Local complications of acute pancreatitis US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Local complications of acute pancreatitis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Local complications of acute pancreatitis US Medical PG Question 1: A 42-year-old woman is brought to the emergency department because of a 5-day history of epigastric pain, fever, nausea, and malaise. Five weeks ago she had acute biliary pancreatitis and was treated with endoscopic retrograde cholangiopancreatography and subsequent cholecystectomy. Her maternal grandfather died of pancreatic cancer. She does not smoke. She drinks 1–2 beers daily. Her temperature is 38.7°C (101.7°F), respirations are 18/min, pulse is 120/min, and blood pressure is 100/70 mm Hg. Abdominal examination shows epigastric tenderness and three well-healed laparoscopy scars. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 10 g/dL
Leukocyte count 15,800/mm3
Serum
Na+ 140 mEq/L
Cl− 103 mEq/L
K+ 4.5 mEq/L
HCO3- 25 mEq/L
Urea nitrogen 18 mg/dL
Creatinine 1.0 mg/dL
Alkaline phosphatase 70 U/L
Aspartate aminotransferase (AST, GOT) 22 U/L
Alanine aminotransferase (ALT, GPT) 19 U/L
γ-Glutamyltransferase (GGT) 55 U/L (N = 5–50)
Bilirubin 1 mg/dl
Glucose 105 mg/dL
Amylase 220 U/L
Lipase 365 U/L (N = 14–280)
Abdominal ultrasound shows a complex cystic fluid collection with irregular walls and septations in the pancreas. Which of the following is the most likely diagnosis?
- A. Pancreatic cancer
- B. Acute cholangitis
- C. Pancreatic abscess (Correct Answer)
- D. Pancreatic pseudocyst
- E. ERCP-induced pancreatitis
Local complications of acute pancreatitis Explanation: ***Pancreatic abscess***
- The presence of fever, leukocytosis (WBC 15,800/mm³), and a complex, septated fluid collection seen on ultrasound, following acute pancreatitis, is highly suggestive of a **pancreatic abscess**.
- **Pancreatic abscesses** develop as a complication of acute pancreatitis, typically resulting from infected pancreatic necrosis and often present with persistent symptoms of infection.
*Pancreatic cancer*
- While there is a family history of pancreatic cancer, her acute presentation with **fever, leukocytosis**, and a tender, complex fluid collection is **not typical** for initial pancreatic cancer presentation.
- Pancreatic cancer typically presents with **jaundice, weight loss**, and chronic abdominal pain rather than acute infectious symptoms and a fluid collection after pancreatitis.
*Acute cholangitis*
- Acute cholangitis is characterized by **Charcot's triad** (fever, jaundice, right upper quadrant pain) or **Reynold's pentad** (Charcot's triad plus altered mental status and hypotension).
- The patient's **normal bilirubin level** (1 mg/dL), absence of jaundice, and epigastric pain (not right upper quadrant specific) make acute cholangitis less likely, especially with a history of cholecystectomy.
*Pancreatic pseudocyst*
- A pancreatic pseudocyst is a **sterile** fluid collection without signs of active infection (e.g., fever, leukocytosis) and typically has well-defined, smooth walls rather than irregular walls or septations.
- While she has a fluid collection from pancreatitis, the **fever, leukocytosis, and irregular/septated walls** on ultrasound point away from a simple pseudocyst and towards an infected collection.
*ERCP-induced pancreatitis*
- ERCP-induced pancreatitis would have occurred **immediately after the procedure**, which was five weeks ago. The current symptoms occurring five weeks later suggest a complication of the initial pancreatitis, not a new induction.
- While ERCP can cause pancreatitis, this diagnosis refers to the initial event, not a **secondary infectious complication** manifesting weeks later.
Local complications of acute pancreatitis US Medical PG Question 2: 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
Local complications of acute 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.
Local complications of acute pancreatitis US Medical PG Question 3: Ten days after undergoing emergent colectomy for a ruptured bowel that she sustained in a motor vehicle accident, a 59-year-old woman has abdominal pain. During the procedure, she was transfused 3 units of packed red blood cells. She is currently receiving total parenteral nutrition. Her temperature is 38.9°C (102.0°F), pulse is 115/min, and blood pressure is 100/60 mm Hg. Examination shows tenderness to palpation in the right upper quadrant of the abdomen. Bowel sounds are hypoactive. Serum studies show:
Aspartate aminotransferase 142 U/L
Alanine aminotransferase 86 U/L
Alkaline phosphatase 153 U/L
Total bilirubin 1.5 mg/dL
Direct bilirubin 1.0 mg/dL
Amylase 20 U/L
Which of the following is the most likely diagnosis?
