PANCREATITIS

Question 1

A 45-year-old male with a history of heavy alcohol consumption presents with severe upper abdominal pain, nausea, and vomiting. Laboratory tests show an elevated serum amylase and lipase. What is the most likely cause of his acute pancreatitis?
A. Gallstones
B. Hypertriglyceridemia
C. Alcohol
D. Endoscopic retrograde cholangiopancreatography (ERCP)

Answer 1

Correct Answer: C
Rationale: Alcohol is the second most common cause of acute pancreatitis in the United States, responsible for 15–30% of cases. Given the patient’s history of heavy alcohol consumption, it is the most likely cause in this scenario.

Question 2

A 50-year-old female with a history of gallstones presents with severe abdominal pain, nausea, and vomiting. She has a history of similar episodes. Which of the following is the most likely cause of her acute pancreatitis?
A. Gallstones
B. Hypertriglyceridemia
C. Medications
D. Alcohol

Answer 2

Correct Answer: A
Rationale: Gallstones are the leading cause of acute pancreatitis, responsible for 30–60% of cases. The patient has a history of gallstones, which is the most likely cause of her recurrent pancreatitis.

Question 3

A 38-year-old male with a history of chronic alcohol use presents with acute abdominal pain, nausea, vomiting, and elevated serum amylase and lipase levels. His triglyceride level is 1200 mg/dL. What is the most likely cause of his pancreatitis?
A. Gallstones
B. Alcohol
C. Hypertriglyceridemia
D. ERCP

Answer 3

Correct Answer: C
Rationale: Hypertriglyceridemia is the cause of acute pancreatitis in 1–4% of cases. Serum triglyceride levels >1000 mg/dL are often seen, and this patient has a triglyceride level of 1200 mg/dL, making hypertriglyceridemia the most likely cause.

Question 4

A 40-year-old male with a history of alcohol use presents with acute pancreatitis. During examination, he develops a faint blue discoloration around the umbilicus. What does this finding most likely indicate?
A. Cullen’s sign
B. Turner’s sign
C. Jaundice
D. Subcutaneous fat necrosis

Answer 4

Correct Answer: A
Rationale: Cullen’s sign refers to blue discoloration around the umbilicus and is associated with hemoperitoneum in the context of severe pancreatitis. It reflects the severity of the condition, especially in cases of hemorrhagic pancreatitis.

Question 5

A 58-year-old female with acute pancreatitis develops a left-sided pleural effusion. What is the most likely cause of this complication in the context of pancreatitis?
A. Atelectasis
B. Pulmonary embolism
C. Acute myocardial infarction
D. Systemic infection from translocation of gut bacteria

Answer 5

Correct Answer: A
Rationale: In acute pancreatitis, pleural effusion (most often left-sided) and atelectasis are common pulmonary complications. These are due to diaphragmatic irritation and the systemic inflammatory response

Question 6

A 50-year-old male with acute pancreatitis presents with a blue-red discoloration of the flanks. What does this finding suggest?
A. Turner’s sign
B. Jaundice
C. Hepatomegaly
D. Ascites

Answer 6

Correct Answer: A
Rationale: Turner’s sign is characterized by blue-red discoloration of the flanks and reflects hemorrhagic pancreatitis. It is a sign of severe necrotizing pancreatitis with associated hemorrhage.

Question 7

A 45-year-old female with acute pancreatitis is found to have abdominal distention and diminished bowel sounds. Which of the following best explains this finding?
A. Gastric and intestinal hypomotility
B. Bowel obstruction due to adhesions
C. Perforated ulcer
D. Acute cholecystitis

Answer 7

Correct Answer: A
Rationale: Gastric and intestinal hypomotility is a common feature of acute pancreatitis, leading to abdominal distention and diminished bowel sounds due to impaired gastrointestinal motility.

