Pain management in chronic pancreatitis US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Pain management in chronic pancreatitis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Pain management in chronic pancreatitis US Medical PG Question 1: A 49-year-old man being treated for Helicobacter pylori infection presents to his primary care physician complaining of lower back pain. His physician determines that a non-steroidal anti-inflammatory drug (NSAID) would be the most appropriate initial treatment. Which of the following is the most appropriate NSAID for this patient?
- A. Aspirin
- B. Ibuprofen
- C. Celecoxib (Correct Answer)
- D. Naproxen
- E. Diclofenac
Pain management in chronic pancreatitis Explanation: **Celecoxib**
- This patient is being treated for a *Helicobacter pylori* infection, indicating a potential risk for **gastrointestinal complications** like ulcers. **Celecoxib** is a selective **COX-2 inhibitor**, which has a lower risk of causing GI side effects compared to non-selective NSAIDs.
- Its selective inhibition of COX-2 helps reduce pain and inflammation while largely sparing the **COX-1 enzyme**, which is responsible for maintaining the **gastric mucosal lining**.
*Aspirin*
- **Aspirin** is a non-selective NSAID that inhibits both **COX-1** and **COX-2** enzymes.
- Inhibition of COX-1 can lead to a significant increase in the risk of **gastrointestinal bleeding** and **ulcer formation**, which is particularly concerning for a patient with an *H. pylori* infection.
*Ibuprofen*
- **Ibuprofen** is a non-selective NSAID that can cause **gastrointestinal irritation** and damage by inhibiting **COX-1**.
- Its use would increase the risk of worsening the patient's existing **gastrointestinal vulnerability** due to the *H. pylori* infection.
*Naproxen*
- **Naproxen** is another non-selective NSAID with a relatively long half-life, making its **gastrointestinal side effects** potentially more prolonged and severe than some other non-selective NSAIDs.
- It carries a **higher risk for GI bleeding** and ulcers compared to selective COX-2 inhibitors, especially in patients with pre-existing GI issues.
*Diclofenac*
- **Diclofenac** is a non-selective NSAID that carries a risk of **gastrointestinal adverse events**, although some studies suggest it might have a slightly better GI safety profile than other non-selective NSAIDs at lower doses.
- However, in a patient with *H. pylori*, it still poses a significant risk for **ulcers** and bleeding compared to a COX-2 selective inhibitor.
Pain management in chronic pancreatitis US Medical PG Question 2: 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
Pain management in chronic 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.
Pain management in chronic pancreatitis US Medical PG Question 3: A 45-year-old obese woman presents to the office complaining of intermittent chest pain for the past 3 days. She states that the pain worsens when she lays down and after she eats her meals. She thinks that she has experienced similar pain before but does not remember it lasting this long. She also complains of a bitter taste in her mouth but is otherwise in no apparent distress. She has a history of asthma, a partial hysterectomy 4 years ago, and hypothyroidism that was diagnosed 7 years ago. She admits to drinking 5–6 cans of beer on weekend nights. Her blood pressure is 130/90 mm Hg, and her heart rate is 105/min. An ECG is performed that shows no abnormal findings. Which of the following is the most likely cause of her pain?
- A. Erosion of the mucosa of the antrum of the stomach
- B. Blockage of the cystic duct leading to inflammation of the wall of the gallbladder
- C. Autodigestion of pancreatic tissue
- D. An atherosclerotic blockage of a coronary artery causing transient ischemia during times of increased cardiac demand
- E. Decreased lower esophageal sphincter tone (Correct Answer)
Pain management in chronic pancreatitis Explanation: ***Decreased lower esophageal sphincter tone***
- The patient's symptoms of intermittent chest pain that worsens when lying down and after meals, along with a bitter taste, are classic for **gastroesophageal reflux disease (GERD)**.
- **Decreased lower esophageal sphincter (LES) tone** is the primary mechanism of GERD, allowing gastric acid to reflux into the esophagus and cause pain and irritation. Factors like obesity and alcohol consumption can exacerbate this.
*Erosion of the mucosa of the antrum of the stomach*
- **Gastric ulcers** typically cause burning epigastric pain that may be relieved by food, or exacerbated by an empty stomach, rather than being primarily positional (lying down) or directly correlated with post-meal worsening in the described manner.
