Acute pancreatitis management US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Acute pancreatitis management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Acute pancreatitis management US Medical PG Question 1: A 42-year-old woman is brought to the emergency department because of a 5-day history of epigastric pain, fever, nausea, and malaise. Five weeks ago she had acute biliary pancreatitis and was treated with endoscopic retrograde cholangiopancreatography and subsequent cholecystectomy. Her maternal grandfather died of pancreatic cancer. She does not smoke. She drinks 1–2 beers daily. Her temperature is 38.7°C (101.7°F), respirations are 18/min, pulse is 120/min, and blood pressure is 100/70 mm Hg. Abdominal examination shows epigastric tenderness and three well-healed laparoscopy scars. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 10 g/dL
Leukocyte count 15,800/mm3
Serum
Na+ 140 mEq/L
Cl− 103 mEq/L
K+ 4.5 mEq/L
HCO3- 25 mEq/L
Urea nitrogen 18 mg/dL
Creatinine 1.0 mg/dL
Alkaline phosphatase 70 U/L
Aspartate aminotransferase (AST, GOT) 22 U/L
Alanine aminotransferase (ALT, GPT) 19 U/L
γ-Glutamyltransferase (GGT) 55 U/L (N = 5–50)
Bilirubin 1 mg/dl
Glucose 105 mg/dL
Amylase 220 U/L
Lipase 365 U/L (N = 14–280)
Abdominal ultrasound shows a complex cystic fluid collection with irregular walls and septations in the pancreas. Which of the following is the most likely diagnosis?
- A. Pancreatic cancer
- B. Acute cholangitis
- C. Pancreatic abscess (Correct Answer)
- D. Pancreatic pseudocyst
- E. ERCP-induced pancreatitis
Acute pancreatitis management Explanation: ***Pancreatic abscess***
- The presence of fever, leukocytosis (WBC 15,800/mm³), and a complex, septated fluid collection seen on ultrasound, following acute pancreatitis, is highly suggestive of a **pancreatic abscess**.
- **Pancreatic abscesses** develop as a complication of acute pancreatitis, typically resulting from infected pancreatic necrosis and often present with persistent symptoms of infection.
*Pancreatic cancer*
- While there is a family history of pancreatic cancer, her acute presentation with **fever, leukocytosis**, and a tender, complex fluid collection is **not typical** for initial pancreatic cancer presentation.
- Pancreatic cancer typically presents with **jaundice, weight loss**, and chronic abdominal pain rather than acute infectious symptoms and a fluid collection after pancreatitis.
*Acute cholangitis*
- Acute cholangitis is characterized by **Charcot's triad** (fever, jaundice, right upper quadrant pain) or **Reynold's pentad** (Charcot's triad plus altered mental status and hypotension).
- The patient's **normal bilirubin level** (1 mg/dL), absence of jaundice, and epigastric pain (not right upper quadrant specific) make acute cholangitis less likely, especially with a history of cholecystectomy.
*Pancreatic pseudocyst*
- A pancreatic pseudocyst is a **sterile** fluid collection without signs of active infection (e.g., fever, leukocytosis) and typically has well-defined, smooth walls rather than irregular walls or septations.
- While she has a fluid collection from pancreatitis, the **fever, leukocytosis, and irregular/septated walls** on ultrasound point away from a simple pseudocyst and towards an infected collection.
*ERCP-induced pancreatitis*
- ERCP-induced pancreatitis would have occurred **immediately after the procedure**, which was five weeks ago. The current symptoms occurring five weeks later suggest a complication of the initial pancreatitis, not a new induction.
- While ERCP can cause pancreatitis, this diagnosis refers to the initial event, not a **secondary infectious complication** manifesting weeks later.
Acute pancreatitis management US Medical PG Question 2: A 37-year-old man presents to the emergency department with rapid onset epigastric pain that started 4 hours ago. He describes the pain as severe, localized to the epigastric region and radiating to the back, which is partially relieved by leaning forward. He admits to binge drinking this evening at a friend’s party. He is nauseated but denies vomiting. Vital signs include: blood pressure 90/60 mm Hg, pulse 110/min, temperature 37.2°C (99.0°F), and respiratory rate 16/min. Physical examination shows tenderness to palpation over the epigastric region with no rebound or guarding. The bowel sounds are decreased on auscultation. The laboratory findings are significant for the following:
Laboratory test
Leukocyte Count 18,000/mm³
Neutrophils 81%
Serum amylase 416 U/L
Serum lipase 520 U/L
Which of the following would be the most helpful in determining the prognosis in this case?
