Management of acute pancreatitis US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Management of acute pancreatitis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Management of acute pancreatitis US Medical PG Question 1: 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
Management of acute 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.
Management of acute pancreatitis US Medical PG Question 2: A 52-year-old woman presents to the urgent care center with several hours of worsening abdominal discomfort that radiates 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℉), and she is diffusely tender on abdominal palpation. Other vital signs include a blood pressure of 126/74 mm Hg, heart rate of 74/min, and respiratory rate of 14/min. Complete blood count is notable for 13,500 white blood cells (WBCs), and her complete metabolic panel shows bilirubin of 2.1 and amylase of 3210. Given the following options, what is the most likely diagnosis?
- A. Choledocholithiasis
- B. Cholelithiasis
- C. Acute cholecystitis
- D. Ascending cholangitis
- E. Gallstone pancreatitis (Correct Answer)
Management of acute pancreatitis Explanation: ***Gallstone pancreatitis***
- The elevated **amylase** (3210) strongly indicates **acute pancreatitis**, while the **elevated bilirubin** (2.1) suggests **biliary obstruction**, pointing toward a **gallstone etiology** blocking the common bile duct.
- The radiating abdominal pain to the back, nausea, and vomiting along with systemic inflammatory response (fever, leukocytosis) are classic symptoms of **acute pancreatitis**.
- While the patient has a history of alcoholism, the elevated bilirubin is the key finding that suggests **gallstone-induced** rather than alcoholic pancreatitis.
*Choledocholithiasis*
- While an elevated bilirubin suggests **biliary obstruction**, the significantly high **amylase** points primarily to **pancreatic inflammation** rather than just a stone in the common bile duct.
- **Choledocholithiasis** typically causes **biliary colic**, jaundice, and potentially cholangitis, but not the markedly elevated amylase seen here unless it leads to pancreatitis.
*Cholelithiasis*
- **Cholelithiasis** (gallstones) often presents as **biliary colic**, characterized by episodic right upper quadrant pain, but usually without the systemic symptoms or markedly elevated amylase.
- While it's a precursor to other biliary conditions, it doesn't explain the patient's severe generalized symptoms, fever, or the definitive **pancreatitis labs**.
*Acute cholecystitis*
- **Acute cholecystitis** involves inflammation of the **gallbladder**, typically causing **right upper quadrant pain**, fever, and leukocytosis, often with a positive Murphy's sign.
- Although there's fever and leukocytosis, the **diffuse abdominal tenderness** and significantly high **amylase** are more indicative of pancreatitis than isolated gallbladder inflammation.
*Ascending cholangitis*
- **Ascending cholangitis** presents with **Charcot's triad** (fever, right upper quadrant pain, jaundice) or **Reynolds' pentad** (adding hypotension and altered mental status), but the key differentiating factor here is the extremely high amylase.
- While **elevated bilirubin** suggests biliary involvement, the primary pathology indicated by the **amylase level** is pancreatic, not solely biliary infection.
Management of acute pancreatitis US Medical PG Question 3: 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)
Management of acute 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.
Management of acute pancreatitis US Medical PG Question 4: A 49-year-old man comes to the emergency department because of recurrent abdominal pain for 1 week. The pain is worse after eating and he has vomited twice during this period. He was hospitalized twice for acute pancreatitis during the past year; the latest being 2 months ago. There is no family history of serious illness. His only medication is a vitamin supplement. He has a history of drinking five beers a day for several years but quit 1 month ago. His temperature is 37.1°C (98.8°F), pulse is 98/min and blood pressure 110/70 mm Hg. He appears uncomfortable. Examination shows epigastric tenderness to palpation; there is no guarding or rebound. A CT scan of the abdomen shows a 6-cm low attenuation oval collection with a well-defined wall contiguous with the body of the pancreas. Which of the following is the most appropriate next step in management?
- A. Magnetic resonance cholangiopancreatography
- B. CT-guided percutaneous drainage (Correct Answer)
- C. Middle segment pancreatectomy
- D. Laparoscopic surgical drainage
- E. Distal pancreatectomy
Management of acute pancreatitis Explanation: ***CT-guided percutaneous drainage***
- The patient presents with a **symptomatic pancreatic pseudocyst** (recurrent abdominal pain, vomiting, epigastric tenderness) that is 6 cm and has a well-defined wall.