- While erosion can cause pain, it doesn't fully explain the **bitter taste** or the strong positional component described.
*Blockage of the cystic duct leading to inflammation of the wall of the gallbladder*
- **Cholecystitis** (inflammation of the gallbladder) typically presents with severe, steady pain in the right upper quadrant or epigastrium, often radiating to the back or shoulder, precipitated by fatty meals.
- While it can be worsened by meals, the pain quality (colicky vs. burning/chest pain), location, absence of fever/leukocytosis, and lack of a bitter taste make it less likely.
*Autodigestion of pancreatic tissue*
- **Pancreatitis** causes severe, constant epigastric pain that often radiates to the back, associated with nausea, vomiting, and abdominal tenderness.
- The patient's symptoms are more consistent with reflux and lack the characteristic severe pain and systemic signs of pancreatitis.
*An atherosclerotic blockage of a coronary artery causing transient ischemia during times of increased cardiac demand*
- While chest pain is a primary symptom of **angina**, it typically worsens with exertion and improves with rest, and is less commonly associated with lying down or a bitter taste.
- The normal ECG and the clear correlation with meals and position point away from a cardiac origin, although cardiac causes should always be considered with chest pain.
Pain management in chronic 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
Pain management in chronic 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.
Pain management in chronic pancreatitis US Medical PG Question 5: 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
Pain management in chronic 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.
Pain management in chronic pancreatitis US Medical PG Question 6: 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)
Pain management in chronic 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.
Pain management in chronic 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)
Pain management in chronic 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.
Pain management in chronic pancreatitis US Medical PG Question 8: A 42-year-old man comes to the physician because of severe epigastric pain for a week. The pain is constant and he describes it as 6 out of 10 in intensity. The pain radiates to his back and is worse after meals. He has had several episodes of nausea and vomiting during this period. He has taken ibuprofen for multiple similar episodes of pain during the past 6 months. He also has had a 5.4-kg (12-lb) weight loss over the past 4 months. He has a 12-year history of drinking 3 to 4 pints of rum daily. He has been hospitalized three times for severe abdominal pain in the past 3 years. He appears ill. His temperature is 37°C (98.6°F), pulse is 87/min, and blood pressure is 110/70 mm Hg. There is severe epigastric tenderness to palpation. Bowel sounds are normal. Cardiopulmonary examination shows no abnormalities. Laboratory studies show:
Hemoglobin 13.6 g/dL
Leukocyte count 7,800/mm3
Serum
Glucose 106 mg/dL
Creatinine 1.1 mg/dL
Amylase 150 U/L
A CT of the abdomen is shown. Which of the following is the most appropriate long-term management for this patient?
- A. Pancreatic enzyme therapy (Correct Answer)
- B. Whipple procedure
- C. Endoscopic stent placement
- D. Celiac ganglion block
- E. Gluten-free diet
Pain management in chronic pancreatitis Explanation: ***Pancreatic enzyme therapy***
- This patient likely has **chronic pancreatitis** due to long-term alcohol abuse, presenting with severe epigastric pain, weight loss, and recurrent episodes. **Pancreatic enzyme replacement therapy (PERT)** helps in managing malabsorption and pain by reducing pancreatic stimulation.
- While amylase is only slightly elevated (150 U/L), this is typical in chronic pancreatitis where extensive glandular destruction prevents dramatic enzyme elevation seen in acute pancreatitis. The abdominal CT would likely show calcifications or ductal dilation, further supporting the diagnosis and the need for enzyme support due to **exocrine insufficiency.**
*Whipple procedure*
- The **Whipple procedure** (pancreaticoduodenectomy) is a complex surgical intervention primarily performed for **pancreatic head tumors** or severe, intractable chronic pancreatitis not amenable to less invasive treatments.
- This patient's symptoms, while severe, do not immediately indicate a need for such aggressive surgery, and other medical managements should be attempted first.
*Endoscopic stent placement*
- **Endoscopic stent placement** is typically used to relieve **biliary obstruction** or **pancreatic duct strictures** that cause pain or cholangitis in chronic pancreatitis.
