasis* - This refers to a stone in the **common bile duct**, which can cause biliary obstruction and elevated bilirubin. - However, choledocholithiasis alone does not explain the **markedly elevated lipase and amylase**, which indicate pancreatic inflammation. - Choledocholithiasis may be present as part of the pathophysiology, but the clinical picture is acute pancreatitis caused by the stone (gallstone pancreatitis). *Ascending cholangitis* - This serious bile duct infection presents with **Charcot's triad** (fever, jaundice, right upper quadrant pain) or **Reynolds' pentad** (adds altered mental status and hypotension). - While the patient is febrile, she lacks **jaundice**, hypotension, or altered mental status. - The **extremely elevated lipase and amylase** point to pancreatitis rather than cholangitis as the primary process. *Cholelithiasis* - This simply means **gallstones in the gallbladder**, which are often asymptomatic. - The patient's acute presentation with fever, systemic symptoms, and markedly elevated pancreatic enzymes indicates a complication of gallstones (pancreatitis), not just their presence. *Acute cholecystitis* - This is **gallbladder inflammation**, typically presenting with right upper quadrant pain, fever, positive Murphy's sign, and leukocytosis. - The **diffuse abdominal tenderness** (not localized to RUQ), pain radiating to the back, and **extremely elevated lipase and amylase** are characteristic of pancreatitis, not cholecystitis. - Acute cholecystitis does not cause such dramatic elevations in pancreatic enzymes.

Pancreatitis US Medical PG Question 3: A 72-year-old woman comes to the emergency department because of upper abdominal pain and nausea for the past hour. The patient rates the pain as an 8 to 9 on a 10-point scale. She has had an episode of nonbloody vomiting since the pain started. She has a history of type 2 diabetes mellitus, hypertension, and osteoporosis. The patient has smoked 2 packs of cigarettes daily for 40 years. She drinks 5–6 alcoholic beverages daily. Current medications include glyburide, lisinopril, and oral vitamin D supplements. Her temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. The patient is admitted to the hospital for pain control and intravenous hydration. Which of the following is the most appropriate next step in the management of this patient’s pain?

• A. Oral gabapentin every 24 hours
• B. Transdermal fentanyl every 72 hours
• C. Oral acetaminophen every 6 hours
• D. Patient-controlled intravenous hydromorphone (Correct Answer)
• E. Transdermal bupivacaine on request

Pancreatitis Explanation: ***Patient-controlled intravenous hydromorphone*** - This patient presents with **acute pancreatitis**, characterized by severe epigastric pain, nausea, vomiting, fever, and findings indicative of pancreatic inflammation (enlarged pancreas on ultrasound, guarding without rebound). **Opioids**, such as hydromorphone, are the mainstay for **severe pain relief** in acute pancreatitis. - **Patient-controlled analgesia (PCA)** with intravenous opioids allows the patient to self-administer small, frequent doses, providing optimal pain control while minimizing the risk of over-sedation, making it suitable for managing **acute severe pain**. *Oral gabapentin every 24 hours* - **Gabapentin** is primarily used for **neuropathic pain** or as an adjunct for chronic pain, not typically for acute severe visceral pain like that seen in acute pancreatitis. - Its **oral route** and every 24-hour dosing schedule are too slow and infrequent for rapid pain control in an emergency setting with severe pain. *Transdermal fentanyl every 72 hours* - **Transdermal fentanyl** is indicated for **chronic severe pain** that requires continuous opioid administration and is not suitable for the rapid onset and fluctuating intensity of acute pancreatitis pain. - The **transdermal route** and long dosing interval mean it would not provide immediate or adequate pain relief for a patient experiencing pain rated 8-9/10. *Oral acetaminophen every 6 hours* - **Acetaminophen** is a non-opioid analgesic generally used for **mild to moderate pain** and fever control. It is insufficient for the severe pain experienced in acute pancreatitis. - The **oral route** takes longer to achieve therapeutic levels and may be limited by the patient's nausea and vomiting. *Transdermal bupivacaine on request* - **Bupivacaine** is a **local anesthetic** typically used for regional anesthesia or nerve blocks, not for systemic management of acute visceral pain like pancreatitis. - **Transdermal application** of bupivacaine is not a standard or effective method for managing widespread, severe abdominal pain and would not provide adequate relief.

