Pancreatic cancer risk in chronic pancreatitis — MCQs

10 questions

A 62-year-old man presents with “yellowing” of the skin. He says he has been having intermittent upper abdominal pain, which is relieved by Tylenol. He also recalls that he has lost some weight over the past several months but can not quantify the amount. His past medical history is significant for type 2 diabetes mellitus. He reports a 40-pack-year smoking history. The patient is afebrile and vital signs are within normal limits. Physical examination reveals mild jaundice and a palpable gallbladder. Laboratory findings are significant for the following: Total bilirubin 13 mg/dL Direct bilirubin: 10 mg/dL Alkaline phosphatase (ALP): 560 IU/L An ultrasound of the abdomen reveals a hypoechoic mass in the epigastric region. The patient is scheduled for a CT abdomen and pelvis with specific organ protocol for further evaluation. Which of the following best describes this patient’s most likely diagnosis?

Researchers are investigating oncogenes, specifically the KRAS gene that is associated with colon, lung, and pancreatic cancer. They have established that the gain-of-function mutation in this gene increases the chance of cancer development. They are also working to advance the research further to study tumor suppressor genes. Which of the genes below is considered a tumor suppressor gene?

A 70-year-old male visits his primary care physician because of progressive weight loss. He has a 20-year history of smoking 2 packs of cigarettes a day and was diagnosed with diabetes mellitus 6 years ago. After physical examination, the physician tells the patient he suspects adenocarcinoma at the head of the pancreas. Which of the following physical examination findings would support the diagnosis?

A 55-year old man living in Midwest USA comes in complaining of painless hematuria for the past week. He denies dysuria but complains of fatigue and lethargy at work. He has lost about 9.0 kg (20.0 lb) in the past 6 months. He drinks 1–2 beers on the weekends over the past 10 years but denies smoking. He has worked at a plastic chemical plant for the past 30 years and has never been out of the country. His father died of a heart attack at age 62 and his mother is still alive and well. There is a distant history of pancreatic cancer, but he can not remember the specifics. His vitals are stable and his physical exam is unremarkable. Urinary analysis is positive for RBCs. A cystoscopy is performed and finds a pedunculated mass projecting into the bladder lumen. A biopsy shows malignant cells. Which of the following is the most concerning risk factor for this patient’s condition?

A 42-year-old man comes to the physician because of a 6-week history of intermittent fever, abdominal pain, bloody diarrhea, and sensation of incomplete rectal emptying. He also has had a 4.5-kg (10-lb) weight loss over the past 3 months. Abdominal examination shows diffuse tenderness. Colonoscopy shows circumferential erythematous lesions that extend without interruption from the anal verge to the cecum. A biopsy specimen taken from the rectum shows mucosal and submucosal inflammation with crypt abscesses. This patient is most likely at risk of developing colon cancer with which of the following characteristics?

A 46-year-old woman presents to her primary care physician for her annual examination. At her prior exam one year earlier, she had a Pap smear which was within normal limits. Which of the following health screenings is recommended for this patient?

A 62-year-old Caucasian man visits his primary care provider with recurrent episodes of moderate to severe abdominal pain, nausea, and anorexia for the past 2 years. Additional complaints include constipation, steatorrhea, weight loss, polyphagia, and polyuria. His personal history is relevant for a 2-year period of homelessness when the patient was 55 years old, cigarette smoking since the age of 20, alcohol abuse, and cocaine abuse for which is currently under the supervision of a psychiatry team. He has a pulse of 70/min, a respiratory rate of 16/min, a blood pressure of 130/70 mm Hg, and a body temperature of 36.4°C (97.5°F). His height is 178 cm (5 ft 10 in) and weight is 90 kg (198 lb). On physical examination, he is found to have telangiectasias over the anterior chest, mild epigastric tenderness, and a small nodular liver. Laboratory test results from his previous visit a month ago are shown below: Fasting plasma glucose 160 mg/dL HbA1c 8% Serum triglycerides 145 mg/dL Total cholesterol 250 mg/dL Total bilirubin 0.8 mg/dL Direct bilirubin 0.2 mg/dL Amylase 180 IU/L Lipase 50 IU/L Stool negative for blood; low elastase This patient’s condition is most likely secondary to which of the following conditions?

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 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?

Q10

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?