Question 8

A 65-year-old patient with acute pancreatitis presents with hyperglycemia. Which of the following is most likely contributing to this patient’s elevated blood glucose levels?
A. Increased release of insulin
B. Decreased release of glucagon
C. Increased release of glucocorticoids
D. Decreased output of catecholamines

Answer 8

Correct Answer: C
Rationale: Hyperglycemia in acute pancreatitis occurs due to decreased insulin release, increased glucagon release, and increased output of adrenal glucocorticoids and catecholamines, all of which contribute to increased blood glucose levels.

Question 9

A patient with acute pancreatitis has an elevation in serum bilirubin to 4.5 mg/dL. What is the most likely cause of this finding?
A. Chronic liver disease
B. Gallstone obstruction of the bile duct
C. Acute viral hepatitis
D. Hepatic congestion

Answer 9

Correct Answer: B
Rationale: Hyperbilirubinemia in acute pancreatitis, often transient, may be caused by extrinsic compression from peripancreatic edema, pancreatic head mass, or common bile duct obstruction due to a gallstone.

Question 10

A 58-year-old male with severe acute pancreatitis develops hypoxemia with an arterial oxygen saturation of 60%. What complication is he most likely developing?
A. Acute respiratory distress syndrome (ARDS)
B. Pulmonary embolism
C. Myocardial infarction
D. Pleural effusion

Answer 10

Correct Answer: A
Rationale: Hypoxemia (arterial Po2 ≤60 mmHg) is seen in 5–10% of patients with acute pancreatitis and often precedes the development of acute respiratory distress syndrome (ARDS), a life-threatening complication.

Question 11

A 50-year-old patient presents with acute epigastric pain that radiates to the back. His serum amylase is three times the normal value, and a CT scan confirms acute pancreatitis. However, his hematocrit is found to be 45%, and his BUN is 24 mg/dL. What do these findings suggest regarding the severity of his condition?
A. No concern for severity; this is a mild case of acute pancreatitis.
B. The patient is at risk for more severe pancreatitis and possible complications.
C. The patient’s condition will improve without intervention.
D. The patient is likely in acute kidney failure unrelated to pancreatitis.

Answer 11

Correct Answer: B
Rationale: Hemoconcentration (hematocrit >44%) and azotemia (BUN >22 mg/dL) are markers of more severe disease in acute pancreatitis and are associated with a higher risk for complications.

Question 12

In the early phase of acute pancreatitis (<2 weeks), which clinical parameter is most important in defining the severity of the disease?
A. CT imaging findings showing pancreatic necrosis.
B. Persistent organ failure for more than 48 hours.
C. The presence of Jaundice or abdominal tenderness.
D. Serum amylase and lipase levels.

Answer 12

Correct Answer: B
Rationale: In the early phase of acute pancreatitis, persistent organ failure (lasting more than 48 hours) is the most important indicator of disease severity, not imaging or initial serum enzyme levels.

Question 13

A 45-year-old male with acute pancreatitis is showing signs of multisystem organ failure, including hypoxemia, hypotension, and renal insufficiency. The modified Marshall scoring system places a score of 2 for each of these systems. How should the severity of his condition be categorized?
A. Mild acute pancreatitis.
B. Severe acute pancreatitis with multisystem organ failure.
C. Moderate acute pancreatitis.
D. Acute pancreatitis with no significant systemic complications.

Answer 13

Correct Answer: B
Rationale: A score of 2 or more for two or more organ systems in the modified Marshall scoring system indicates severe acute pancreatitis with multisystem organ failure, which correlates with a poor prognosis.

Question 14

What is the most critical clinical feature used to assess severity in the late phase of acute pancreatitis (>2 weeks)?
A. Serum amylase and lipase levels.
B. CT imaging findings of necrotizing pancreatitis.
C. The appearance of pleural effusion.
D. The development of biliary obstruction.

Answer 14

Correct Answer: B
Rationale: In the late phase, CT imaging is used to assess for complications like necrotizing pancreatitis, which can significantly affect the course of the disease and require intervention if infected.

Question 15

Which of the following is true regarding moderately severe acute pancreatitis?

A) It is characterized by persistent organ failure for more than 48 hours.
B) Necrosis of the pancreas is present in all patients.
C) It may involve transient organ failure or local/systemic complications that resolve in less than 48 hours.
D) The condition typically resolves without the need for hospitalization.