Pancreatitis US Medical PG Question 4: A 51-year-old homeless man presents to the emergency department with severe abdominal pain and cramping for the past 3 hours. He endorses radiation to his back. He adds that he vomited multiple times. He admits having been hospitalized repeatedly for alcohol intoxication and abdominal pain. His temperature is 103.8° F (39.8° C), respiratory rate is 15/min, pulse is 107/min, and blood pressure is 100/80 mm Hg. He refuses a physical examination due to severe pain. Blood work reveals the following: Serum: Albumin: 3.2 gm/dL Alkaline phosphatase: 150 U/L Alanine aminotransferase: 76 U/L Aspartate aminotransferase: 155 U/L Gamma-glutamyl transpeptidase: 202 U/L Lipase: 800 U/L What is the most likely diagnosis of this patient?

• A. Duodenal peptic ulcer
• B. Choledocholithiasis
• C. Pancreatitis (Correct Answer)
• D. Cholecystitis
• E. Gallbladder cancer

Pancreatitis Explanation: ***Pancreatitis*** - The patient's history of **repeated alcohol intoxication** and abdominal pain, combined with **severe abdominal pain radiating to the back**, vomiting, and significantly elevated **lipase (800 U/L)**, are highly indicative of **acute pancreatitis**. - The elevated **liver enzymes (ALT, AST, GGT)** and **alkaline phosphatase** can be associated with cholestasis or liver involvement often seen in alcohol-induced pancreatitis or can be elevated due to a gallstone lodged in the common bile duct, which is also a common cause of pancreatitis. *Duodenal peptic ulcer* - While duodenal ulcers cause severe abdominal pain, they typically present with **epigastric pain** that may be relieved by food, and often cause **melena or hematemesis** if bleeding. - The extremely high **lipase level** and pain radiating to the back are not characteristic of an uncomplicated duodenal ulcer. *Choledocholithiasis* - **Choledocholithiasis** (gallstones in the common bile duct) can cause severe right upper quadrant or epigastric pain and elevated liver enzymes, but it doesn't typically present with an isolated, dramatically high **lipase** level without concomitant pancreatitis. - The main symptom is **biliary colic**, often post-prandial, and usually involves jaundice or cholangitis if infected. *Cholecystitis* - **Cholecystitis** presents with **right upper quadrant pain**, often radiating to the shoulder, associated with fever and nausea, and is usually triggered by fatty meals. - Although there might be some elevation in liver enzymes and amylase/lipase, the **markedly elevated lipase** and pain radiating to the back are more suggestive of pancreatitis. *Gallbladder cancer* - **Gallbladder cancer** typically presents with more insidious symptoms, such as chronic right upper quadrant pain, weight loss, jaundice, and anorexia. - It would not usually present with an acute episode of **severe abdominal pain and drastically high lipase** in this manner.

Pancreatitis US Medical PG Question 5: A 29-year-old woman presents with a 2-hour history of sudden onset of severe mid-epigastric pain. The pain radiates to the back, and is not relieved by over-the-counter antacids. The patient also complains of profuse vomiting. The patient’s medical history is negative for similar symptoms. She consumes 3–4 alcoholic drinks daily. The blood pressure is 80/40 mm Hg and the heart rate is 105/min. Examination of the lungs reveals bibasilar crackles. Abdominal examination reveals diffuse tenderness involving the entire abdomen, marked guarding, rigidity, and reduced bowel sounds. The chest X-ray is normal. However, the abdominal CT scan reveals peritoneal fluid collection and diffuse pancreatic enlargement. The laboratory findings include: Aspartate aminotransferase 63 IU/L Alkaline phosphatase 204 IU/L Alanine aminotransferase 32 IU/L Serum amylase 500 IU/L (Normal: 25-125 IU/L) Serum lipase 1,140 IU/L (Normal: 0-160 IU/L) Serum calcium 2 mmol/L Which of the following cellular changes are most likely, based on the clinical and laboratory findings?