Pancreatic cancer risk in chronic pancreatitis US Medical PG Practice Questions and MCQs

Question 1: A 62-year-old man presents with “yellowing” of the skin. He says he has been having intermittent upper abdominal pain, which is relieved by Tylenol. He also recalls that he has lost some weight over the past several months but can not quantify the amount. His past medical history is significant for type 2 diabetes mellitus. He reports a 40-pack-year smoking history. The patient is afebrile and vital signs are within normal limits. Physical examination reveals mild jaundice and a palpable gallbladder. Laboratory findings are significant for the following: Total bilirubin 13 mg/dL Direct bilirubin: 10 mg/dL Alkaline phosphatase (ALP): 560 IU/L An ultrasound of the abdomen reveals a hypoechoic mass in the epigastric region. The patient is scheduled for a CT abdomen and pelvis with specific organ protocol for further evaluation. Which of the following best describes this patient’s most likely diagnosis?

A. Caffeine consumption is an established risk factor for this condition.
B. Patients with this condition often rapidly develop glucose intolerance and severe diabetes.
C. This condition is most common in Caucasians.
D. The majority of cases occur in the body of the pancreas.
E. CA 19-9 is a marker for this condition. (Correct Answer)

Explanation: ***CA 19-9 is a marker for this condition.*** - The patient's presentation with **painless jaundice**, **weight loss**, **palpable gallbladder (Courvoisier's sign)**, and markedly elevated **direct bilirubin** and **ALP** strongly suggests **pancreatic head adenocarcinoma**, which obstructs the common bile duct [1]. - **CA 19-9** is a widely used and clinically relevant tumor marker for **pancreatic cancer**, though its utility is primarily for monitoring treatment response and recurrence rather than initial diagnosis. *Caffeine consumption is an established risk factor for this condition.* - **Smoking**, not caffeine consumption, is a significant and well-established **risk factor for pancreatic cancer**, aligning with the patient's 40-pack-year history. - Other risk factors include **chronic pancreatitis**, **obesity**, **diabetes**, and certain **hereditary syndromes** [1]. *Patients with this condition often rapidly develop glucose intolerance and severe diabetes.* - While pancreatic cancer can cause **new-onset diabetes** or worsen pre-existing diabetes, this is typically a **consequence of the tumor** affecting pancreatic islet cells, not a characteristic of its development [1]. - The patient already has a history of **type 2 diabetes mellitus**, which is a *risk factor* for pancreatic cancer. *This condition is most common in Caucasians.* - **Pancreatic cancer** shows a slightly higher incidence in **African Americans** compared to Caucasians. - The incidence generally **increases with age** and is more common in males. *The majority of cases occur in the body of the pancreas.* - Approximately **60-70% of pancreatic adenocarcinomas** occur in the **head of the pancreas**, consistent with the patient's presentation of obstructive jaundice and a palpable gallbladder [1]. - Tumors in the body or tail are less likely to present with jaundice early as they do not obstruct the bile duct.

Question 2: Researchers are investigating oncogenes, specifically the KRAS gene that is associated with colon, lung, and pancreatic cancer. They have established that the gain-of-function mutation in this gene increases the chance of cancer development. They are also working to advance the research further to study tumor suppressor genes. Which of the genes below is considered a tumor suppressor gene?

A. Her2/neu
B. BRAF
C. BCL-2
D. JAK2
E. Rb (Correct Answer)

Explanation: ***Rb*** - The **retinoblastoma (Rb)** gene is a classic example of a **tumor suppressor gene**. Its protein product, Rb, plays a critical role in regulating the **cell cycle** by preventing uncontrolled cell division. - When **Rb is mutated or inactivated**, cells can divide without proper checks, leading to tumor formation, particularly in cases like retinoblastoma. *Her2/neu* - **Her2/neu** (also known as ERBB2) is an **oncogene** that encodes a receptor tyrosine kinase involved in cell growth and differentiation. - Its overexpression or amplification is associated with certain cancers, notably **breast cancer**, but it is not a tumor suppressor. *BRAF* - **BRAF** is an **oncogene** that codes for a serine/threonine kinase involved in the RAS/MAPK signaling pathway, which regulates cell growth. - **Gain-of-function mutations** in BRAF are frequently found in melanoma, thyroid cancer, and colorectal cancer, promoting uncontrolled cell proliferation. *BCL-2* - **BCL-2** is an **anti-apoptotic gene**, meaning it prevents programmed cell death. While its overexpression can contribute to cancer by allowing abnormal cells to survive, it is not classified as a tumor suppressor gene. - Instead, BCL-2 is considered an **oncogene** because mutations or overexpression promote cell survival and inhibit apoptosis. *JAK2* - **JAK2** (Janus Kinase 2) is a **proto-oncogene** encoding a tyrosine kinase involved in cytokine receptor signaling, which regulates hematopoiesis. - **Gain-of-function mutations**, such as JAK2 V617F, are frequently found in **myeloproliferative neoplasms** (e.g., polycythemia vera, essential thrombocythemia, myelofibrosis), leading to uncontrolled blood cell production.