- A. Acute Physiology and Chronic Health Examination (APACHE) II score
- B. Ranson's criteria
- C. Bedside Index of Severity in Acute Pancreatitis (BISAP) score (Correct Answer)
- D. Modified Glasgow Score
- E. C-reactive protein level
Acute pancreatitis management Explanation: ***Bedside Index of Severity in Acute Pancreatitis (BISAP) score***
- The **BISAP score** is quick and easy to calculate at the bedside, using routinely available clinical and laboratory parameters within the first 24 hours of admission.
- It effectively stratifies patients with acute pancreatitis into different risk categories for in-hospital mortality, making it a valuable tool for early **prognostic assessment**.
*Acute Physiology and Chronic Health Examination (APACHE) II score*
- The **APACHE II score** is a comprehensive tool used for assessing severity in critically ill patients, not specifically for acute pancreatitis, and requires extensive data collection over 24 hours.
- While it can predict mortality, its complexity and the need for numerous parameters make it less practical for rapid initial **prognostic assessment** in the emergency setting compared to BISAP.
*Ranson's criteria*
- **Ranson's criteria** are effective for predicting the severity of acute pancreatitis, but they require data collected over a 48-hour period (some parameters at admission, others at 48 hours).
- This delay in obtaining all necessary information limits its usefulness for immediate, early **prognostic evaluation** in the emergency department.
*Modified Glasgow Score*
- Similar to Ranson's criteria, the **Modified Glasgow Score** for acute pancreatitis also requires some parameters to be assessed at 48 hours post-admission.
- Its inability to provide an immediate severity assessment makes it less useful for initial rapid **prognostication** compared to the BISAP score.
*C-reactive protein level*
- An elevated **C-reactive protein (CRP) level** is an indicator of systemic inflammation and can suggest severe pancreatitis, particularly if very high, but it is not specific for acute pancreatitis and can be elevated in various inflammatory conditions.
- CRP levels typically peak after 48-72 hours, making it less useful for very early **prognostic assessment** in the initial hours of presentation.
Acute pancreatitis management US Medical PG Question 3: A 72-year-old woman comes to the emergency department because of upper abdominal pain and nausea for the past hour. The patient rates the pain as an 8 to 9 on a 10-point scale. She has had an episode of nonbloody vomiting since the pain started. She has a history of type 2 diabetes mellitus, hypertension, and osteoporosis. The patient has smoked 2 packs of cigarettes daily for 40 years. She drinks 5–6 alcoholic beverages daily. Current medications include glyburide, lisinopril, and oral vitamin D supplements. Her temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. The patient is admitted to the hospital for pain control and intravenous hydration. Which of the following is the most appropriate next step in the management of this patient’s pain?
- A. Oral gabapentin every 24 hours
- B. Transdermal fentanyl every 72 hours
- C. Oral acetaminophen every 6 hours
- D. Patient-controlled intravenous hydromorphone (Correct Answer)
- E. Transdermal bupivacaine on request
Acute pancreatitis management 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.
Acute pancreatitis management US Medical PG Question 4: A 50-year-old Caucasian man is admitted to the ER with an 8-hour history of intense abdominal pain that radiates to the back, nausea, and multiple episodes of vomiting. Past medical history is insignificant. His blood pressure is 90/60 mm Hg, pulse is 120/min, respirations are 20/min, and body temperature is 37.8°C (100°F). Upon examination, he has significant epigastric tenderness, and hypoactive bowel sounds. Serum lipase and amylase are elevated and the patient rapidly deteriorates, requiring transfer to the intensive care unit for a month. After being stabilized, he is transferred to the general medicine floor with an abdominal computed tomography (CT) reporting a well-circumscribed collection of fluid of homogeneous density. Which of the following best describes the condition this patient has developed?
- A. Acute necrotic collection
- B. Fistula formation
- C. Walled-off necrosis
- D. Pancreatic pseudocyst (Correct Answer)
- E. Pancreatic cancer
Acute pancreatitis management Explanation: ***Pancreatic pseudocyst***
- The patient experienced an episode of **severe acute pancreatitis**, followed by the development of a well-circumscribed collection of fluid with homogeneous density, which is characteristic of a **pancreatic pseudocyst**.
