Severity assessment in acute pancreatitis US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Severity assessment in acute pancreatitis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Severity assessment in acute pancreatitis US Medical PG Question 1: A 29-year-old female is hospitalized 1 day after an endoscopic retrograde cholangiopancreatography (ERCP) because of vomiting, weakness, and severe abdominal pain. Physical examination findings include abdominal tenderness and diminished bowel sounds. A CT scan demonstrates fluid around the pancreas. Serum levels of which of the following are likely to be low in this patient?
- A. Amylase
- B. Triglycerides
- C. Calcium (Correct Answer)
- D. Glucose
- E. Lipase
Severity assessment in acute pancreatitis Explanation: ***Calcium***
- In **acute pancreatitis**, systemic inflammation can lead to **saponification** of perinecrotic fat, binding calcium and causing **hypocalcemia**.
- Additionally, glucagon release and hypomagnesemia can contribute to decreased parathyroid hormone (PTH) secretion and end-organ resistance, further lowering calcium levels.
*Amylase*
- **Amylase** levels are typically **elevated** in acute pancreatitis due to the release of pancreatic enzymes into the bloodstream.
- An elevated amylase, along with lipase, is a key diagnostic marker for pancreatitis.
*Triglycerides*
- **Hypertriglyceridemia** can cause acute pancreatitis, and triglyceride levels would be expected to be **elevated** in such cases.
- Triglycerides themselves are not directly lowered by the pancreatitis process in the way calcium is.
*Glucose*
- **Glucose** levels often become **elevated** in acute pancreatitis due to impaired insulin secretion and increased glucagon release.
- Pancreatic damage can affect the endocrine function of the pancreas, leading to hyperglycemia.
*Lipase*
- **Lipase** levels are also typically **elevated** in acute pancreatitis, often staying elevated longer than amylase.
- It is a more specific marker for pancreatic injury than amylase.
Severity assessment in acute pancreatitis US Medical PG Question 2: A 55-year-old woman presents with fatigue and flu-like symptoms. She says her symptoms started 5 days ago with a low-grade fever and myalgia, which have not improved. For the past 4 days, she has also had chills, sore throat, and rhinorrhea. She works as a kindergarten teacher and says several children in her class have had similar symptoms. Her past medical history is significant for depression managed with escitalopram, and dysmenorrhea. A review of systems is significant for general fatigue for the past 5 months. Her vital signs include: temperature 38.5°C (101.3°F), pulse 99/min, blood pressure 115/75 mm Hg, and respiratory rate 22/min. Physical examination reveals pallor of the mucous membranes. Initial laboratory findings are significant for the following:
Hematocrit 24.5%
Hemoglobin 11.0 g/dL
Platelet Count 215,000/mm3
Mean corpuscular volume (MCV) 82 fL
Red cell distribution width (RDW) 10.5%
Which of the following is the best next diagnostic test in this patient?
- A. Serum iron level
- B. Serum ferritin level
- C. Reticulocyte count (Correct Answer)
- D. Hemoglobin electrophoresis
- E. Serum folate level
Severity assessment in acute pancreatitis Explanation: ***Reticulocyte count***
- The patient presents with **fatigue, pallor, and anemia (Hb 11.0 g/dL)**. Given the acute illness (flu-like symptoms) and underlying chronic fatigue, a **reticulocyte count** helps determine if the bone marrow is adequately responding to the anemia.
- A low or inappropriately normal reticulocyte count in the setting of anemia suggests a problem with **red blood cell production** (e.g., marrow suppression, nutritional deficiency), while a high count would suggest hemolysis or acute blood loss.
*Serum iron level*
- While iron-deficiency anemia is common, the patient's **MCV of 82 fL** is within the normal range, suggesting a **normocytic anemia**, which makes iron deficiency less likely as a primary cause without further investigation.
- Furthermore, **serum iron levels** can be acutely affected by inflammation or infection, making them unreliable in the presence of acute flu-like symptoms.
*Serum ferritin level*
- **Ferritin** is an acute-phase reactant; therefore, in the context of an acute infection or inflammation (flu-like symptoms, fever), a **serum ferritin level** can be falsely elevated, masking true iron deficiency, which makes it less reliable as the *best first* diagnostic test in this scenario.
- While low ferritin is diagnostic of iron deficiency, a normal or even elevated ferritin does not rule it out in the presence of inflammation, thus complicating interpretation.