Question 3: A 70-year-old male visits his primary care physician because of progressive weight loss. He has a 20-year history of smoking 2 packs of cigarettes a day and was diagnosed with diabetes mellitus 6 years ago. After physical examination, the physician tells the patient he suspects adenocarcinoma at the head of the pancreas. Which of the following physical examination findings would support the diagnosis?

A. Lymphadenopathy of the umbilicus
B. Splenomegaly
C. Acanthosis nigricans
D. Palpable gallbladder (Correct Answer)
E. Renal artery bruits

Explanation: ***Palpable gallbladder*** - A palpable, non-tender gallbladder in the presence of **jaundice** (often caused by obstruction of the common bile duct) is known as **Courvoisier's sign**, which is highly suggestive of pancreatic head adenocarcinoma. - The tumor in the head of the pancreas can compress the distal common bile duct, leading to bile stasis and gallbladder distension. *Lymphadenopathy of the umbilicus* - **Umbilical lymphadenopathy**, specifically a **Sister Mary Joseph nodule**, indicates distant metastatic disease, often from intra-abdominal cancers like gastrointestinal or ovarian. - While it points to an advanced malignancy, it is not a direct physical finding specific for initial suspicion of primary pancreatic head adenocarcinoma. *Splenomegaly* - **Splenomegaly** can be a feature of pancreatic cancer if there is splenic vein thrombosis due to tumor invasion, leading to **portal hypertension**. - However, it is not a primary sign of pancreatic head adenocarcinoma and typically occurs in more advanced or specific cases. *Acanthosis nigricans* - **Acanthosis nigricans** is characterized by hyperpigmented, velvety plaques, often in skin folds, and can be a paraneoplastic syndrome associated with various malignancies, including pancreatic cancer. - While possible, it is a less direct and less specific sign for pancreatic head adenocarcinoma compared to Courvoisier's sign. *Renal artery bruits* - **Renal artery bruits** indicate turbulent blood flow through the renal arteries, most commonly due to **renal artery stenosis**, which can cause hypertension. - This finding is unrelated to pancreatic adenocarcinoma and would not support such a diagnosis.

Question 4: A 55-year old man living in Midwest USA comes in complaining of painless hematuria for the past week. He denies dysuria but complains of fatigue and lethargy at work. He has lost about 9.0 kg (20.0 lb) in the past 6 months. He drinks 1–2 beers on the weekends over the past 10 years but denies smoking. He has worked at a plastic chemical plant for the past 30 years and has never been out of the country. His father died of a heart attack at age 62 and his mother is still alive and well. There is a distant history of pancreatic cancer, but he can not remember the specifics. His vitals are stable and his physical exam is unremarkable. Urinary analysis is positive for RBCs. A cystoscopy is performed and finds a pedunculated mass projecting into the bladder lumen. A biopsy shows malignant cells. Which of the following is the most concerning risk factor for this patient’s condition?