- **Pseudocysts** are collections of pancreatic fluid and inflammatory exudates that become encapsulated by a fibrous wall, typically appearing around 4 weeks after an episode of acute pancreatitis.
*Acute necrotic collection*
- An **acute necrotic collection** is an early phase (within 4 weeks) of peripancreatic fluid collection that contains both fluid and non-viable pancreatic or peripancreatic tissue, which is not described as homogeneous in density.
- This term usually refers to the initial, unorganized collection of necrotic material, prior to the development of a well-defined wall.
*Fistula formation*
- **Fistula formation** involves an abnormal connection between two epithelialized organs or between an organ and the skin, which is not described by a well-circumscribed fluid collection.
- While it can be a complication of pancreatitis, the CT finding of a homogeneous fluid collection does not directly indicate a fistula.
*Walled-off necrosis*
- **Walled-off necrosis (WON)** is a mature collection (typically >4 weeks) of pancreatic and/or peripancreatic necrotic tissue that has developed a well-defined inflammatory wall but contains a significant solid/necrotic component.
- The CT description of a "homogeneous density" fluid collection does not align with WON, which would typically show heterogeneous density due to solid necrotic debris.
*Pancreatic cancer*
- **Pancreatic cancer** is an abnormal growth of cells within the pancreas and would typically present as a mass lesion, often with tissue invasion.
- While a pseudocyst can sometimes mimic a cystic tumor, the history of acute pancreatitis and the specific CT description of a homogeneous fluid collection make pancreatic cancer less likely in this context.
Acute pancreatitis management 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
Acute pancreatitis management 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.
Acute pancreatitis management US Medical PG Question 6: 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
Acute pancreatitis management 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.
Acute pancreatitis management US Medical PG Question 7: A 27-year-old-man is brought to the emergency department 30 minutes after being involved in a motorcycle accident. He lost control at high speed and was thrown forward onto the handlebars. On arrival, he is alert and responsive. He has abdominal pain and superficial lacerations on his left arm. Vital signs are within normal limits. Examination shows a tender, erythematous area over his epigastrium. The abdomen is soft and non-distended. A CT scan of the abdomen shows no abnormalities. Treatment with analgesics is begun, the lacerations are cleaned and dressed, and the patient is discharged home after 2 hours of observation. Four days later, the patient returns to the emergency department with gradually worsening upper abdominal pain, fever, poor appetite, and vomiting. His pulse is 91/min and blood pressure is 135/82 mm Hg. Which of the following is the most likely diagnosis?
- A. Abdominal compartment syndrome
- B. Aortic dissection
- C. Splenic rupture
- D. Pancreatic ductal injury (Correct Answer)
- E. Diaphragmatic rupture
Acute pancreatitis management Explanation: ***Pancreatic ductal injury***
- A forceful impact to the **epigastrium** (e.g., falling onto handlebars) can cause **pancreatic injury**, particularly a **ductal transection**, due to the pancreas being compressed against the vertebral column.
- Initial CT scans can be normal because the injury to the **ductal system** takes time to manifest, leading to delayed symptoms like **worsening abdominal pain, fever, vomiting**, and **poor appetite** several days later due to **pancreatitis** or a **pseudocyst** formation.
*Abdominal compartment syndrome*
- This typically presents with **acute abdominal distension**, increased intra-abdominal pressure, and organ dysfunction (e.g., oliguria, respiratory compromise), which are not described here.
- It's an immediate complication of severe trauma or fluid resuscitation, not a delayed presentation like described.
*Aortic dissection*
- Characterized by **sudden-onset, severe, tearing chest or back pain** and often involves hypertension or Marfan syndrome.
- It would manifest immediately with hemodynamic instability and distinct pain, not a delayed presentation of progressive abdominal symptoms.
*Splenic rupture*
- Often causes **left upper quadrant pain**, **Kehr's sign** (referred shoulder pain), and **hemodynamic instability** due to significant blood loss.
- While possible in trauma, a normal initial CT scan makes this less likely, and its symptoms usually appear earlier or are more severe.
