Abdomen: Liver, GB, Panc and Spleen

Question 1

What is the mechanism of hypotension in severe cases of acute pancreatitis?

Answer 1

Fluid sequestration in the intestine and retroperitoneum, systemic vascular effects of kinins and TNF, vomiting and bleeding.

Question 2

T/F: Idiopathic acute pancreatitis may be the result of occult biliary microlithiasis or biliary sludge.

Answer 2

True

Question 3

When and where is iatrogenic injury to the common bile duct most common?

Answer 3

During laparoscopic cholecystectomy at the triangle of calot.

Question 4

What is the most common type of lipid profile associated with pancreatitis?

Answer 4

Type V - hypertriglyceridemia

Question 5

What is the optimal method of determining whether a pancreatic phlegmon is infected?

Answer 5

CT scan to look for retroperitoneal air and CT guided aspiration of fluid for culture.

Question 6

What is the treatment for infected pancreatic phlegmon?

Answer 6

Pancreatic necrosectomy with wide retroperitoneal drainage. It should be done as soon as the diagnosis is made to reduce the risk of ARDS and septic shock.

Question 7

How does excess lipid promote pancreatitis?

Answer 7

By the toxic action of fatty acids released by lipase in the pancreas.

Question 8

What is the role of abdominal ultrasound in pancreatitis?

Answer 8

Detection of biliary obstruction and evaluation of pseudocysts.

Question 9

What percentage of common bile duct stones pass spontaneously?

Answer 9

90%

Question 10

What should be the initial management of gallstone pancreatitis?

Answer 10

Hospital admission, NPO status, and IV hydration. Observe bilirubin and pancreatic enzymes for evidence of stone passage in first 24 to 36 hours. If no evidence of passage or evidence of cholangitis exists, then ercp is the next step to relieve biliary obstruction. If a stone clinically passes, perform lap coli with cholangiogram. If pancreatitis is severe, operation should ideally be delayed until improvement unless biliary obstruction refractory to ercp stone extraction is present.

Question 11

What are the management options for a common bile duct stone detected during laparoscopic cholecystectomy cholangiogram?

Answer 11

Laparoscopic basket retrieval, Fogarty balloon retrieval, forcibly inject saline to push out ampulla, post-operative ercp, and laparoscopic or open common bile duct exploration.

Question 12

What are the ranson’s criteria for severity in biliary pancreatitis on admission?

Answer 12

Age greater than 70, WBC greater than 18, glucose greater than 220, LDH greater than 400, and AST greater than 250.

Question 13

What are the ranson’s criteria for severity in non biliary pancreatitis at 48 hours?

Answer 13

Fall in hematocrit greater than 10%, rise in BUN greater than 5%, serum calcium less than 8, pao2 less than 60, base deficit greater than 4, and fluid sequestration greater than 6 liters.

Question 14

Should antibiotics be given empirically to patients with severe pancreatitis?

Answer 14

Yes. Imipenem is the most popular choice.

Question 15

What single-agent regimen does the surgical infection Society guidelines call for in relation to enter abdominal infections?

Answer 15

Cefoxitin, cefotetan, ampicillin sulbactam, ticarcillin clavulanic acid, meropenem, piperacillin tazobactam, imipenem cilastatin.

Question 16

What combination regimens do the surgical infection Society guidelines call for in relation to an intraabdominal infection?

Answer 16

Cefuroxime plus metronidazole, 3rd or 4th Gen cephalosporin plus antianaerobe, aztreonam plus clindamycin, ciprofloxacin plus metronidazole, aminoglycoside plus clinda or metro.