A. Aromatic amine exposure (Correct Answer)
B. Alcohol
C. Vinyl chloride exposure
D. Genetic predisposition
E. Schistosoma haematobium infection

Explanation: ***Aromatic amine exposure*** - The patient's 30-year employment at a **plastic chemical plant** is a significant risk factor, as many chemicals used in such industries contain **aromatic amines**. - Exposure to **aromatic amines** is a well-established cause of **transitional cell carcinoma** of the bladder, which is consistent with the painless hematuria and the finding of a malignant bladder mass. *Alcohol* - While heavy alcohol consumption can contribute to various health issues, it is **not considered a direct or strong risk factor** for bladder cancer. - The patient's reported consumption of "1-2 beers on the weekends" over 10 years is relatively moderate and unlikely to be the primary cause of his severe presentation. *Vinyl chloride exposure* - **Vinyl chloride** exposure is primarily associated with **hepatic angiosarcoma** and, to a lesser extent, lung cancer and brain tumors. - It is **not a significant risk factor** for bladder cancer, differentiating it from the patient's presentation of a bladder mass. *Genetic predisposition* - While there can be a genetic component to some cancers, the familial history mentioned (father died of heart attack, distant history of pancreatic cancer) does **not specifically point to a strong genetic predisposition** for bladder cancer. - The powerful occupational exposure to chemicals is a much more direct and concerning risk factor in this case. *Schistosoma haematobium infection* - **Schistosoma haematobium** infection is a known cause of **squamous cell carcinoma** of the bladder, especially in endemic regions like parts of Africa and the Middle East. - The patient has **never been out of the country** and lives in the Midwest USA, making this infection highly unlikely.

Question 5: A 42-year-old man comes to the physician because of a 6-week history of intermittent fever, abdominal pain, bloody diarrhea, and sensation of incomplete rectal emptying. He also has had a 4.5-kg (10-lb) weight loss over the past 3 months. Abdominal examination shows diffuse tenderness. Colonoscopy shows circumferential erythematous lesions that extend without interruption from the anal verge to the cecum. A biopsy specimen taken from the rectum shows mucosal and submucosal inflammation with crypt abscesses. This patient is most likely at risk of developing colon cancer with which of the following characteristics?

A. Low-grade lesion
B. Unifocal lesion
C. Non-polypoid dysplasia (Correct Answer)
D. Late p53 mutation
E. Early APC mutation

Explanation: ***Non-polypoid dysplasia*** - The patient's symptoms (bloody diarrhea, abdominal pain, crypt abscesses, continuous inflammation extending to the cecum) are highly suggestive of **ulcerative colitis (UC)**. - In UC, the chronic inflammation causes a field defect across the colonic mucosa, leading to a higher risk of **non-polypoid (flat) dysplasia** and subsequent colon cancer (colitis-associated cancer). *Low-grade lesion* - While dysplasia can be low-grade, the primary characteristic of colon cancer development in UC is the **type of growth** (flat/non-polypoid) rather than simply its grade. - The presence and progression of **dysplasia** (regardless of initial grade) are critical for risk stratification in UC. *Unifocal lesion* - Colitis-associated cancer in UC often arises from widespread field changes due to chronic inflammation, making **multifocal or diffuse dysplasia** more common than a single, isolated lesion. - The diffuse nature of UC inflammation across the colon makes a unifocal cancerous change less typical compared to sporadic colon cancer. *Late p53 mutation* - **p53 mutations** are commonly found in colitis-associated colon cancer and are generally considered an **early event** in the progression from dysplasia to invasive carcinoma, rather than a late one. - Mutations in tumor suppressor genes like **p53** contribute to genomic instability early in the neoplastic process. *Early APC mutation* - **APC mutations** are a hallmark of **sporadic colorectal cancer** and familial adenomatous polyposis (FAP), where they typically initiate the adenoma-carcinoma sequence. - In **colitis-associated cancer**, APC mutations are less frequently the initiating event and often occur later, with other pathways (e.g., p53, microsatellite instability) being more prominent in early carcinogenesis.

Question 6: A 46-year-old woman presents to her primary care physician for her annual examination. At her prior exam one year earlier, she had a Pap smear which was within normal limits. Which of the following health screenings is recommended for this patient?