• A. Liquefactive necrosis
• B. Dry gangrene
• C. Caseous necrosis
• D. Coagulative necrosis
• E. Fat necrosis (Correct Answer)

Pancreatitis Explanation: ***Fat necrosis*** - The patient's presentation with severe epigastric pain radiating to the back, elevated serum amylase and lipase, **alcohol abuse**, and diffuse pancreatic enlargement indicates **acute pancreatitis**. - **Fat necrosis** is a characteristic pathologic finding in acute pancreatitis, resulting from the release of activated pancreatic enzymes (like lipase) into the surrounding adipose tissue, causing **FFA (free fatty acid)** formation that complexes with calcium (saponification). *Liquefactive necrosis* - This type of necrosis is characterized by the complete digestion of dead cells, resulting in a **viscous liquid mass**. - It is typically seen in **bacterial infections** or **cerebral infarcts**, not primarily in pancreatitis. *Dry gangrene* - **Dry gangrene** involves ischemic necrosis, usually affecting the extremities, where the tissue becomes **dry, shrunken, and black**. - It is caused by **lack of blood supply** and does not fit the clinical picture of acute pancreatitis. *Caseous necrosis* - **Caseous necrosis** is a distinct form of coagulative necrosis, characterized by a **cheese-like appearance** of the necrotic tissue. - It is most commonly associated with **tuberculosis** and certain fungal infections, not acute pancreatitis. *Coagulative necrosis* - **Coagulative necrosis** is characterized by the preservation of the cell shape and tissue architecture for several days after cell death, often due to **ischemia** (e.g., myocardial infarction). - While pancreatic cells can undergo coagulative necrosis in severe ischemia, **fat necrosis** is specifically and prominently associated with the enzymatic destruction in acute pancreatitis.

Pancreatitis US Medical PG Question 6: A 46-year-old man is brought to the emergency department because of severe epigastric pain and vomiting for the past 4 hours. The pain is constant, radiates to his back, and is worse on lying down. He has had 3–4 episodes of greenish-colored vomit. He was treated for H. pylori infection around 2 months ago with triple-regimen therapy. He has atrial fibrillation and hypertension. He owns a distillery on the outskirts of a town. The patient drinks 4–5 alcoholic beverages daily. Current medications include dabigatran and metoprolol. He appears uncomfortable. His temperature is 37.8°C (100°F), pulse is 102/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Bowel sounds are hypoactive. Rectal examination shows no abnormalities. Laboratory studies show: Hematocrit 53% Leukocyte count 11,300/mm3 Serum Na+ 133 mEq/L Cl- 98 mEq/L K+ 3.1 mEq/L Calcium 7.8 mg/dL Urea nitrogen 43 mg/dL Glucose 271 mg/dL Creatinine 2.0 mg/dL Total bilirubin 0.7 mg/dL Alkaline phosphatase 61 U/L AST 19 U/L ALT 17 U/L γ-glutamyl transferase (GGT) 88 u/L (N=5–50 U/L) Lipase 900 U/L (N=14–280 U/L) Which of the following is the most appropriate next step in management?

• A. Crystalloid fluid infusion (Correct Answer)
• B. Fomepizole therapy
• C. Calcium gluconate therapy
• D. Endoscopic retrograde cholangio-pancreatography
• E. Laparotomy

Pancreatitis Explanation: ***Crystalloid fluid infusion*** - The patient presents with **acute pancreatitis**, indicated by severe epigastric pain radiating to the back, vomiting, epigastric tenderness, and markedly elevated **lipase** (900 U/L). - He shows clear signs of **hypovolemia**: elevated hematocrit (53%), elevated BUN/Cr ratio (43/2.0 = 21.5), and tachycardia. - Pancreatitis causes significant **fluid shifts** and third-spacing, requiring aggressive **intravenous fluid resuscitation** with crystalloids (preferably lactated Ringer's) to prevent hypovolemic shock, acute kidney injury, and organ dysfunction. - Early aggressive fluid resuscitation (250–500 mL/h initially) is the **cornerstone of acute pancreatitis management** and improves outcomes. *Fomepizole therapy* - **Fomepizole** is an antidote for **methanol** or **ethylene glycol** poisoning, which cause a high anion gap metabolic acidosis and visual disturbances. - While the patient owns a distillery, his symptoms and lab findings (elevated lipase, hypocalcemia, mild leukocytosis) are consistent with **alcoholic pancreatitis**, not toxic alcohol ingestion. - No anion gap is present, and there are no visual symptoms. *Calcium gluconate therapy* - Although the patient has **hypocalcemia** (7.8 mg/dL), which is common in severe pancreatitis due to fat saponification and calcium sequestration, routine calcium gluconate administration is generally **not recommended unless symptomatic**. - Symptomatic hypocalcemia includes tetany, paresthesias, seizures, or prolonged QT interval, none of which are present. - Aggressive fluid resuscitation and management of the underlying pancreatitis are higher priorities. *Endoscopic retrograde cholangio-pancreatography* - **ERCP** is primarily indicated for **gallstone pancreatitis with cholangitis** or persistent biliary obstruction. - This patient likely has **alcoholic pancreatitis** (heavy alcohol use, elevated GGT), and there's no evidence of biliary obstruction (normal bilirubin, AST, ALT, ALP). - Routine early ERCP in acute pancreatitis without cholangitis is not beneficial and carries procedural risks. *Laparotomy* - **Laparotomy** (surgical exploration) is rarely indicated in the initial management of acute pancreatitis. - It might be considered for complications such as infected necrosis, pancreatic abscess, or abdominal compartment syndrome, but there is no indication for surgical intervention in this patient at this stage. - Initial management focuses on medical stabilization with fluid resuscitation and supportive care.