Answer 15

Answer: C) It may involve transient organ failure or local/systemic complications that resolve in less than 48 hours.

Rationale:
Moderately severe acute pancreatitis involves transient organ failure (resolves within 48 hours) or local or systemic complications in the absence of persistent organ failure. This type of pancreatitis may require a prolonged hospitalization but typically has a low mortality rate.

Question 15

Which of the following is the defining characteristic of mild acute pancreatitis?

A) Persistent organ failure lasting more than 48 hours
B) Transient organ failure that resolves in less than 48 hours
C) No local complications or organ failure, self-limited disease
D) Necrosis of the pancreas confirmed on imaging

Answer 15

Answer: C) No local complications or organ failure, self-limited disease

Rationale:
Mild acute pancreatitis is characterized by the absence of local complications or organ failure. It is self-limited and typically resolves within 3-7 days without the need for invasive interventions. Patients can resume oral intake once they have normal bowel function, are without nausea and vomiting, and feel hungry.

Question 16

Which of the following is the most appropriate dietary recommendation for a patient recovering from mild acute pancreatitis?

A) A high-fat solid diet
B) A clear or full liquid diet initially, progressing to a low-fat solid diet once recovery is underway
C) Immediate solid foods with no dietary restrictions
D) Parenteral nutrition until the patient is symptom-free

Answer 16

Answer: B) A clear or full liquid diet initially, progressing to a low-fat solid diet once recovery is underway

Rationale:
For patients recovering from mild acute pancreatitis, it is common practice to start with a clear or full liquid diet and then transition to a low-fat solid diet once symptoms have subsided and bowel function has normalized. This gradual approach minimizes pancreatic stimulation during the recovery process.

Question 17

In patients with severe acute pancreatitis, which of the following is the appropriate imaging technique to evaluate for complications or necrosis?

A) Abdominal X-ray
B) Abdominal ultrasound
C) CT scan or MRI
D) Endoscopic retrograde cholangiopancreatography (ERCP)

Answer 17

Answer: C) CT scan or MRI

Rationale:
In severe acute pancreatitis, a CT scan or MRI is recommended to assess for complications such as pancreatic necrosis or fluid collections. These imaging techniques provide high-resolution images to guide management decisions, including whether interventions are needed for local complications.

Question 18

Which of the following is a characteristic feature of severe acute pancreatitis?

A) Self-limited with spontaneous resolution within 3-7 days
B) Persistent organ failure lasting more than 48 hours
C) Resolves without requiring imaging or hospitalization
D) No involvement of organ failure or complications

Answer 18

Answer: B) Persistent organ failure lasting more than 48 hours

Rationale:
Severe acute pancreatitis is defined by persistent organ failure (>48 hours) that involves one or more organs. It is a more serious form of the disease that requires intensive monitoring and may lead to complications such as necrosis, which is assessed using imaging like CT or MRI.

Question 19

What is the most appropriate management for a patient with severe acute pancreatitis who has developed infected pancreatic necrosis?

A) Prophylactic antibiotics
B) Immediate surgery for pancreatic necrosis
C) Supportive care with no need for intervention
D) Percutaneous, endoscopic, or surgical intervention based on infection and clinical stability

Answer 19

Answer: D) Percutaneous, endoscopic, or surgical intervention based on infection and clinical stability

Rationale:
For severe acute pancreatitis with infected pancreatic necrosis, the approach includes supportive care along with intervention (percutaneous, endoscopic, or surgical) based on the patient’s clinical condition and the severity of the infection. Prophylactic antibiotics are not recommended for preventing infection in necrosis.

Question 20

Which type of pancreatitis is characterized by diffuse gland enlargement, homogeneous contrast enhancement, and mild inflammatory changes or peripancreatic stranding on CT imaging?

A) Necrotizing pancreatitis
B) Interstitial pancreatitis
C) Chronic pancreatitis
D) Pancreatic cancer

Answer 20

Answer: B) Interstitial pancreatitis

Rationale:
Interstitial pancreatitis is the most common form of acute pancreatitis, occurring in 90-95% of cases. On CT imaging, it is characterized by diffuse gland enlargement, homogeneous contrast enhancement, and mild inflammatory changes or peripancreatic stranding. This type generally resolves with supportive care within a week.

