05a: Da Pancreas

Question 1

Diagnosis of acute pancreatitis requires 2 out of which criteria?

Answer 1

1. Characteristic abd pain
2. Elevated serum lipase/amylase (3x ULN)
3. Characteristic imaging findings

Question 2

Characteristic pain in acute pancreatitis is quite similar to (X) pain, but is (exacerbated/alleviated) by (Y).

Answer 2

X = biliary cholic (acute onset, persistent and severe epigastric pain that radiates to back and exacerbated by eating)
Alleviated
Y = leaning forward

Question 3

(Lipase/amylase) elevation is more specific for acute pancreatitis. It stays elevated for (shorter/longer) period of time.

Answer 3

Lipase (can increase 10x normal!); longer (72-96h)

Question 4

Which imaging modalities used to diagnose acute pancreatitis? Star the preferred method.

Answer 4

CT*, MRI, US

Question 5

Most (50%) cases of acute pancreatitis are attributed to:

Answer 5

Gallstones

Question 6

Second most common cause of acute pancreatitis is:

Answer 6

EtOH (30%)

Question 7

Patient presenting with acute pancreatitis. Which finding is considered incredibly high predictor of gallstone etiology (95% PPV!)?

Answer 7

ALT elevated 3x ULN

Question 8

You diagnose patient with acute pancreatitis. What are your initial steps for therapy?

Answer 8

1. NPO
2. Analgesics
3. Early, aggressive IV fluid resuscitation

Question 9

Acute pancreatitis: IV fluids are preferentially (normal saline/lactate ringers) to prevent which complications?

Answer 9

Lactate ringers;

Metabolic acidosis and increased trypsinogen activation

Question 10

“BISAP” scoring system used to predict (X). What does it stand for?

Answer 10

X = severity of acute pancreatitis

BUN over 25 mg/dL
Impaired mental status
SIRS
Age over 60
Pleural effusion on imaging

Question 11

T/F: Like other zymogens, pancreatic amylase and lipase are secreted in inactive forms.

Answer 11

False

Question 12

Based on experimental models, the initiating event in acute pancreatitis is:

Answer 12

Intra-acinar conversion of trypsinogen to trypsin (resulting in acute intracell injury)

Question 13

T/F: The magnitude

of serum amylase/lipase elevation correlates with the severity of pancreatitis.

Answer 13

False

Question 14

Which two main complications of acute pancreatitis occur due to toxic materials (liberated by pancreas) reaching systemic circulation?

Answer 14

SIRS and MODS (multiple organ dysfunction syndrome)

Question 15

T/F: All pancreatic pseudocysts are removed to avoid infection/compression.

Answer 15

False - asymptomatic ones are just followed

Question 16

Fat necrosis is an example of (autodigestion/local spread/systemic spread) in acute pancreatitis.

Answer 16

Local spread

Question 17

(X) tool is useful for distinguishing between interstitial and necrotizing pancreatitis. What is the difference between these?

Answer 17

X = CT (with contrast)

Interstitial: intact microcirculation (uniform enhancement)
Necrotizing: disrupted microcirculation (large areas won’t enhance with contrast)

Question 18

(X) is the leading cause of mortality (80%) in acute pancreatitis.

Answer 18

X = infected necrosis

Question 19

Treatment of infected necrosis (in acute pancreatitis) includes which drugs?

Answer 19

Antibiotics that penetrate pancreatic necrosis:

Carbapenems, quinolones, metronidazole

Question 20

T/F: All patients with infected necrosis (secondary to acute pancreatitis) require debridement.

Answer 20

False - stable patients may only require antibiotics

Question 21

Mild pancreatitis: when should oral diet be restarted?

Answer 21

Immediately after resolution of pain, N/V (early re-feeding associated with short hospital stays, decreased complications)

Question 22

T/F: In severe pancreatitis, parenteral nutrition is preferred to avoid additional stress on the gut.

Answer 22

False! Enteral preferred;

TPN only if enteral route unavailable/not tolerated (higher risk of infection, organ failure, mortality)

Question 23

T/F: The changes in chronic pancreatitis are fibro-inflammatory and irreversible.

Answer 23

True

Question 24

Almost 75% of chronic pancreatitis is due to which etiology?

Answer 24

EtOH

Question 25

Three main clinical manifestations of chronic pancreatitis:

Answer 25

1. Abdominal pain (similar to that in acute pancreatitis)
2. Fat and fat-soluble vitamin malabsorption (exocrine insufficiency)
3. Diabetes (endocrine insufficiency)

Question 26

Which 3 main imaging methods used to diagnose chronic pancreatitis?

Answer 26

CT, MRCP, EUS

Question 27

(X) CT finding is pathognomonic (indicative of) chronic pancreatitis. Which other findings might be present?

Answer 27

X = calcifications in pancreas

Atrophy, fatty replacement, ductal dilation

Question 28

(X) imaging modality is excellent for evaluation of biliary/pancreatic duct changes in chronic pancreatitis.

Answer 28

X = MRCP

Question 29

(X) imaging modality is useful for detecting mild chronic pancreatitis (before radiographic abnormalities are evident).

Answer 29

X = EUS (Endoscopic ultrasound)

Question 30

Diabetes is a(n) (early/late) complication of chronic pancreatitis. About (X)% of gland is damaged when clinical diabetes becomes apparent.

Answer 30

Late;

X = 80-90

Question 31

(X) is the gold standard functional test for diagnosis of chronic pancreatitis.

Answer 31

X = secretin stimulation

With diagnostic decrease in HCO3 production, even in early pancreatitis

Question 32

(Fecal/serum) measurement of (X) is seen as superior to serum trympsinogen and fecal chymotrypsin in testing function of (Y).

Answer 32

Fecal
X = elastase
Y = pancreas (i.e. for chronic pancreatitis)

Question 33

Chronic pancreatitis Rx is focused on managing:

Answer 33

1. Pain

2. Exocrine/endocrine insufficiency

Question 34

Diet/supplementation in chronic pancreatitis involves:

Answer 34

1. Low fat diet
2. Vitamin and pancreatic enzyme supplementation
3. Diabetes control

Question 35

Patient with CKD and HCV infection can be treated with (X) combo for which genotypes?

Answer 35

X = Grazoprevir (NS3/4A inhibitor) and Elbasvir (NS5A inhibitor)

Genotypes 1 and 4

Question 36

Patient with decompensated cirrhosis and HCV (Genotype 2) should be treated with (X) drug combo, which covers which genotypes?

Answer 36

X = Velpatasvir (NS5Ai) and Sofosbuvir (NS5Bi)

All (1-6) genotype

Question 37

Patient with decompensated cirrhosis and HCV (Genotype 5) can be treated with (X) drug combo, which covers which SELECT genotypes?

Answer 37

X = Ledipasvir (NS5Ai) and Sofosbuvir (NS5Bi)

Genotypes 1,4-6