*Hemoglobin electrophoresis*
- **Hemoglobin electrophoresis** is used to diagnose **hemoglobinopathies** like **sickle cell disease** or **thalassemia**. There are no clinical or laboratory findings (e.g., microcytosis, prior family history of hemoglobinopathies) to suggest this as the most appropriate initial investigation for this patient's acute presentation.
- The patient's **normocytic anemia** (MCV 82 fL) further argues against typical thalassemia presentations, which are usually microcytic.
*Serum folate level*
- **Folate deficiency** typically causes a **macrocytic anemia** (elevated MCV), which is not observed in this patient (MCV 82 fL being normocytic).
- There are no specific risk factors or clinical signs presented that would clearly point towards folate deficiency as the primary cause for her anemia.
Severity assessment in 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)
Severity assessment in 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.
Severity assessment in acute pancreatitis US Medical PG Question 4: A 57-year-old man is admitted to the ER due to an abrupt onset of abdominal pain that radiates to the back, nausea, and multiple vomiting episodes for the past 10 hours. He does not have any significant past medical history. He admits to drinking alcohol every night. During admission, he is found to have a body temperature of 37.5°C (99.5°F), a respiratory rate of 20/min, a pulse of 120/min, and a blood pressure of 120/76 mm Hg. He looks pale with sunken eyes and has significant epigastric tenderness and flank discoloration. An initial laboratory panel shows the following:
Total count (WBC) 10,000/mm3
Platelet count 140,000/mm3
Serum glucose 160 mg/dL
Serum LDH 500 IU/L
Aspartate aminotransferase 400 IU/dL
Serum Amylase 500 IU/L
Serum Lipase 300 IU/L
Which of the following combinations would best predict severity in this case?
- A. WBC, platelet count, AST
- B. Age, glucose, amylase
- C. Age, LDH, AST (Correct Answer)
- D. Glucose, LDH, AST
- E. AST, amylase, lipase
Severity assessment in acute pancreatitis Explanation: ***Age, LDH, AST***
- The **Ranson's criteria** for predicting the severity of acute pancreatitis on admission include **age greater than 55 years**, **LDH greater than 350 IU/L**, and **AST greater than 250 IU/L**.
- In this patient, his age is 57 years, LDH is 500 IU/L, and AST is 400 IU/L, all of which align with poor prognostic indicators according to Ranson's criteria.
*WBC, platelet count, AST*
- While **WBC count** is part of Ranson's criteria (greater than 16,000/mm3 is a poor prognostic sign), the patient's WBC is 10,000/mm3, which is not elevated enough to indicate severe pancreatitis.
- **Platelet count** is not typically used as an acute prognostic indicator in Ranson's criteria for pancreatitis severity.
*Age, glucose, amylase*
- **Age greater than 55 years** and **glucose greater than 200 mg/dL** are initial Ranson's criteria for severity. However, the patient's glucose is 160mg/dL, which is not above the specified cutoff.
- **Amylase** and **lipase** are diagnostic for pancreatitis but are not used as prognostic indicators within Ranson’s criteria to predict severity.
*Glucose, LDH, AST*
- **Glucose greater than 200 mg/dL**, **LDH greater than 350 IU/L**, and **AST greater than 250 IU/L** are all included in Ranson's criteria. However, because the patient’s glucose level (160 mg/dL) is below the cutoff of 200 mg/dL, this combination is not the **best** predictor of severity in this specific case.
- The age of the patient is also an important factor in Ranson's criteria and is missing from this option.
*AST, amylase, lipase*
- While **AST greater than 250 IU/L** is a Ranson's criterion for severity, **amylase** and **lipase** levels, though elevated and diagnostic, are not used as prognostic indicators in Ranson's criteria for predicting the severity of acute pancreatitis.
- Amylase and lipase levels often do not correlate with the severity of the disease.
Severity assessment in acute pancreatitis US Medical PG Question 5: 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
Severity assessment in 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.
Severity assessment in acute 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)
Severity assessment in 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.
Severity assessment in acute pancreatitis US Medical PG Question 7: 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)
Severity assessment in 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.
Severity assessment in acute pancreatitis US Medical PG Question 8: 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
Severity assessment in acute 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.
Severity assessment in acute pancreatitis US Medical PG Question 9: 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
Severity assessment in 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.
Severity assessment in acute 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
Severity assessment in acute 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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