- A. Hemolytic transfusion reaction
- B. Acalculous cholecystitis (Correct Answer)
- C. Acute cholecystitis (calculous)
- D. Small bowel obstruction
- E. Acute pancreatitis
Local complications of acute pancreatitis Explanation: ***Acalculous cholecystitis***
- This patient's clinical picture of **fever**, **RUQ tenderness**, **leukocytosis**, and mildly elevated liver enzymes in the setting of recent **major surgery**, **trauma**, and **total parenteral nutrition (TPN)** is highly suggestive of **acalculous cholecystitis**.
- **Acalculous cholecystitis** often occurs in critically ill patients due to gallbladder stasis, ischemia, and inflammation, usually without the presence of stones.
*Hemolytic transfusion reaction*
- While the patient received blood transfusions, a **hemolytic transfusion reaction** typically presents with fever, chills, flank pain, and **hemoglobinuria**, none of which are explicitly mentioned.
- Liver enzyme elevations can occur, but the significant RUQ tenderness and absence of signs of hemolysis make it less likely.
*Acute cholecystitis (calculous)*
- **Acute cholecystitis with gallstones** typically presents with similar symptoms to acalculous cholecystitis (pain, fever), but requires the presence of gallstones causing obstruction.
- The clinical context of critical illness, recent surgery, and TPN use points more towards acalculous inflammation rather than stone-related disease.
*Small bowel obstruction*
- **Small bowel obstruction** would present with more pronounced **abdominal distention**, **vomiting**, and often **high-pitched bowel sounds** followed by absent sounds, which is not the primary picture here.
- Although bowel sounds are hypoactive, the focal RUQ tenderness and liver enzyme changes are not typical of a primary small bowel obstruction.
*Acute pancreatitis*
- **Acute pancreatitis** is usually characterized by **severe epigastric pain** radiating to the back, and significantly elevated **amylase** and **lipase** levels.
- The patient's amylase is normal, and lipase is not mentioned but usually tracks with amylase in pancreatitis.
Local complications of acute pancreatitis US Medical PG Question 4: A 34-year-old man is admitted to the emergency department after a motor vehicle accident in which he sustained blunt abdominal trauma. On admission, he is conscious, has a GCS score of 15, and has normal ventilation with no signs of airway obstruction. Vitals initially are blood pressure 95/65 mmHg, heart rate 87/min, respiratory rate 14/min, and oxygen saturation of 95% on room air. The physical exam is significant only for tenderness to palpation over the left flank. Noncontrast CT of the abdomen shows fractures of the 9th and 10th left ribs. Intravenous fluids are administered and the patient's blood pressure increases to 110/80 mm Hg. Three days later after admission, the patient suddenly complains of weakness and left upper quadrant (LUQ) pain. Vitals are blood pressure 80/50 mm Hg, heart rate 97/min, respiratory rate 18/min, temperature 36.2℃ (97.2℉) and oxygen saturation of 99% on room air. Prompt administration of 2L of IV fluids increases the blood pressure to 100/70 mm Hg. On physical exam, there is dullness to percussion and rebound tenderness with guarding in the LUQ. Bowel sounds are present. Raising the patient's left leg results in pain in his left shoulder. Stat hemoglobin level is 9.8 g/dL. Which of the following findings would be most likely seen if a CT scan were performed now?
- A. Subdiaphragmatic air collection
- B. Low-density areas within the splenic parenchyma (Correct Answer)
- C. Heterogeneous parenchymal enhancement of the pancreatic tail
- D. Herniation of the stomach into the thoracic cavity
- E. Irregular linear areas of hypoattenuation in the liver parenchyma
Local complications of acute pancreatitis Explanation: **Low-density areas within the splenic parenchyma**
- The patient's history of trauma, initial left rib fractures, LUQ pain, and **Kehr's sign** (left shoulder pain from diaphragmatic irritation), followed by sudden decompensation and anemia, are highly indicative of **delayed splenic rupture**.
- On CT scan, **low-density areas** (fluid collections or hematomas) within the splenic parenchyma or around the spleen are characteristic findings of splenic injury and rupture, including intraparenchymal hematomas or subcapsular hematomas.
*Subdiaphragmatic air collection*
- This finding suggests a **perforated viscus**, such as the stomach or intestine, allowing air to escape into the peritoneal cavity.
- While blunt trauma can cause hollow organ injury, the patient's symptoms (Kehr's sign, LUQ pain, initial rib fractures) and the delayed presentation of hypovolemic shock are more consistent with splenic rupture than perforation.