- Given the patient's symptoms and the size/maturity of the pseudocyst, **CT-guided percutaneous drainage** is the most appropriate initial management to relieve symptoms and drain the fluid.
*Magnetic resonance cholangiopancreatography*
- **MRCP** is primarily used to visualize the **biliary and pancreatic ductal systems**, often to identify stones, strictures, or anatomical variations.
- While it can provide more detailed imaging of the pancreatic ducts, it is not a treatment for a symptomatic pseudocyst and would not relieve the patient's immediate pain and vomiting.
*Middle segment pancreatectomy*
- **Pancreatectomies** are **surgical resections** of part or all of the pancreas, typically reserved for tumors, severe necrosis, or intractable pain from chronic pancreatitis not amenable to less invasive treatments.
- This is an **overly aggressive surgical intervention** for a pseudocyst that can likely be managed with drainage.
*Laparoscopic surgical drainage*
- **Laparoscopic internal drainage** (e.g., cystogastrostomy) is an option for mature, symptomatic pseudocysts, but it is typically performed after a period of observation and if percutaneous drainage is unsuccessful or not feasible.
- Percutaneous drainage is generally preferred as the **initial less invasive approach** for managing symptomatic pseudocysts.
*Distal pancreatectomy*
- **Distal pancreatectomy** involves the surgical removal of the body and tail of the pancreas and is indicated for conditions such as tumors localized in these regions or for specific cases of chronic pancreatitis.
- It is an **aggressive surgical procedure** and not the first-line treatment for a symptomatic pancreatic pseudocyst, especially if less invasive options are available.
Management of acute pancreatitis US Medical PG Question 5: A 61-year-old woman presents to the urgent care unit with a 2-week history of abdominal pain after meals. The patient reports vomiting over the past few days. The past medical history is significant for osteoarthritis and systemic lupus erythematosus. She regularly drinks alcohol. She does not smoke cigarettes. The patient currently presents with vital signs within normal limits. On physical examination, the patient appears to be in moderate distress, but she is alert and oriented. The palpation of the abdomen elicits tenderness in the epigastric region. The CT of the abdomen shows no signs of an acute process. The laboratory results are listed below. Which of the following is the most likely diagnosis?
Na+ 139 mEq/L
K+ 4.4 mEq/L
Cl- 109 mmol/L
HCO3- 20 mmol/L
BUN 14 mg/dL
Cr 1.0 mg/dL
Glucose 101 mg/dL
Total cholesterol 187 mg/dL
LDL 110 mg/dL
HDL 52 mg/dL
TG 120 mg/dL
AST 65 IU/L
ALT 47 IU/L
GGT 27 IU/L
Amylase 512 U/L
Lipase 1,262 U/L
- A. Acute liver failure
- B. Acute pancreatitis (Correct Answer)
- C. Acute mesenteric ischemia
- D. Acute cholecystitis
- E. Gastric ulcer
Management of acute pancreatitis Explanation: **Acute pancreatitis**
- The patient presents with classic symptoms of **acute pancreatitis**, including **epigastric abdominal pain** that worsens after meals, and **vomiting**.
- Significantly elevated **amylase** (512 U/L) and **lipase** (1,262 U/L) levels (both more than three times the upper limit of normal) confirm the diagnosis. The patient's history of **alcohol consumption** is a major risk factor.
*Acute liver failure*
- Acute liver failure would typically present with significantly elevated **ALT and AST values**, often in the thousands, along with signs of **hepatic encephalopathy** or coagulopathy, none of which are present here.
- While the AST and ALT are mildly elevated, they are not indicative of acute liver failure, and the patient's other liver function tests (GGT, cholesterol panel) are relatively normal.
*Acute mesenteric ischemia*
- **Acute mesenteric ischemia** presents with severe, **disproportionate pain** to physical findings, often described as "pain out of proportion to examination." It is less commonly associated with elevated lipase and amylase.
