A patient presents with acute epigastric pain and an increase in serum lipase. Several days after stabilization, a chest X-ray shows bilateral diffuse infiltrates. What is the most common pathology explaining the chest X-ray findings?
Q2
A 48-year old man comes to the physician for the evaluation of an 8-month history of fatigue and profuse, watery diarrhea. He reports that he has had a 10.5-kg (23-lb) weight loss during this time. Physical examination shows conjunctival pallor and poor skin turgor. Laboratory studies show:
Hemoglobin 9.8 g/dl
Serum
Glucose (fasting) 130 mg/dl
K+ 2.5 mEq/L
Ca2+ 12 mg/dl
A CT scan of the abdomen with contrast shows a 3.0 × 3.2 × 4.4 cm, well-defined, enhancing lesion in the pancreatic tail. Further evaluation of this patient is most likely to show which of the following findings?
Q3
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?
Q4
An 82-year-old woman presents with 2 months of foul-smelling, greasy diarrhea. She says that she also has felt very tired recently and has had some associated bloating and flatus. She denies any recent abdominal pain, nausea, melena, hematochezia, or vomiting. She also denies any history of recent travel and states that her home has city water. Which of the following tests would be most appropriate to initially work up the most likely diagnosis in this patient?
Q5
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?
Pancreatitis US Medical PG Practice Questions and MCQs
Question 1: A patient presents with acute epigastric pain and an increase in serum lipase. Several days after stabilization, a chest X-ray shows bilateral diffuse infiltrates. What is the most common pathology explaining the chest X-ray findings?
A. Increased PCWP
B. Pulmonary thromboembolism
C. Non-cardiogenic pulmonary edema (Correct Answer)
D. Aspiration pneumonitis
E. Pleural effusion
Explanation: ***Non-cardiogenic pulmonary edema***
- The patient's presentation with **acute epigastric pain** and **elevated serum lipase** is consistent with **acute pancreatitis**, which is a known cause of **ARDS (acute respiratory distress syndrome)**.
- The chest X-ray findings of **bilateral diffuse infiltrates** without signs of cardiomegaly or pleural effusions are characteristic of **non-cardiogenic pulmonary edema** caused by ARDS.
- ARDS complicates approximately **10-20% of severe acute pancreatitis cases** and presents with hypoxemia and bilateral pulmonary infiltrates.
*Increased PCWP*
- **Increased pulmonary capillary wedge pressure (PCWP)** is characteristic of **cardiogenic pulmonary edema**, where a failing heart causes increased pressure in the lungs.
- The X-ray findings and clinical context of pancreatitis suggest a **non-cardiac cause** for the pulmonary edema, and PCWP would be **normal or low in ARDS**.
*Pulmonary thromboembolism*
- **Pulmonary embolism (PE)** often presents with **dyspnea, pleuritic chest pain**, and sometimes **tachycardia** or **hemoptysis**.
- Chest X-rays in PE are often **normal** or show subtle findings like **Westermark sign** or **Hampton's hump**, which are not seen here.
- The **bilateral diffuse infiltrates** are not typical of PE.
*Aspiration pneumonitis*
- **Aspiration pneumonitis** typically occurs in patients with impaired consciousness or dysphagia and usually presents with infiltrates in **dependent lung segments**, often the right lower lobe.
- While pancreatitis can lead to nausea and vomiting, the **diffuse and bilateral** nature of the infiltrates is less typical for a primary aspiration event.
*Pleural effusion*
- **Pleural effusions** are a common complication of acute pancreatitis (occurring in up to **20% of cases**), typically left-sided or bilateral.
- However, the described chest X-ray findings of **bilateral diffuse infiltrates** represent **parenchymal disease**, not simply fluid in the pleural space.
- Pleural effusions would appear as **blunting of costophrenic angles** or fluid layering, not diffuse infiltrates.
Question 2: A 48-year old man comes to the physician for the evaluation of an 8-month history of fatigue and profuse, watery diarrhea. He reports that he has had a 10.5-kg (23-lb) weight loss during this time. Physical examination shows conjunctival pallor and poor skin turgor. Laboratory studies show:
Hemoglobin 9.8 g/dl
Serum
Glucose (fasting) 130 mg/dl
K+ 2.5 mEq/L
Ca2+ 12 mg/dl
A CT scan of the abdomen with contrast shows a 3.0 × 3.2 × 4.4 cm, well-defined, enhancing lesion in the pancreatic tail. Further evaluation of this patient is most likely to show which of the following findings?