- While it might be considered for specific ductal complications, it is not the initial long-term management for the diverse symptoms of chronic pancreatitis, especially **exocrine insufficiency**.
*Celiac ganglion block*
- A **celiac ganglion block** provides temporary pain relief for severe abdominal pain, particularly in conditions like **chronic pancreatitis** or **pancreatic cancer**, by interrupting nerve signals.
- It is a **palliative measure** for pain control and does not address the underlying **exocrine insufficiency** or disease progression, making it not a long-term comprehensive management strategy.
*Gluten-free diet*
- A **gluten-free diet** is the primary treatment for **celiac disease**, an autoimmune disorder affecting the small intestine.
- There is no clinical indication or laboratory finding in this patient's presentation (e.g., diarrhea, positive celiac serology) to suggest celiac disease as the cause of his symptoms or to warrant a gluten-free diet.
Pain management in chronic pancreatitis US Medical PG Question 9: 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
Pain management in chronic 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.
Pain management in chronic pancreatitis US Medical PG Question 10: A 21-year-old college student comes to the emergency department because of a two-day history of vomiting and epigastric pain that radiates to the back. He has a history of atopic dermatitis and Hashimoto thyroiditis. His only medication is levothyroxine. He has not received any routine vaccinations. He drinks 1–2 beers on the weekends and occasionally smokes marijuana. The patient appears distressed and is diaphoretic. His temperature is 37.9°C (100.3°F), pulse is 105/min, respirations are 16/min, and blood pressure is 130/78 mm Hg. Physical examination shows abdominal distention with tenderness to palpation in the epigastrium. There is no guarding or rebound tenderness. Skin examination shows several clusters of yellow plaques over the trunk and extensor surfaces of the extremities. Hemoglobin concentration is 15.2 g/dL and serum calcium concentration is 7.9 mg/dL. Which of the following is the most appropriate next step in evaluation?
- A. Measure serum mumps IgM titer
- B. Measure serum lipid levels (Correct Answer)
- C. Obtain an upright x-ray of the abdomen
- D. Perform a pilocarpine-induced sweat test
- E. Measure stool elastase level
Pain management in chronic pancreatitis Explanation: ***Measure serum lipid levels***
- This patient presents with **epigastric pain radiating to the back**, vomiting, and potential signs of systemic inflammation (fever, tachycardia), suggestive of **pancreatitis**. One of the most common causes of pancreatitis, especially in the absence of gallstones or significant alcohol abuse, is **severe hypertriglyceridemia**.
- The presence of **yellow plaques over the trunk and extensor surfaces** (likely **eruptive xanthomas**) is a strong indicator of **severe hypertriglyceridemia**, making serum lipid measurement the most appropriate next step to confirm this etiology for his pancreatitis.
*Measure serum mumps IgM titer*
- While mumps can cause pancreatitis, this patient has not received routine vaccinations, but there is no specific exposure history or other symptoms (like **parotitis**) to strongly suggest mumps as the primary cause.
- The more compelling physical finding of eruptive xanthomas points more directly to **hypertriglyceridemia** as the cause of pancreatitis.
*Obtain an upright x-ray of the abdomen*
- An upright abdominal x-ray is primarily used to look for **free air under the diaphragm** as an indicator of a perforated viscus, which would present with peritonitis and guarding. This patient has **no guarding or rebound tenderness**.
- While it can show signs of ileus, it is not the most targeted test for diagnosing the *cause* of pancreatitis or conditions indicated by eruptive xanthomas.
*Perform a pilocarpine-induced sweat test*
- A **pilocarpine-induced sweat test** is used to diagnose **cystic fibrosis (CF)**, which can cause pancreatic insufficiency and pancreatitis, especially in younger individuals.
- While CF could be considered in a young patient with pancreatic symptoms, his presentation with clear signs of **hyperlipidemia (eruptive xanthomas)** makes this a less direct or immediate next step.
*Measure stool elastase level*
- **Stool elastase** is a test for **exocrine pancreatic insufficiency**, indicating chronic damage to the pancreas.
- This patient is presenting with acute pancreatitis, not chronic insufficiency, and the prominent physical findings point to an **acute metabolic cause** rather than chronic pancreatic dysfunction as the primary differential at this stage.
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