- While patient has a history of systemic lupus erythematosus that could potentially increase the risk of thrombotic events, the absence of severe abdominal pain and the very high lipase levels make this less likely.
*Acute cholecystitis*
- **Acute cholecystitis** typically presents with right upper quadrant pain, fever, and leukocytosis, often precipitated by fatty meals. **Murphy's sign** is usually positive.
- While abdominal pain after meals and vomiting could occur, the pain is specifically epigastric, and there are no signs of inflammation (fever, WBC count not provided but general physical examination findings are not pointing to cholecystitis) and the remarkably elevated lipase and amylase are not features of cholecystitis.
*Gastric ulcer*
- A **gastric ulcer** typically causes **epigastric pain** that may be relieved by food (duodenal ulcer) or worsened by food (gastric ulcer), and can cause vomiting.
- However, the extremely high **amylase and lipase levels** are not characteristic of a gastric ulcer and point towards a pancreatic etiology.
Management of acute pancreatitis US Medical PG Question 6: A 58-year-old woman comes to the emergency department because of a 2-day history of worsening upper abdominal pain. She reports nausea and vomiting, and is unable to tolerate oral intake. She appears uncomfortable. Her temperature is 38.1°C (100.6°F), pulse is 92/min, respirations are 18/min, and blood pressure is 132/85 mm Hg. Examination shows yellowish discoloration of her sclera. Her abdomen is tender in the right upper quadrant. There is no abdominal distention or organomegaly. Laboratory studies show:
Hemoglobin 13 g/dL
Leukocyte count 16,000/mm3
Serum
Urea nitrogen
25 mg/dL
Creatinine 2 mg/dL
Alkaline phosphatase 432 U/L
Alanine aminotransferase 196 U/L
Aspartate transaminase 207 U/L
Bilirubin
Total 3.8 mg/dL
Direct 2.7 mg/dL
Lipase 82 U/L (N = 14–280)
Ultrasound of the right upper quadrant shows dilated intrahepatic and extrahepatic bile ducts and multiple hyperechoic spheres within the gallbladder. The pancreas is not well visualized. Intravenous fluid resuscitation and antibiotic therapy with ceftriaxone and metronidazole is begun. Twelve hours later, the patient appears acutely ill and is not oriented to time. Her temperature is 39.1°C (102.4°F), pulse is 105/min, respirations are 22/min, and blood pressure is 112/82 mm Hg. Which of the following is the most appropriate next step in management?
- A. Abdominal CT scan
- B. Laparoscopic cholecystectomy
- C. Endoscopic retrograde cholangiopancreatography (Correct Answer)
- D. Extracorporeal shock wave lithotripsy
- E. Percutaneous cholecystostomy
Management of acute pancreatitis Explanation: ***Endoscopic retrograde cholangiopancreatography***
- The patient exhibits signs of **cholangitis** (fever, jaundice, RUQ pain), complicated by **sepsis** and **altered mental status**, necessitating urgent biliary decompression.
- **ERCP** allows for direct visualization of the biliary tree, removal of stones, and stent placement to relieve obstruction.
*Abdominal CT scan*
- While CT can provide more detailed anatomical information, it is not the most immediate or definitive therapeutic intervention for acute biliary obstruction and sepsis.
- **Delaying definitive biliary decompression** for imaging could worsen the patient's rapidly deteriorating clinical status.
*Laparoscopic cholecystectomy*
- **Cholecystectomy** is indicated for symptomatic gallstones, but in the setting of acute cholangitis, especially with increasing severity and signs of sepsis, it carries a higher risk.
- The primary and most urgent goal is to **decompress the obstructed biliary system**, which cholecystectomy alone may not achieve if the obstruction is in the common bile duct.
*Extracorporeal shock wave lithotripsy*
- **ESWL** is generally used for breaking up gallstones or kidney stones but is not suitable for the urgent management of **obstructive cholangitis with sepsis**.
- It does not provide immediate biliary decompression and is typically considered for less acute biliary issues or specific stone types.
*Percutaneous cholecystostomy*
- **PCD** involves placing a drain into the gallbladder percutaneously to decompress the gallbladder, often used in critically ill patients with acute cholecystitis who are not surgical candidates.