Pancreatitis US Medical PG Question 7: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

• A. "Does the diarrhea typically precede the constipation, or vice-versa?"
• B. "Is the diarrhea foul-smelling?"
• C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
• D. "Are the symptoms worse in the morning or at night?"
• E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Pancreatitis Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Pancreatitis US Medical PG Question 8: A 27-year-old-man is brought to the emergency department 30 minutes after being involved in a motorcycle accident. He lost control at high speed and was thrown forward onto the handlebars. On arrival, he is alert and responsive. He has abdominal pain and superficial lacerations on his left arm. Vital signs are within normal limits. Examination shows a tender, erythematous area over his epigastrium. The abdomen is soft and non-distended. A CT scan of the abdomen shows no abnormalities. Treatment with analgesics is begun, the lacerations are cleaned and dressed, and the patient is discharged home after 2 hours of observation. Four days later, the patient returns to the emergency department with gradually worsening upper abdominal pain, fever, poor appetite, and vomiting. His pulse is 91/min and blood pressure is 135/82 mm Hg. Which of the following is the most likely diagnosis?

• A. Abdominal compartment syndrome
• B. Aortic dissection
• C. Splenic rupture
• D. Pancreatic ductal injury (Correct Answer)
• E. Diaphragmatic rupture

Pancreatitis Explanation: ***Pancreatic ductal injury*** - A forceful impact to the **epigastrium** (e.g., falling onto handlebars) can cause **pancreatic injury**, particularly a **ductal transection**, due to the pancreas being compressed against the vertebral column. - Initial CT scans can be normal because the injury to the **ductal system** takes time to manifest, leading to delayed symptoms like **worsening abdominal pain, fever, vomiting**, and **poor appetite** several days later due to **pancreatitis** or a **pseudocyst** formation. *Abdominal compartment syndrome* - This typically presents with **acute abdominal distension**, increased intra-abdominal pressure, and organ dysfunction (e.g., oliguria, respiratory compromise), which are not described here. - It's an immediate complication of severe trauma or fluid resuscitation, not a delayed presentation like described. *Aortic dissection* - Characterized by **sudden-onset, severe, tearing chest or back pain** and often involves hypertension or Marfan syndrome. - It would manifest immediately with hemodynamic instability and distinct pain, not a delayed presentation of progressive abdominal symptoms. *Splenic rupture* - Often causes **left upper quadrant pain**, **Kehr's sign** (referred shoulder pain), and **hemodynamic instability** due to significant blood loss. - While possible in trauma, a normal initial CT scan makes this less likely, and its symptoms usually appear earlier or are more severe. *Diaphragmatic rupture* - Can present with **dyspnea, shoulder pain**, or signs of **herniated abdominal organs** into the chest. - It causes more immediate respiratory distress or gastrointestinal obstruction symptoms, and the abdominal symptoms described are not typical for this injury.