A. Colorectal screening (Correct Answer)
B. Blood glucose and/or HbA1c screening
C. Blood pressure at least once every 3 years
D. Yearly Pap smear
E. Bone mineral density screening

Explanation: ***Colorectal screening*** - **Colorectal cancer screening** is generally recommended to start at age **45 years** for individuals at average risk. - This patient is 46 years old, making immediate colorectal screening appropriate based on current guidelines. *Blood glucose and/or HbA1c screening* - **Blood glucose or HbA1c screening** for diabetes is recommended starting at age **35 for all adults** or earlier if there are risk factors such as obesity or a family history of diabetes. - While this patient is 46, this screening should have already been initiated, and it is not the *most* uniquely recommended screening for this specific age that might have been overlooked. *Blood pressure at least once every 3 years* - **Blood pressure screening** should be performed **at least annually** for adults aged 40 and older, or more frequently if there are risk factors. - Screening only every 3 years is insufficient for a 46-year-old patient. *Yearly Pap smear* - **Pap smear frequency** has changed; for women aged 30-65 with normal results, screening is recommended every **3 years** with cytology alone, or every 5 years with high-risk HPV testing alone or co-testing. - A yearly Pap smear is no longer typical practice for a woman with normal prior results and no specific risk factors. *Bone mineral density screening* - **Bone mineral density (BMD) screening** for osteoporosis is typically recommended for women starting at age **65 years** or earlier if they have significant risk factors. - This patient is 46 years old and has no mentioned risk factors, so BMD screening is not routinely indicated at this age.

Question 7: A 62-year-old Caucasian man visits his primary care provider with recurrent episodes of moderate to severe abdominal pain, nausea, and anorexia for the past 2 years. Additional complaints include constipation, steatorrhea, weight loss, polyphagia, and polyuria. His personal history is relevant for a 2-year period of homelessness when the patient was 55 years old, cigarette smoking since the age of 20, alcohol abuse, and cocaine abuse for which is currently under the supervision of a psychiatry team. He has a pulse of 70/min, a respiratory rate of 16/min, a blood pressure of 130/70 mm Hg, and a body temperature of 36.4°C (97.5°F). His height is 178 cm (5 ft 10 in) and weight is 90 kg (198 lb). On physical examination, he is found to have telangiectasias over the anterior chest, mild epigastric tenderness, and a small nodular liver. Laboratory test results from his previous visit a month ago are shown below: Fasting plasma glucose 160 mg/dL HbA1c 8% Serum triglycerides 145 mg/dL Total cholesterol 250 mg/dL Total bilirubin 0.8 mg/dL Direct bilirubin 0.2 mg/dL Amylase 180 IU/L Lipase 50 IU/L Stool negative for blood; low elastase This patient’s condition is most likely secondary to which of the following conditions?

A. Hypertriglyceridemia
B. Alcohol abuse (Correct Answer)
C. Cocaine abuse
D. Hypercholesterolemia
E. Obesity

Explanation: ***Alcohol abuse*** - Chronic alcohol abuse is a major risk factor for **chronic pancreatitis**, which manifests with recurrent abdominal pain, steatorrhea, weight loss, and can lead to **diabetes mellitus** (polyphagia, polyuria, elevated fasting glucose and HbA1c). - The elevated amylase, although not diagnostic for chronic pancreatitis on its own, along with low stool elastase (indicating **pancreatic exocrine insufficiency**), telangiectasias (suggesting liver disease often associated with alcohol), and a nodular liver (pointing to **cirrhosis**), strongly support chronic pancreatitis secondary to alcohol. *Hypertriglyceridemia* - While severe hypertriglyceridemia (typically >1000 mg/dL) can cause acute pancreatitis, the patient's triglyceride level (145 mg/dL) is not high enough to be the cause of his chronic pancreatic issues. - Furthermore, chronic pancreatitis symptoms like steatorrhea and diabetes are better explained by long-term alcohol exposure. *Cocaine abuse* - Cocaine can cause **vasoconstriction** and ischemia, potentially leading to acute pancreatitis, but it is not a common cause of chronic pancreatitis with the constellation of symptoms observed here. - The clinical picture strongly aligns with the chronic effects of alcohol on the pancreas and liver. *Hypercholesterolemia* - While hypercholesterolemia (total cholesterol 250 mg/dL) is a risk factor for cardiovascular disease, it is not directly implicated in causing pancreatitis or liver disease in the way described. - It does not explain the recurrent abdominal pain, steatorrhea, or the development of diabetes and liver changes seen in this patient. *Obesity* - Obesity is a risk factor for various metabolic disorders, including type 2 diabetes and non-alcoholic fatty liver disease (NAFLD), but it is not a primary cause of chronic pancreatitis. - The specific signs of liver damage (telangiectasias, nodular liver) and the pancreatic exocrine insufficiency point away from obesity as the primary etiology for this patient's condition.

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

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.

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

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.

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

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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