*Heterogeneous parenchymal enhancement of the pancreatic tail*
- This symptom is indicative of **pancreatic injury**, which can occur with blunt abdominal trauma, especially with rapid deceleration.
- However, the patient's presentation, particularly the prominent Kehr's sign and the context of left rib fractures, points more strongly towards splenic involvement rather than primary pancreatic injury.
*Herniation of the stomach into the thoracic cavity*
- This describes a **diaphragmatic rupture**, which can occur in severe blunt trauma and lead to gastric herniation.
- While possible with severe trauma, the immediate presentation of **Kehr's sign** and the progressive symptoms are more characteristic of splenic rupture than an acute diaphragmatic hernia with gastric displacement.
*Irregular linear areas of hypoattenuation in the liver parenchyma*
- These findings suggest **hepatic lacerations** or hematomas, indicating liver injury.
- Although liver injury is a common finding in blunt abdominal trauma, the patient's specific presentation of **left-sided pain**, **left shoulder pain**, and left rib fractures points preferentially to **splenic injury** rather than liver injury.
Local complications of acute pancreatitis US Medical PG Question 5: A 38-year-old man comes to the emergency department because of epigastric pain and multiple episodes of vomiting for 4 hours. Initially, the vomit was yellowish in color, but after the first couple of episodes it was streaked with blood. He had 2 episodes of vomiting that contained streaks of frank blood on the way to the hospital. He has been hospitalized twice in the past year for acute pancreatitis. He drinks 2 pints of vodka daily but had over 4 pints during the past 12 hours. He takes naproxen for his 'hangovers.' He appears uncomfortable. His temperature is 37°C (99.1°F), pulse is 105/min, and blood pressure is 110/68 mm Hg. Examination shows dry mucous membranes and a tremor of his hands. The abdomen is soft and shows tenderness to palpation in the epigastric region; there is no organomegaly. Cardiopulmonary examination shows no abnormalities. Rectal examination is unremarkable. His hemoglobin concentration is 11.3 g/dL and hematocrit concentration is 40%. Which of the following is the most likely cause of this patient's findings?
- A. Inflammation of the esophageal wall
- B. Transmural tear of the lower esophagus
- C. Pseudoaneurysm of the gastroduodenal artery
- D. Neoplastic growth at the gastroesophageal junction
- E. Mucosal tear at the gastroesophageal junction (Correct Answer)
Local complications of acute pancreatitis Explanation: ***Mucosal tear at the gastroesophageal junction***
- The patient's history of heavy alcohol consumption, recurrent acute pancreatitis, and severe, repeated vomiting followed by **hematemesis** (Mallory-Weiss tear) strongly points to a mucosal tear.
- The use of naproxen, an **NSAID**, further increases the risk of gastric mucosal irritation and bleeding, compounding the effects of vomiting.
*Inflammation of the esophageal wall*
- While prolonged vomiting can cause esophagitis, **inflammation of the esophageal wall** typically presents with dysphagia and odynophagia, not rapidly progressing hematemesis associated with forceful vomiting.
- Esophagitis may cause superficial bleeding, but the described **streaks of frank blood** after initial yellowish vomit suggests a more significant mucosal breach.
*Transmural tear of the lower esophagus*
- A **transmural tear** (Boerhaave syndrome) is a medical emergency that would present with severe chest pain, subcutaneous emphysema, and signs of mediastinitis, which are not described in this patient.
- The patient's presentation of forceful vomiting leading to hematemesis is more consistent with a **Mallory-Weiss tear**, which is a mucosal tear and not transmural.
*Pseudoaneurysm of the gastroduodenal artery*
- A **pseudoaneurysm of the gastroduodenal artery** is a rare but life-threatening complication often associated with severe pancreatitis or abdominal trauma, leading to massive gastrointestinal bleeding.
- While the patient has a history of pancreatitis, the presence of **repeated forceful vomiting immediately preceding the hematemesis** makes a Mallory-Weiss tear more likely than a pseudoaneurysm as the primary cause in this acute presentation.
*Neoplastic growth at the gastroesophageal junction*
- **Neoplastic growth** typically presents with chronic symptoms such as progressive dysphagia, weight loss, and chronic, low-grade bleeding (melena or guaiac-positive stool) rather than acute, forceful vomiting leading to immediate hematemesis.
- The acute onset of symptoms following a binge of alcohol and repeated vomiting points away from a chronic cause like cancer and towards an **acute mechanical injury**.