Question 21

In which scenario is CT imaging most beneficial for assessing local complications in acute pancreatitis?

A) Within the first 24 hours of admission in all patients
B) After 3–5 days of hospitalization if the patient is not responding to supportive care
C) For patients with mild pancreatitis to confirm diagnosis
D) Immediately after diagnosis of acute pancreatitis to identify severity

Answer 21

Answer: B) After 3–5 days of hospitalization if the patient is not responding to supportive care

Rationale:
CT imaging with IV contrast is best performed 3-5 days into hospitalization in patients not responding to supportive care. This allows time for the evolution of necrosis or other local complications, which are best evaluated after the initial inflammatory phase. Overutilization of CT within the first 72 hours is not recommended, particularly in mild cases.

Question 22

Which of the following is characteristic of necrotizing pancreatitis as observed on CT imaging?

A) Diffuse gland enlargement and homogenous contrast enhancement
B) Lack of pancreatic parenchymal enhancement and/or peripancreatic necrosis
C) No inflammatory changes in peripancreatic areas
D) Only mild peripancreatic stranding without necrosis

Answer 22

Answer: B) Lack of pancreatic parenchymal enhancement and/or peripancreatic necrosis

Rationale:
Necrotizing pancreatitis is characterized by a lack of pancreatic parenchymal enhancement on contrast-enhanced CT, and the presence of peripancreatic necrosis. This is seen in 5-10% of acute pancreatitis cases and typically requires more careful monitoring due to its increased risk for complications and mortality.

Question 23

Which factor is most predictive of increased mortality in necrotizing pancreatitis?

A) Presence of pancreatic necrosis with or without extrapancreatic necrosis
B) Presence of a single organ system failure
C) Mild inflammatory changes on imaging
D) Early initiation of supportive care

Answer 23

Answer: A) Presence of pancreatic necrosis with or without extrapancreatic necrosis

Rationale:
The presence of pancreatic necrosis, whether with or without extrapancreatic necrosis, is a significant factor for increased mortality in acute pancreatitis. Necrotizing pancreatitis is associated with high rates of organ failure, especially if the necrosis becomes infected, and the mortality rate can increase sharply with multiorgan failure.

those with only extrapancreatic necrosis have
a more favorable prognosis than patients with pancreatic necrosis
(with or without extrapancreatic necrosis).

Question 24

What is the most important treatment intervention in the early management of acute pancreatitis?

A) Administration of broad-spectrum antibiotics
B) Early, aggressive intravenous fluid resuscitation
C) Early surgical intervention to drain the pancreas
D) Immediate use of high-dose corticosteroids

Answer 24

Answer: B) Early, aggressive intravenous fluid resuscitation

Rationale:
The most important treatment intervention in the early management of acute pancreatitis is early, aggressive intravenous fluid resuscitation. This helps prevent systemic complications arising from the secondary systemic inflammatory response and ensures adequate perfusion to vital organs. IV fluids

Lactated Ringer’s solution has been shown to decrease systemic inflammation (lower C-reactive protein levels from
admission) and may be a better crystalloid than normal saline

Question 25

What is the goal urine output during the early management of acute pancreatitis with intravenous fluid resuscitation?

A) >2 mL/kg per hour
B) >0.5 mL/kg per hour
C) >1 mL/kg per hour
D) >1.5 mL/kg per hour

Answer 25

Answer: B) >0.5 mL/kg per hour

Rationale:
During the early management of acute pancreatitis, the goal is to maintain a urine output greater than 0.5 mL/kg per hour. This ensures that the kidneys are adequately perfused and functioning properly, which helps to monitor the effectiveness of fluid resuscitation.

Question 26

What is the primary reason for keeping a patient with acute pancreatitis NPO (nothing by mouth) initially?