*Diaphragmatic rupture*
- Can present with **dyspnea, shoulder pain**, or signs of **herniated abdominal organs** into the chest.
- It causes more immediate respiratory distress or gastrointestinal obstruction symptoms, and the abdominal symptoms described are not typical for this injury.
Acute pancreatitis management US Medical PG Question 8: A 68-year-old man presents to the emergency department with left lower quadrant abdominal pain and fever for 1 day. He states during this time frame he has had weight loss and a decreased appetite. The patient had surgery for a ruptured Achilles tendon 1 month ago and is still recovering but is otherwise generally healthy. His temperature is 102°F (38.9°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is remarkable for an uncomfortable and thin man with left lower quadrant abdominal tenderness without rebound findings. Fecal occult test for blood is positive. Laboratory studies are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 3,500/mm^3 with normal differential
Platelet count: 157,000/mm^3
Which of the following is the most appropriate next step in management?
- A. Ceftriaxone and metronidazole
- B. Ciprofloxacin and metronidazole
- C. Colonoscopy
- D. CT abdomen (Correct Answer)
- E. MRI abdomen
Acute pancreatitis management Explanation: ***CT abdomen***
- A **CT scan of the abdomen and pelvis** is the most appropriate initial diagnostic step for acute left lower quadrant pain with fever, leukopenia, and a positive fecal occult blood test, as it can efficiently evaluate for **diverticulitis**, bowel perforation, or **colonic malignancy**.
- The patient's presentation with constitutional symptoms like **weight loss and decreased appetite** in an older male, along with signs of anemia and occult blood, raises concern for **colorectal cancer**, making imaging a critical next step to differentiate potential etiologies.
*Ceftriaxone and metronidazole*
- While this is a common antibiotic regimen for suspected **diverticulitis**, it should not be initiated without definitive imaging, especially given the patient's concerning systemic symptoms and signs of **anemia and occult bleeding**, which could indicate a more serious underlying condition.
- Empirical antibiotic therapy without a clear diagnosis could delay the identification of conditions like **colorectal cancer** or abscess, which require different management strategies.
*Ciprofloxacin and metronidazole*
- This is also a typical antibiotic combination for uncomplicated **diverticulitis**; however, giving antibiotics without confirmation of the diagnosis via imaging is inappropriate in this case due to the patient's **systemic symptoms** and signs of **GI bleeding**.
- Without imaging to rule out intestinal perforation or malignancy, starting antibiotics could mask symptoms or delay crucial diagnostic and therapeutic interventions.
*Colonoscopy*
- A **colonoscopy** is indicated to investigate the **positive fecal occult blood** and rule out colorectal malignancy, but it is generally *contraindicated* in the acute setting of suspected diverticulitis due to the risk of **perforation**.
- Imaging (like CT) should always precede colonoscopy when acute abdominal pain and inflammation are present to assess for safety and guide the timing of endoscopy.
*MRI abdomen*
- While **MRI provides excellent soft tissue delineation**, it is typically not the first-line imaging modality for acute abdominal pain presentations in the emergency department.
- **CT scans are faster, more readily available**, and provide comprehensive imaging of the bowel, mesentery, and surrounding structures, making them superior for initial evaluation of acute abdominal conditions like diverticulitis or perforation.
Acute pancreatitis management US Medical PG Question 9: A 75-year-old man presents to the emergency department for abdominal pain. The patient states the pain started this morning and has been worsening steadily. He decided to come to the emergency department when he began vomiting. The patient has a past medical history of obesity, diabetes, alcohol abuse, and hypertension. His current medications include captopril, insulin, metformin, sodium docusate, and ibuprofen. His temperature is 104.0°F (40°C), blood pressure is 160/97 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Abdominal exam reveals left lower quadrant tenderness. Cardiac exam reveals a crescendo systolic murmur heard best by the right upper sternal border. Lab values are ordered and return as below.
Hemoglobin: 15 g/dL
Hematocrit: 42%
Leukocyte count: 19,500 cells/mm^3 with normal differential
Platelet count: 226,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 101 mEq/L
K+: 4.4 mEq/L
HCO3-: 24 mEq/L
BUN: 22 mg/dL
Glucose: 144 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 9.8 mg/dL
Which of the following is the most accurate test for this patient's condition?