Pancreatitis US Medical PG Question 9: A 74-year-old woman with a past medical history of hypertension, peripheral artery disease, and migraine headaches presents to the emergency department with a two hour history of severe abdominal pain. The patient cannot recall any similar episodes, although she notes occasional abdominal discomfort after eating. She describes the pain as sharp periumbilical pain. She denies recent illness, fever, chills, nausea, vomiting, or diarrhea. Her last normal bowel movement was yesterday evening. Her temperature is 37.1°C (98.8°F), pulse is 110/min, blood pressure is 140/80 mmHg, and respirations are 20/min. On exam, the patient is grimacing and appears to be in significant discomfort. Heart and lung exams are within normal limits. The patient's abdomen is soft and non-distended with diffuse periumbilical pain on palpation. There is no rebound tenderness or guarding, and bowel sounds are present. The rest of the exam is unremarkable. Labs in the emergency room show: Serum: Na+: 144 mEq/L Cl-: 105 mEq/L K+: 3.7 mEq/L HCO3-: 20 mEq/L BUN: 15 mg/dL Glucose: 99 mg/dL Creatinine: 1.2 mg/dL Ca2+: 10.7 mg/dL Phosphorus: 5.2 mg/dL Lactate: 7.0 mmol/L Amylase: 240 U/L Hemoglobin: 13.4 g/dL Hematocrit: 35% Leukocyte count: 12,100 cells/mm^3 with normal differential Platelet count: 405,000/mm^3 What is the next best step in diagnosis?

• A. Plain abdominal radiograph
• B. Exploratory laparotomy
• C. Abdominal duplex ultrasound
• D. CT angiography (Correct Answer)
• E. D-dimer level

Pancreatitis Explanation: ***CT angiography*** - The patient's presentation with **severe abdominal pain out of proportion to physical exam findings**, history of **peripheral artery disease**, and elevated **lactate** strongly suggests **acute mesenteric ischemia**. - **CT angiography** is the most sensitive and specific imaging modality to confirm the diagnosis of arterial occlusion in acute mesenteric ischemia by visualizing the mesenteric vessels. *Plain abdominal radiograph* - A plain abdominal radiograph has **poor sensitivity** for mesenteric ischemia and is primarily useful for detecting free air, bowel obstruction, or severe constipation, which are not the primary concerns here. - While it can sometimes show **thumbprinting** in later stages due to bowel wall edema, it is not the initial diagnostic choice for acute vascular compromise. *Exploratory laparotomy* - **Exploratory laparotomy** is a surgical intervention, not a diagnostic step, and is typically performed after a diagnosis of mesenteric ischemia is established and definitive management is required. - While it can directly visualize the bowel, it is **invasive** and should not be the first step in diagnosis, especially when less invasive imaging options are available. *Abdominal duplex ultrasound* - **Abdominal duplex ultrasound** can assess blood flow in the mesenteric arteries but is often **limited by bowel gas** and body habitus, making it less reliable for diagnosing acute mesenteric ischemia than CT angiography. - Its utility is primarily in screening for chronic mesenteric ischemia rather than acute presentations. *D-dimer level* - An elevated **D-dimer level** indicates recent or ongoing clot formation or breakdown and can be elevated in many conditions, including thrombosis, inflammation, and infection, making it a **non-specific marker**. - While it might be elevated in mesenteric ischemia, it is not specific enough to confirm the diagnosis and should not be relied upon as the primary diagnostic tool.

Pancreatitis US Medical PG Question 10: A 23-year-old man presents to the emergency department for altered mental status after a finishing a marathon. He has a past medical history of obesity and anxiety and is not currently taking any medications. His temperature is 104°F (40°C), blood pressure is 147/88 mmHg, pulse is 200/min, respirations are 33/min, and oxygen saturation is 99% on room air. Physical exam reveals dry mucous membranes, hot flushed skin, and inappropriate responses to the physician's questions. Laboratory values are ordered as seen below. Hemoglobin: 15 g/dL Hematocrit: 44% Leukocyte count: 8,500/mm^3 with normal differential Platelet count: 199,000/mm^3 Serum: Na+: 165 mEq/L Cl-: 100 mEq/L K+: 4.0 mEq/L HCO3-: 22 mEq/L BUN: 30 mg/dL Glucose: 133 mg/dL Creatinine: 1.5 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L Which of the following is the best next step in management?

• A. Lactated ringer
• B. Hypotonic saline
• C. 50% normal saline 50% dextrose
• D. Normal saline (Correct Answer)
• E. Dextrose solution