A. Achlorhydria (Correct Answer)
B. Cholelithiasis
C. Deep vein thrombosis
D. Hyperinsulinemia
E. Episodic hypertension
Explanation: ***Achlorhydria***
- The patient's symptoms (profuse watery diarrhea, hypokalemia, hyperglycemia, hypercalcemia, and a pancreatic tail mass) are highly suggestive of a **VIPoma (vasoactive intestinal peptide-secreting tumor)**.
- VIP acts on gastric parietal cells to inhibit the secretion of gastric acid, leading to **achlorhydria** or **hypochlorhydria**.
*Cholelithiasis*
- While sometimes associated with neuroendocrine tumors, **cholelithiasis** is not a primary or direct effect of VIP excess.
- It would not explain the constellation of symptoms, particularly the severe watery diarrhea, hypokalemia, and disturbances in glucose and calcium.
*Deep vein thrombosis*
- **Deep vein thrombosis (DVT)** is a known complication of various malignancies, including some neuroendocrine tumors (e.g., pancreatic adenocarcinoma), but it is not a specific or direct consequence of VIPoma.
- The patient's primary symptoms are related to fluid and electrolyte imbalance and endocrine dysregulation.
*Hyperinsulinemia*
- The patient presents with **hyperglycemia** (fasting glucose 130 mg/dL), which indicates impaired glucose metabolism, not hyperinsulinemia.
- While insulinomas cause hyperinsulinemia, VIPomas typically lead to hyperglycemia due to VIP's diabetogenic effects.
*Episodic hypertension*
- **Episodic hypertension** is characteristic of **pheochromocytoma**, a different type of neuroendocrine tumor arising from the adrenal medulla.
- VIPomas do not typically cause hypertension; their main effects are on gut motility, secretion, and electrolyte balance.
Question 3: 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
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.
Question 4: An 82-year-old woman presents with 2 months of foul-smelling, greasy diarrhea. She says that she also has felt very tired recently and has had some associated bloating and flatus. She denies any recent abdominal pain, nausea, melena, hematochezia, or vomiting. She also denies any history of recent travel and states that her home has city water. Which of the following tests would be most appropriate to initially work up the most likely diagnosis in this patient?
A. Fecal fat test (Correct Answer)
B. Tissue transglutaminase antibody test
C. Stool O&P
D. Stool guaiac test
E. CT of the abdomen with oral contrast
Explanation: ***Fecal fat test***
- The patient's symptoms of **foul-smelling, greasy diarrhea**, along with **fatigue, bloating, and flatus**, strongly suggest **malabsorption**, specifically **steatorrhea** (excess fat in stool).
- A **fecal fat test** (e.g., Sudan stain or 72-hour quantitative stool fat collection) directly assesses fat malabsorption and would be the most appropriate initial diagnostic test.
*Tissue transglutaminase antibody test*
- This test is used to screen for **celiac disease**, which can cause malabsorption symptoms.
- While celiac disease is a possibility, a fecal fat test is a more general and appropriate initial step to confirm fat malabsorption before looking for specific causes.
*Stool O&P*
- Stands for **Stool Ova and Parasites**, used to detect parasitic infections like **Giardia** or **Cryptosporidium**, which can cause diarrhea.
- However, the absence of recent travel, city water, and the prominent greasy nature of the stool make this less likely as the primary initial investigation compared to confirming malabsorption.
*Stool guaiac test*
- This test detects **occult blood in stool**.
- The patient denies **melena or hematochezia**, and there are no signs pointing to gastrointestinal bleeding, making this test irrelevant for her presenting symptoms.
*CT of the abdomen with oral contrast*
- A CT scan with contrast might be used to investigate structural abnormalities or inflammation if other tests confirm malabsorption or point to a specific organ pathology (e.g., pancreatitis, Crohn's disease).
- It's an imaging study and generally not the most appropriate *initial* test for evaluating the described symptoms of malabsorption.
Question 5: 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
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.