- A. Colonoscopy
- B. Sigmoidoscopy
- C. Amylase and lipase levels
- D. Barium enema
- E. CT scan (Correct Answer)
Acute pancreatitis management Explanation: ***CT scan***
- The patient presents with classic symptoms of **diverticulitis**, including **left lower quadrant pain**, **fever**, and **leukocytosis**. A **CT scan with oral and IV contrast** is the most accurate diagnostic test to identify diverticular inflammation, abscess formation, or perforation.
- A CT scan can also help rule out other causes of abdominal pain and guide further management, such as the need for percutaneous drainage of an abscess.
*Colonoscopy*
- **Colonoscopy is contraindicated during an acute episode of diverticulitis** due to the risk of **perforation** of an inflamed colon.
- It may be considered **6-8 weeks after resolution of acute diverticulitis** to investigate for other pathologies such as malignancy.
*Sigmoidoscopy*
- Similar to colonoscopy, **sigmoidoscopy is generally avoided in acute diverticulitis** because of the risk of **perforation** of the inflamed bowel from instrumentation.
- Its diagnostic yield in acute settings is also limited compared to CT imaging.
*Amylase and lipase levels*
- These tests are primarily used to diagnose **pancreatitis**, which typically presents with **epigastric pain radiating to the back**, often associated with elevated enzyme levels.
- While vomiting is present, the **left lower quadrant tenderness and fever** point away from pancreatitis as the primary diagnosis.
*Barium enema*
- **Barium enema is generally contraindicated in acute diverticulitis** due to the risk of **perforation** and the introduction of barium into the peritoneum, which can cause severe peritonitis.
- It has largely been replaced by **CT scanning** for its superior safety profile and diagnostic accuracy in acute abdominal conditions.
Acute pancreatitis management US Medical PG Question 10: A 55-year-old man presents to the emergency department with nausea and vomiting. The patient states that he has felt nauseous for the past week and began vomiting last night. He thought his symptoms would resolve but decided to come in when his symptoms worsened. He feels that his symptoms are exacerbated with large fatty meals and when he drinks alcohol. His wife recently returned from a cruise with symptoms of vomiting and diarrhea. The patient has a past medical history of poorly managed diabetes, constipation, anxiety, dyslipidemia, and hypertension. His temperature is 99.5°F (37.5°C), blood pressure is 197/128 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals a systolic murmur heard loudest along the left upper sternal border. Abdominal exam reveals an obese, tympanitic and distended abdomen with a 3 cm scar in the right lower quadrant. Vascular exam reveals weak pulses in the lower extremities. Which of the following is the most likely diagnosis?
- A. Enteric nervous system damage
- B. Twisting of the bowel
- C. Adhesions (Correct Answer)
- D. Norovirus
- E. Impacted stool
Acute pancreatitis management Explanation: ***Adhesions***
- The patient's history of a 3 cm scar in the right lower quadrant suggests a prior abdominal surgery, which is the most common cause of **intra-abdominal adhesions**.
- **Adhesions** can lead to **small bowel obstruction**, causing symptoms like nausea, vomiting, abdominal distension, and tympany, which are all present in this patient.
*Enteric nervous system damage*
- Poorly managed diabetes can cause **diabetic gastroparesis**, which involves damage to the **enteric nervous system** leading to delayed gastric emptying.
- While it can cause nausea and vomiting, it doesn't typically present with significant abdominal distension or tympany, which are indicative of a mechanical obstruction.
*Twisting of the bowel*
- **Volvulus**, or twisting of the bowel, causes acute abdominal pain, distension, and often complete obstruction.
- While it's a possibility for bowel obstruction, the presence of a surgical scar and gradual worsening of symptoms over a week makes **adhesions** a more likely cause in this scenario.
*Norovirus*
- **Norovirus** is a common cause of acute gastroenteritis, characterized by abrupt onset of vomiting and diarrhea, often with a rapid resolution.
- Although his wife has similar symptoms, the patient's symptoms have been ongoing for a week, are exacerbated by fatty meals, and include abdominal distension, which is inconsistent with typical norovirus infection.
*Impacted stool*
- **Fecal impaction** can cause constipation, abdominal pain, and sometimes paradoxical diarrhea.
- While the patient has a history of constipation, the significant **tympanic distension** and persistent vomiting suggest a mechanical obstruction rather than just impacted stool.
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