A) To prevent infection of the pancreas
B) To minimize nutrient-induced stimulation of the pancreas
C) To reduce the risk of vomiting
D) To manage electrolyte imbalances

Answer 26

Answer: B) To minimize nutrient-induced stimulation of the pancreas

Rationale:
The primary reason for keeping a patient NPO initially in acute pancreatitis is to minimize nutrient-induced stimulation of the pancreas. Allowing the pancreas to rest prevents further inflammation and pancreatic enzyme release, which could exacerbate the condition.

Question 27

Which of the following is the typical initial bolus volume of intravenous fluids for a patient with acute pancreatitis?

A) 500–750 mL
B) 1000–1200 mL
C) 15–20 mL/kg (1050–1400 mL)
D) 2000 mL

Answer 27

Answer: C) 15–20 mL/kg (1050–1400 mL)

Rationale:
The initial bolus of intravenous fluids in acute pancreatitis is typically 15-20 mL/kg (approximately 1050-1400 mL for a 70 kg patient). This helps to restore intravascular volume quickly, address hypovolemia, and improve tissue perfusion. Subsequent fluid administration is adjusted based on ongoing clinical assessment.

Intravenous fluids of lactated Ringer’s or normal saline are initially bolused at 15–20 mL/kg (1050–1400 mL), followed by 2–3 mL/kg per hour (200–250 mL/h), to maintain urine output >0.5 mL/kg per hour

Question 28

Which of the following is not a parameter included in the Bedside Index of Severity in Acute Pancreatitis (BISAP) within the first 24 hours of hospitalization?

A) BUN >25 mg/dL
B) Glasgow coma scale score <15
C) Serum amylase >1000 U/L
D) Pleural effusion on radiography

Answer 28

Answer: C) Serum amylase >1000 U/L

Rationale:
The Bedside Index of Severity in Acute Pancreatitis (BISAP) includes five clinical and laboratory parameters: BUN >25 mg/dL, impaired mental status (Glasgow coma scale score <15), SIRS, age >60 years, and pleural effusion on radiography.

Question 29

Which of the following laboratory findings is associated with more severe acute pancreatitis?

A) Hematocrit <44%
B) BUN >22 mg/dL
C) Serum lipase >500 U/L
D) Serum calcium >9 mg/dL

Answer 29

Answer: B) BUN >22 mg/dL

Rationale:
An elevated BUN >22 mg/dL is associated with more severe acute pancreatitis. It may reflect dehydration, renal impairment, or the severity of the inflammatory process, which is why it is a key factor in assessing severity. Hematocrit >44% is another marker of severity.

Question 30

The Bedside Index of Severity in Acute Pancreatitis (BISAP) can be used to assess the severity of pancreatitis and risk of in-hospital mortality. What would indicate a high risk of mortality based on BISAP?

A) 1 or 2 parameters present
B) 3 or more parameters present
C) No parameters present
D) Age <40 years

Answer 30

Answer: B) 3 or more parameters present

Rationale:
A BISAP score of 3 or more parameters significantly increases the risk for in-hospital mortality. These factors include elevated BUN, impaired mental status, SIRS, age >60 years, and pleural effusion. The presence of multiple severity markers signals a need for closer monitoring and potential escalation of care.

Question 31

In a patient with gallstone pancreatitis who presents with evidence of ascending cholangitis, what is the most appropriate next step in management?

A) Perform a cholecystectomy immediately
B) Administer broad-spectrum antibiotics and observe
C) Perform endoscopic retrograde cholangiopancreatography (ERCP) within 24–48 hours
D) Schedule a follow-up appointment for 1–2 weeks for further assessment

Answer 31

Answer: C) Perform endoscopic retrograde cholangiopancreatography (ERCP) within 24–48 hours

Rationale:
Patients with gallstone pancreatitis and evidence of ascending cholangitis, characterized by rising white blood cell count and increasing liver enzymes, require urgent ERCP within 24–48 hours. This procedure is essential to relieve any biliary obstruction and prevent further complications such as sepsis.

Question 32

For patients with mild gallstone pancreatitis, which of the following is the most appropriate management strategy during the same admission?

