Acute pancreatitis I/ Summary Acute pancreatitis is an inflammatory condition of the pancreas most commonly caused by biliary tract disease or alcohol abuse Damage to the pancreas causes local release of digestive proteolytic enzymes that autodigest pancreatic tissue Acute pancreatitis usually presents with epigastric pain radiating to the back, nausea and vomiting, and epigastric tenderness on palpation The diagnosis is made based on the clinical presentation, elevated serum pancreatic enzymes, and findings on imaging (CT, MRI, ultrasound) that suggest acute pancreatitis Treatment is mostly supportive and includes bowel rest, fluid resuscitation, and painmedication Enteral feeding is usually quickly resumed once the pain and inflammatory markers begin to subside Interventional procedures may be indicated for the treatment of underlying conditions, such as ERCP or cholecystectomy in gallstone pancreatitis Localized complications of pancreatitis include necrosis, pancreatic pseudocysts, and abscesses Systemic complications involve sepsis, ARDS, organ failure, and shock and are associated with a considerable rise in mortality II/ Etiology  Most common causes Biliary pancreatitis (e.g., gallstones, constriction of the ampulla of Vater) ∼ 40% of cases Alcohol-induced (∼ 30% of cases) Idiopathic (∼ 15%–25% of cases)  Other causes  Hypertriglyceridemia, hypercalcemia  Post-ERCP  Toxic drugs (e.g., steroids, azathioprine, sulfonamides, furosemide, estrogen, protease inhibitors, NRTIs)  Scorpion stings  Viral infections (e.g., coxsackievirus B, mumps)  Trauma  Autoimmune and rheumatological disorders (e.g., Sjögren's syndrome)  Pancreas divisum  Hereditary (e.g., mutation of the trypsinogen gene, cystic fibrosis) "I GET SMASHED": I = Idiopathic, G = Gall stones, E = Ethanol, T = Trauma, S = Steroids, M = Mumps, A = Autoimmune, S = Scorpion poison, H = Hypercalcemia, Hypertriglyceridemia, E = ERCP, D = Drugs III/ Pathophysiology Sequence of events leading to pancreatitis: Intrapancreatic activation of pancreatic enzymes: secondary to pancreatic ductal outflow obstruction (e.g., gallstones, cystic fibrosis) or direct injury to pancreatic acinar cells (e.g., alcohol, drugs) Enzymatic autodigestion of pancreatic parenchyma Attraction of inflammatory cells (neutrophils, macrophages) → release of inflammatory cytokines → pancreatic inflammation (pancreatitis) Sequelae of pancreatitis (depending on the severity of pancreatitis) Capillary leakage: Release of inflammatory cytokines and vascular injury by pancreatic enzymes → vasodilation and increased vascular permeability → shift of fluid from the intravascular space into the interstitial space (third space loss) → hypotension, tachycardia → distributive shock Pancreatic necrosis: Uncorrected hypotension and third space loss → decreased organ perfusion → multiorgan dysfunction (mainly renal) and pancreaticnecrosis Hypocalcemia: Lipase breaks down peripancreatic and mesenteric fat → release of free fatty acids that bind calcium → hypocalcemia Disease progression  Mild acute pancreatitis: interstitial edema, no necrosis; no local and systemic complications, no organ failure  Moderate acute pancreatitis: associated with local (e.g., necrosis, abscesses, pseudocysts) or systemic complications, such as temporary organ failure (e.g., kidney failure), which improves within 48 hours  Severe pancreatitis: associated with persistent pancreatic failure (> 48 hours), as well as single or multiple organ failure IV/ Clinical features  Constant, severe epigastric pain  Classically radiating towards the back  Worse after meals and when supine  Improves on leaning forwards  Nausea, vomiting  General physical examination  Signs of shock: tachycardia, hypotension, oliguria/anuria  Possibly jaundice in patients with biliary pancreatitis  Abdominal examination  Abdominal tenderness, distention, guarding  Ileus with reduced bowel sounds and tympany on percussion  Ascites  Skin changes (rare)  Cullen's sign: periumbilical ecchymosis and discoloration (bluish-red)  Grey Turner's sign: flank ecchymosis with discoloration  Fox's sign: ecchymosis over the inguinal ligament V/ Diagnostics Acute pancreatitis is diagnosed based on a typical clinical presentation, with abdominal pain radiating to the back, and either detection of highly elevated pancreatic enzymes or characteristic findings on imaging Serum hematocrit is an easy test that should be conducted to help quickly predict disease severity Laboratory tests  Tests to confirm clinical diagnosis  ↑ Serum pancreatic enzymes  Lipase: if ≥ x the upper reference range → highly indicative of acute pancreatitis  Amylase (nonspecific)  The enzyme levels are not directly proportional to severity or prognosis!  