- However, the primary issue here is **common bile duct obstruction and cholangitis**, not just cholecystitis, so PCD would not address the main problem of biliary outflow obstruction.
Management of acute pancreatitis US Medical PG Question 7: A 42-year-old man comes to the emergency department because of tingling in his hands and legs and palpitations for 1 week. He has also had severe cramping in his hands, feet, and abdomen during this period. Three months ago, he was hospitalized for acute pancreatitis. He discharged himself against medical advice at that time. There is no family history of illness. He does not smoke. He drinks 2–3 beers and a pint of vodka daily. He has a history of using intravenous heroin. He has not had a stable job for a year. He is only oriented to place and person. His temperature is 37.1°C (98.8°F), pulse is 90/min, and blood pressure is 110/96 mm Hg. There is a carpopedal spasm while measuring his blood pressure. Cardiopulmonary examination shows no abnormalities. Deep tendon reflexes are 4+ bilaterally. Neurologic examination shows no focal findings. Which of the following is the most appropriate pharmacotherapy?
- A. Magnesium sulfate (Correct Answer)
- B. Lorazepam
- C. Sodium bicarbonate
- D. Fomepizole
- E. Vitamin B1 (thiamine)
Management of acute pancreatitis Explanation: ***Magnesium sulfate***
- The patient exhibits symptoms like **tingling**, **palpitations**, **severe cramping** (hands, feet, abdomen), **carpopedal spasm** (Trousseau's sign), and **hyperreflexia (4+)**, which are classic signs of **hypocalcemia** or **hypomagnesemia**.
- Given his history of **alcohol abuse**, **intravenous drug use**, and recent **pancreatitis**, **hypomagnesemia** is a likely diagnosis, often leading to secondary hypocalcemia. **Magnesium sulfate** is the appropriate treatment.
*Lorazepam*
- Lorazepam is a **benzodiazepine** used to treat seizures, anxiety, and alcohol withdrawal.
- While the patient has a history of alcohol use, his current symptoms are more indicative of electrolyte imbalance (hypomagnesemia/hypocalcemia) rather than acute alcohol withdrawal or seizures.
*Sodium bicarbonate*
- **Sodium bicarbonate** is used to treat metabolic acidosis or certain poisonings.
- There is no indication of acidosis in the given clinical presentation; the symptoms are primarily related to neuromuscular irritability.
*Fomepizole*
- **Fomepizole** is an antidote used in cases of **methanol** or **ethylene glycol poisoning**.
- The patient's presentation does not suggest ingestion of these toxic alcohols.
*Vitamin B1 (thiamine)*
- **Thiamine** is crucial for preventing and treating **Wernicke-Korsakoff syndrome** in patients with chronic alcohol abuse.
- While appropriate for patients with alcohol abuse, it does not directly address the acute neuromuscular irritability and tetany symptoms (tingling, carpopedal spasm, hyperreflexia) observed in this patient.
Management of acute pancreatitis US Medical PG Question 8: A 72-year-old man is brought to the emergency department from hospice. The patient has been complaining of worsening pain over the past few days and states that it is no longer bearable. The patient has a past medical history of pancreatic cancer which is being managed in hospice. The patient desires no "heroic measures" to be made with regards to treatment and resuscitation. His temperature is 98.8°F (37.1°C), blood pressure is 107/68 mmHg, pulse is 102/min, respirations are 22/min, and oxygen saturation is 99% on room air. Physical exam reveals an uncomfortable elderly man who experiences severe pain upon abdominal palpation. Laboratory values reveal signs of renal failure, liver failure, and anemia. Which of the following is the best next step in management?
- A. Ketorolac and fentanyl
- B. Ketorolac
- C. Morphine (Correct Answer)
- D. No intervention warranted
- E. Morphine and fentanyl patch
Management of acute pancreatitis Explanation: ***Morphine***
- This patient is in **hospice** with **acute, unbearable pain** requiring **immediate relief** in the emergency department. **Intravenous or subcutaneous morphine** is the **best next step** as it provides **rapid onset of analgesia** (within 5-10 minutes for IV, 15-30 minutes for SC).