Local complications of acute pancreatitis US Medical PG Question 6: 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
Local complications of acute 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.
Local complications of acute pancreatitis US Medical PG Question 7: A 68-year-old woman is brought to the emergency department with intense abdominal pain for the past 2 hours. She has had 1 episode of bloody diarrhea recently. She has an 18-year history of diabetes mellitus. She was diagnosed with hypertension and ischemic heart disease 6 years ago. She is fully alert and oriented. Her temperature is 37.5°C (99.5°F), blood pressure is 145/90 mm Hg, pulse is 78/min, and respirations are 14/min. Abdominal examination shows mild generalized abdominal tenderness without guarding or rebound tenderness. An abdominal plain X-ray shows no abnormalities. Abdominal CT reveals colonic wall thickening and pericolonic fat stranding in the splenic curvature. Bowel rest, intravenous hydration, and IV antibiotics are initiated. Which of the following is the most important diagnostic evaluation at this time?
- A. Angiography
- B. Gastrografin-enhanced X-ray
- C. Laparotomy
- D. Inpatient observation
- E. Sigmoidoscopy (Correct Answer)
Local complications of acute pancreatitis Explanation: ***Sigmoidoscopy***
- The patient's presentation with acute abdominal pain, bloody diarrhea, history of cardiovascular disease, and CT findings consistent with **colonic wall thickening** and **pericolonic fat stranding** strongly suggests **ischemic colitis**.
- **Flexible sigmoidoscopy** allows for direct visualization of the colonic mucosa to confirm the diagnosis, assess the extent and severity of ischemia, and rule out other causes of colitis, such as inflammatory bowel disease or infection.
*Angiography*
- While angiography can identify mesenteric arterial occlusion, it is generally reserved for cases of acute mesenteric ischemia involving the superior mesenteric artery, which typically presents with more severe pain out of proportion to physical exam findings and less clear CT findings of colitis.
- In cases of ischemic colitis, where the primary concern is mucosal ischemia rather than immediate large vessel occlusion, angiography is usually not the first-line diagnostic.
*Gastrografin-enhanced X-ray*
- This study (also known as a **Gastrografin swallow or enema**) is primarily used to evaluate for **perforations** or **obstructions**, or to assess lumen integrity.
- It does not provide the mucosal detail necessary to diagnose or assess the severity of **ischemic colitis**, and the contrast agent itself could potentially exacerbate an inflamed bowel.
*Laparotomy*
- **Laparotomy** (surgical exploration) is an invasive procedure reserved for cases with signs of peritonitis, bowel perforation, or severe, unresponsive ischemia requiring surgical intervention.
- Given the patient's stable vital signs, mild tenderness, and lack of guarding or rebound, immediate surgical exploration is not warranted without further diagnostic steps.
*Inpatient observation*
- While inpatient observation is part of the initial management (bowel rest, IV fluids, antibiotics), it is not a **diagnostic evaluation** itself.
- The question asks for the most important diagnostic evaluation to determine the underlying cause and guide further management.
Local complications of acute pancreatitis US Medical PG Question 8: A 50-year-old Caucasian man is admitted to the ER with an 8-hour history of intense abdominal pain that radiates to the back, nausea, and multiple episodes of vomiting. Past medical history is insignificant. His blood pressure is 90/60 mm Hg, pulse is 120/min, respirations are 20/min, and body temperature is 37.8°C (100°F). Upon examination, he has significant epigastric tenderness, and hypoactive bowel sounds. Serum lipase and amylase are elevated and the patient rapidly deteriorates, requiring transfer to the intensive care unit for a month. After being stabilized, he is transferred to the general medicine floor with an abdominal computed tomography (CT) reporting a well-circumscribed collection of fluid of homogeneous density. Which of the following best describes the condition this patient has developed?
- A. Acute necrotic collection
- B. Fistula formation
- C. Walled-off necrosis
- D. Pancreatic pseudocyst (Correct Answer)
- E. Pancreatic cancer
Local complications of acute pancreatitis Explanation: ***Pancreatic pseudocyst***
- The patient experienced an episode of **severe acute pancreatitis**, followed by the development of a well-circumscribed collection of fluid with homogeneous density, which is characteristic of a **pancreatic pseudocyst**.
- **Pseudocysts** are collections of pancreatic fluid and inflammatory exudates that become encapsulated by a fibrous wall, typically appearing around 4 weeks after an episode of acute pancreatitis.
*Acute necrotic collection*
- An **acute necrotic collection** is an early phase (within 4 weeks) of peripancreatic fluid collection that contains both fluid and non-viable pancreatic or peripancreatic tissue, which is not described as homogeneous in density.