Tests to assess severity  Hematocrit (Hct)  Should be conducted at presentation as well as 12 and 24 hours after admissions  ↑ Hct (due to hemoconcentration) indicates third space fluid loss and inadequate fluid resuscitation  ↓ Hct indicates the rarer acute hemorrhagic pancreatitis  WBC count  Blood urea nitrogen  ↑ CRP and procalcitonin levels  ↑ ALT  Tests to determine etiology  Alkaline phosphatase, bilirubin levels (evidence of gallstone pancreatitis)  Serum calcium levels  Serum triglyceride levels (fasting) !!! Determining calcium values is very important: Hypercalcemia may cause pancreatitis, which may then, in turn, cause hypocalcemia! Imaging  Ultrasound (most useful initial test): indicated in all patients with acute pancreatitis  Main purpose: detection of gallstones and/or dilatation of the biliary tract (indicating biliary origin)  Signs of pancreatitis  Indistinct pancreatic margins (edematous swelling)  Peripancreatic build-up of fluid ; evidence of ascites in some cases  Evidence of necrosis, abscesses, pancreatic pseudocysts  CT scan: not routinely indicated  Indications  At admission: only when the diagnosis is in doubt (e.g., not very highly elevated pancreatic enzymes, nonspecific symptoms)  > 72 hours of symptom onset: if complications such as necrotizing pancreatitis or pancreatic abscess (e.g., persistent fever and leukocytosis, no clinical improvement or evidence of organ failure > 72 hours of therapy) are suspected  Findings  Enlargement of the pancreatic parenchyma with edema; indistinct pancreatic margins with surrounding fat stranding  Necrotizing pancreatitis: lack of parenchymal enhancement or presence of air in the pancreatic tissue  Pancreatic abscess: circumscribed fluid collection  MRCP and ERCP  Indications: suspected biliary or pancreatic duct obstructions  MRCP is noninvasive but less sensitive than ERCP  ERCP can be combined with sphincterotomy and stone extraction; but may worsen pancreatitis  Conventional x-ray  Sentinel loop sign: dilatation of a loop of small intestine in the upper abdomen (duodenum/jejunum)  Colon cut off sign: gaseous distention of the ascending and transverse colon that abruptly terminates at the splenic flexure  Evidence of possible complications: pleural effusions, pancreatic calcium stones; helps rule out intestinal perforation with free air VI/ Treatment General measures  Admission to hospital and assessment of disease severity (consider ICU admission)  Fluid resuscitation: aggressive hydration with crystalloids (e.g., lactated Ringer's solution , normal saline)  Analgesia: IV opioids (e.g., fentanyl)  Bowel rest (NPO)and IV fluids are recommended until the pain subsides  Nasogastric tube insertion: not routinely recommended; indicated in patients with vomiting and/or significant abdominal distention  Nutrition  Begin enteral feeding (oral/nasogastric/nasojejunal) as soon as the pain subsides  Total parenteral nutrition: only in patients who cannot tolerate enteral feeds (e.g., those with persistent ileus and abdominal pain) Drug therapy  Analgesics: fentanyl or hydromorphone; consider pump administration (patient controlled analgesia = PCA)  Antibiotics  Prophylactic antibiotic therapy is not recommended  Antibiotics should only be used in patients with evidence of infected necrosis  Fenofibrates: in hyperlipidemia-induced acute pancreatitis Procedures/surgery  Biliary pancreatitis  Urgent ERCP and sphincterotomy (within 24 hours): in patients with evidence of choledocholithiasis and/or cholangitis; followed by cholecystectomy  Cholecystectomy (preferably during same admission once the patient is stabilized; or within weeks): in all patients with