- In the **ED setting**, the priority is to achieve **immediate pain control** for this acute exacerbation. Once stabilized, a comprehensive long-acting regimen can be coordinated with hospice, but the question asks for the **best next step**, which is immediate-acting opioid administration.
- Morphine is appropriate despite renal failure in end-of-life care where **comfort is the primary goal**. Doses may need adjustment, but pain relief takes precedence in hospice patients.
*Ketorolac and fentanyl*
- **Ketorolac (NSAID)** is **contraindicated** in patients with **renal failure** and carries risk of **gastrointestinal bleeding**, especially concerning in advanced cancer with anemia.
- While fentanyl is appropriate for pain management, a **fentanyl patch** takes **12-24 hours** to reach therapeutic levels and is unsuitable for **acute pain** requiring immediate relief.
*Ketorolac*
- **Ketorolac (NSAID)** is contraindicated due to **renal failure** and would be insufficient for severe cancer-related pain.
- NSAIDs are generally avoided in hospice patients with multi-organ dysfunction and do not provide adequate analgesia for unbearable pain.
*Morphine and fentanyl patch*
- While this represents a comprehensive pain management approach, it is **not the best next step** in the **emergency department** for **acute pain**.
- **Fentanyl patches** have a **delayed onset** (12-24 hours to reach steady state) and are designed for **chronic, stable pain management**, not acute exacerbations.
- The immediate priority is rapid pain relief with short-acting opioids; long-acting formulations should be coordinated with hospice after acute stabilization.
*No intervention warranted*
- This is **unethical and inappropriate** given the patient's explicit complaint of unbearable pain.
- **Comfort and symptom management** are the primary objectives of hospice care, making pain relief an absolute necessity.
Management of acute pancreatitis US Medical PG Question 9: 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)
Management 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.
Management of acute pancreatitis US Medical PG Question 10: A 45-year-old man with a history of biliary colic presents with one-day of intractable nausea, vomiting, and abdominal pain radiating to the back. Temperature is 99.7 deg F (37.6 deg C), blood pressure is 102/78 mmHg, pulse is 112/min, and respirations are 22/min. On abdominal exam, he has involuntary guarding and tenderness to palpation in the right upper quadrant and epigastric regions. Laboratory studies show white blood cell count 18,200/uL, alkaline phosphatase 650 U/L, total bilirubin 2.5 mg/dL, amylase 500 U/L, and lipase 1160 U/L. Which of the patient's laboratory findings is associated with increased mortality?
- A. White blood cell count (Correct Answer)
- B. Lipase
- C. Amylase
- D. Total bilirubin
- E. Alkaline phosphatase
Management of acute pancreatitis Explanation: ***White blood cell count***
- An **elevated white blood cell count (leukocytosis)** above 16,000/uL is a component of the **Ranson criteria** and can indicate severe inflammation and systemic response, which is associated with increased mortality in acute pancreatitis.
- This finding, in conjunction with other clinical and laboratory signs, points towards a more severe inflammatory process and potential for complications leading to worse outcomes.
*Lipase*
- While significantly elevated **lipase** levels (more than three times the upper limit of normal) are diagnostic for acute pancreatitis, the absolute value itself is not directly correlated with the severity or prognosis of the disease.
- Extremely high lipase levels confirm the diagnosis but do not reliably predict increased mortality.
*Amylase*
- Similar to lipase, markedly elevated **amylase** levels are crucial for diagnosing acute pancreatitis but do not significantly correlate with disease severity or mortality.
- The degree of amylase elevation does not predict the likelihood of complications or death.
*Total bilirubin*
- An elevated **total bilirubin** suggests biliary obstruction, which is often the underlying cause of gallstone pancreatitis in this case.
- While it points to the etiology, isolated bilirubin elevation is not a direct prognostic marker for increased mortality in acute pancreatitis unless it leads to severe complications like cholangitis or liver failure.
*Alkaline phosphatase*
- An elevated **alkaline phosphatase** also indicates cholestasis or biliary obstruction.
- Similar to bilirubin, it helps identify the cause of pancreatitis but is not included in common prognostic scoring systems (like Ranson's or APACHE II) as a direct predictor of increased mortality in acute pancreatitis itself.
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