Pancreatitis Explanation: ***Normal saline*** - The patient presents with **heat stroke** (temperature 104°F, altered mental status after marathon) complicated by **severe hypernatremia (Na+ 165 mEq/L)** and **hypovolemia** (elevated BUN/Cr ratio, tachycardia, dry mucous membranes). - In **hypovolemic hypernatremia**, the best initial step is to restore **intravascular volume** with **isotonic crystalloid** (normal saline or lactated Ringer's) to stabilize hemodynamics and organ perfusion. - **Normal saline (0.9% NaCl, 154 mEq/L Na+)** is hypotonic relative to the patient's serum (165 mEq/L), so it will begin **gradual correction** of hypernatremia while providing volume resuscitation. - After volume restoration, hypotonic fluids (0.45% saline or D5W) may be used for further correction, but they should NOT be given initially to a volume-depleted patient due to risk of worsening hypotension. - Correction rate should be **≤10-12 mEq/L per 24 hours** to avoid cerebral edema. *Hypotonic saline* - While hypotonic saline (0.45% NaCl) is used to correct hypernatremia, it should **not** be the first-line choice in a **hypovolemic** patient. - Administering hypotonic fluids to a volume-depleted patient can worsen hypotension and compromise organ perfusion before adequately restoring intravascular volume. - Hypotonic saline is appropriate **after** volume status has been restored with isotonic fluids. *Lactated ringer* - **Lactated Ringer's solution** is an isotonic crystalloid (130 mEq/L Na+) and would be an equally acceptable choice for initial volume resuscitation. - It is slightly more hypotonic than normal saline, which could provide marginally faster correction of hypernatremia. - Either normal saline or lactated Ringer's is appropriate for initial management; normal saline is more commonly cited in USMLE resources for hypernatremia management. *50% normal saline 50% dextrose* - This mixture would create a **hypertonic solution** that could worsen hypernatremia rather than correct it. - The patient's glucose is normal (133 mg/dL), so dextrose supplementation is not indicated. - This option is inappropriate for managing hypernatremia. *Dextrose solution* - **D5W (5% dextrose in water)** provides free water and would correct hypernatremia by diluting serum sodium. - However, in a **volume-depleted** patient, giving free water without adequate sodium can lead to rapid osmotic shifts, worsening hypotension, and potentially causing cerebral edema if correction occurs too rapidly. - D5W is reserved for **euvolemic or hypervolemic hypernatremia**, not hypovolemic hypernatremia.

Pancreatitis Flashcard 1 of 10

Question: Chronic pancreatitis may present with _____, which results in malabsorption with steatorrhea and fat-soluble vitamin deficiences

Answer: pancreatic insufficiency

Pancreatitis Flashcard 2 of 10

Question: Chronic pancreatitis is most often secondary to recurrent acute _____

Answer: pancreatitis

Pancreatitis Flashcard 3 of 10

Question: Which pancreatic enzyme (amylase or lipase) is more specific for acute pancreatitis?_____

Answer: Lipase

Pancreatitis Flashcard 4 of 10

Question: Pancreatic insufficiency is associated with _____ excretion of fecal elastase

Answer: decreased

Pancreatitis Flashcard 5 of 10

Question: What endocrine pathology may arise secondary to chronic pancreatitis? _____

Answer: Diabetes mellitus

Pancreatitis Flashcard 6 of 10

Question: Complications of acute pancreatitis include _____ due to activation of coagulation factors

Answer: DIC

Pancreatitis Flashcard 7 of 10

Question: Complications of acute pancreatitis include _____ due to damage to the alveolar capillary interface

Answer: ARDS

Pancreatitis Flashcard 8 of 10

Question: The increased level of calcium in primary hyperparathyroidism may lead to activation of pancreatic enzymes, causing _____

Answer: acute pancreatitis

Pancreatitis Flashcard 9 of 10

Question: Disseminated Intravascular Coagulation (DIC) is almost always secondary to another disease, which may be remembered with "STOP Making New Thrombi" S:_____, _____ T: Trauma O: *Obstetric complications P: Pancreatitis (acute) Making: Malignancy New: Nephrotic syndrome Thrombi: Transfusion

Answer: Sepsis

Extra Information:   * Pancreas shaped hair= Pancreatitis -> DIC Watch Acquired Coagulation Defects [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-blood-coagulation/videos/medical-pathophysiology-blood-and-coagulation-coagulopathies-and-platelet-disorders-acquired-coagulation-defects?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical]Watch associated Bootcamp video [https://app.bootcamp.com/med-school/hematology-and-oncology/videos/coagulation-and-fibrinolysis?index=9] https://onlinemeded.org/spa/heme-onc/hemostasis/acquire?ref=anki 

Pancreatitis Flashcard 10 of 10

Question: In addition to parotitis, mumps may also present with _____, pancreatitis, and aseptic meningitis

Answer: orchitis

Extra Information:  https://onlinemeded.org/spa/pediatrics/peds-infectious-rashes/acquire?ref=anki