- This term usually refers to the initial, unorganized collection of necrotic material, prior to the development of a well-defined wall.
*Fistula formation*
- **Fistula formation** involves an abnormal connection between two epithelialized organs or between an organ and the skin, which is not described by a well-circumscribed fluid collection.
- While it can be a complication of pancreatitis, the CT finding of a homogeneous fluid collection does not directly indicate a fistula.
*Walled-off necrosis*
- **Walled-off necrosis (WON)** is a mature collection (typically >4 weeks) of pancreatic and/or peripancreatic necrotic tissue that has developed a well-defined inflammatory wall but contains a significant solid/necrotic component.
- The CT description of a "homogeneous density" fluid collection does not align with WON, which would typically show heterogeneous density due to solid necrotic debris.
*Pancreatic cancer*
- **Pancreatic cancer** is an abnormal growth of cells within the pancreas and would typically present as a mass lesion, often with tissue invasion.
- While a pseudocyst can sometimes mimic a cystic tumor, the history of acute pancreatitis and the specific CT description of a homogeneous fluid collection make pancreatic cancer less likely in this context.
Local complications of acute pancreatitis US Medical PG Question 9: 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)
Local complications of acute 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.
Local complications of acute pancreatitis US Medical PG Question 10: A 43-year-old man is brought to the emergency department because of severe epigastric pain and vomiting for 6 hours. The pain radiates to his back and he describes it as 9 out of 10 in intensity. He has had 3–4 episodes of vomiting during this period. He admits to consuming over 13 alcoholic beverages the previous night. There is no personal or family history of serious illness and he takes no medications. He is 177 cm (5 ft 10 in) tall and weighs 55 kg (121 lb); BMI is 17.6 kg/m2. He appears uncomfortable. His temperature is 37.5°C (99.5°F), pulse is 97/min, and blood pressure is 128/78 mm Hg. Abdominal examination shows severe epigastric tenderness to palpation. Bowel sounds are hypoactive. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 13.5 g/dL
Hematocrit 62%
Leukocyte count 13,800/mm3
Serum
Na+ 134 mEq/L
K+ 3.6 mEq/L
Cl- 98 mEq/L
Calcium 8.3 mg/dL
Glucose 180 mg/dL
Creatinine 0.9 mg/dL
Amylase 150 U/L
Lipase 347 U/L (N = 14–280)
Total bilirubin 0.8 mg/dL
Alkaline phosphatase 66 U/L
AST 19 U/L
ALT 18 U/L
LDH 360 U/L
Which of the following laboratory studies is the best prognostic indicator for this patient's condition?
- A. AST/ALT ratio
- B. Alkaline phosphatase
- C. Total bilirubin
- D. Lipase
- E. Hematocrit (Correct Answer)
Local complications of acute pancreatitis Explanation: ***Hematocrit***
- A rising **hematocrit** (due to **hemoconcentration**) or one that fails to fall after initial fluid resuscitation is an important indicator of volume depletion and a **poor prognostic sign** in **acute pancreatitis**.
- This patient's hematocrit is elevated at **62%**, suggesting significant hemoconcentration and a higher risk for complications like **pancreatic necrosis**.
*AST/ALT ratio*
- While an elevated AST/ALT ratio can suggest **alcoholic liver disease**, it is not a direct **prognostic indicator** for the severity or outcome of **acute pancreatitis**.
- In pancreatitis, liver enzymes are typically elevated secondarily to inflammation or biliary obstruction, but their ratio does not directly predict the course of the pancreatitis itself.
*Alkaline phosphatase*
- **Alkaline phosphatase** is an indicator of **biliary obstruction** or **cholestasis**, which can be a cause of pancreatitis (e.g., gallstone pancreatitis).
- Its value does not directly predict the **severity** or **prognosis** of acute pancreatitis once it has developed, especially in a case of alcoholic pancreatitis.
*Total bilirubin*
- **Total bilirubin** levels primarily reflect **biliary obstruction** or **liver dysfunction**.
- While gallstone pancreatitis can increase bilirubin, it is not a primary prognostic marker for the development of severe complications in **acute pancreatitis**, nor is it significantly elevated in this patient.
*Lipase*
- **Elevated lipase** is highly specific and sensitive for the **diagnosis of acute pancreatitis**, confirming the diagnosis in this case.
- However, the absolute level of lipase does **not correlate** with the **severity** or **prognosis** of acute pancreatitis; even mild pancreatitis can have very high lipase levels.
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