A) Initiate oral antibiotics and discharge the patient
B) Perform an early cholecystectomy
C) Perform a biliary drainage procedure and discharge without surgery
D) Provide conservative management and consider cholecystectomy at a later time

Answer 32

Answer: B) Perform an early cholecystectomy

Rationale:
In patients with mild gallstone pancreatitis, it is appropriate to consider performing a cholecystectomy during the same admission to reduce the risk of recurrence. This approach helps avoid further episodes of pancreatitis and related complications, as gallstones are the underlying cause.

Question 33

In a patient with acute pancreatitis and serum triglycerides >1000 mg/dL, what is the initial treatment strategy?

A) Start intravenous insulin therapy to correct hyperglycemia and hypertriglyceridemia
B) Initiate plasmapheresis immediately to reduce triglyceride levels
C) Administer statin therapy for rapid lipid reduction
D) Provide only supportive care without specific interventions for hypertriglyceridemia

Answer 33

Answer: A) Start intravenous insulin therapy to correct hyperglycemia and hypertriglyceridemia

Rationale:
The primary treatment for hypertriglyceridemia in acute pancreatitis with triglycerides >1000 mg/dL is intravenous insulin therapy. Insulin helps to reduce triglyceride levels by enhancing lipoprotein lipase activity, which facilitates the breakdown of triglycerides. This is an essential part of managing hypertriglyceridemia in the context of pancreatitis.

Question 34

Which of the following long-term outpatient strategies is most important for preventing recurrent hypertriglyceridemia in patients with acute pancreatitis caused by hypertriglyceridemia?

A) Weight loss and lipid-lowering agents
B) Regular administration of intravenous insulin
C) Avoidance of alcohol consumption
D) Aggressive hydration and use of diuretics

Answer 34

Answer: A) Weight loss and lipid-lowering agents

Rationale:
Outpatient management after an episode of acute pancreatitis due to hypertriglyceridemia includes controlling any underlying diabetes, using lipid-lowering agents, and promoting weight loss. These measures help to reduce triglyceride levels and prevent future episodes of pancreatitis.

Question 35

What is the role of plasmapheresis in the management of acute pancreatitis associated with hypertriglyceridemia?

A) It is the first-line treatment for hypertriglyceridemia in acute pancreatitis
B) It may be considered for refractory cases, but evidence does not support its routine use
C) It is indicated for all patients with triglyceride levels >500 mg/dL
D) Plasmapheresis should always be performed immediately upon diagnosis of hypertriglyceridemia

Answer 35

Answer: B) It may be considered for refractory cases, but evidence does not support its routine use

Rationale:
Plasmapheresis may be considered for patients with hypertriglyceridemia and acute pancreatitis if other treatments, such as insulin therapy, are ineffective. However, there is no strong evidence supporting its routine use, and it is not a first-line therapy.

Question 36

In the treatment of steatorrhea due to exocrine pancreatic insufficiency, which of the following is considered the cornerstone of therapy?

A) Low-fat diet
B) Pancreatic enzyme replacement therapy
C) Oral rehydration therapy
D) Antibiotic therapy

Answer 36

Answer: B) Pancreatic enzyme replacement therapy

Rationale:
The cornerstone of therapy for steatorrhea in patients with exocrine pancreatic insufficiency is pancreatic enzyme replacement therapy. This therapy provides the necessary enzymes to aid in the digestion and absorption of fats, which are not properly broken down due to insufficient pancreatic enzyme production.

Question 37

What is the usual starting dosage for pancreatic enzyme replacement therapy (lipase) in adult patients with exocrine pancreatic insufficiency?

A) 10,000–20,000 units per meal
B) 25,000–50,000 units per meal
C) 100,000–150,000 units per meal
D) 200,000–250,000 units per meal

Answer 37

Answer: B) 25,000–50,000 units per meal

Rationale:
In adults with exocrine pancreatic insufficiency, the recommended starting dose for pancreatic enzyme replacement therapy is 25,000–50,000 units of lipase per meal. The dose may be adjusted based on the patient’s symptoms, nutritional status, and pancreatic function tests.