biliary pancreatitis !!! The most important therapeutic measure is adequate fluid replacement (minimum of 3–4 liters of crystalloids per day)! "PANCREAS" - Perfusion (fluid replacement), Analgesia, Nutrition, Clinical (observation), Radiology (imaging), ERC (endoscopic stone extraction), Antibiotics, Surgery (surgical intervention, if necessary) VII/ Complications Localized  Bacterial superinfection of necrotic tissue → fever  Diagnosis: CT-guided percutaneous drainage + culture of the aspirate  Treatment: surgical debridement, antibiotics  High mortality rate; multiple organ failure in ∼ 50% of cases  Pancreatic pseudocysts  Pancreatic abscess  Walled-off infected necrotic tissue or pancreatic pseudocyst; typically develops > weeks after an attack of acute pancreatitis  Abdominal CT: visible contrast-enhanced abscess capsule with evidence of fluid (pus)  Ultrasound: complex cystic, fluid collection with irregular walls and septations  Treatment: cannulation and drainage; necrosectomy if other measures are not effective  Pleural effusion  Abdominal compartment syndrome  Blood vessel erosion with bleeding Systemic  SIRS, sepsis, DIC  Pneumonia, respiratory failure, ARDS  Shock  Prerenal failure due to volume depletion  Hypocalcemia  Pleural effusion, pancreatic ascites  Paralytic ileus We list the most important complications The selection is not exhaustive VIII/ Prognosis  Mortality  In patients without organ failure: < 1%  In patients with organ failure: ∼ 30%  Higher mortality in patients with biliary pancreatitis than in patients with alcoholic pancreatitis  Important predictors of severity  Age > 55  Gastrointestinal bleeding  Abnormal hematocrit within 48 hours  Acute hemorrhagic pancreatitis: ↓ Hct  Third space fluid loss: ↑ Hct  Hypocalcemia and/or hyperglycemia  Inflammatory markers: ↑↑ CRP, ↑ IL-6, ↑ IL-8  Evidence of shock and/or organ failure  ↑ AST, ↑ ALT  ↑ BUN, creatinine  ↑ LDH  ABG: pO2 < 60 mmHg, metabolic acidosis with a base deficit > mmol/L  CT findings: pancreatic edema, peripancreatic fluid collection, and/or necrosis of > 33% of the pancreas !!! Amylase and lipase, which are used for the diagnosis of pancreatitis, cannot be used to predict the prognosis!  Numerous scoring systems exist (e.g, Ranson criteria) for assessing the severity and predicting the prognosis of acute pancreatitis QUESTION Q1 A previously healthy 32-year-old man comes to the emergency department because of a 2-day history of worsening abdominal pain and vomiting He has had chills but has not measured his temperature He has not had diarrhea He takes no medications He drinks to beers daily but says that he drank more while on a recent vacation He does not use illicit drugs His temperature is 38.4°C (101.2°F), pulse is 104/min, respirations are 18/min, and blood pressure is 132/82 mm Hg Abdominal exam shows epigastric pain to palpation with guarding but no rebound Murphy sign is negative He has no jaundice Serum studies are most likely to show which of the following sets of findings in this patient? Q2 A 43-year-old man is brought to the emergency department because of severe epigastric pain and vomiting for hours The pain radiates to his back and he describes it as out of 10 in intensity He has had 3–4 episodes of vomiting during this period He admits to consuming over 13 alcoholic beverages the previous night There is no personal or family history of serious illness and he takes no medications He is 177 cm (5 ft 10 in) tall and weighs 55 kg (121 lb); BMI is 17.6 kg/m2 He appears uncomfortable His temperature is 37.5°C (99.5°F), pulse is 97/min, and blood pressure is 128/78 mm Hg Abdominal examination shows severe epigastric tenderness to palpation Bowel sounds are hypoactive The remainder of the physical examination shows no abnormalities Laboratory studies show: Hemoglobin 13.5 g/dL Hematocrit 62% Leukocyte count 13,800/mm3 Serum Na+ 134 mEq/L K+ 3.6 mEq/L Cl98 mEq/L Calcium 8.3 mg/dL Glucose 180 mg/dL Creatinine 0.9 mg/dL Amylase 150 U/L Lipase 347 U/L (N = 14–280) Total bilirubin 0.8 mg/dL Alkaline phosphatase 66 U/L AST 19 U/L ALT 18 U/L LDH 360 U/L Which of the following laboratory studies is the best prognostic indicator for this patient's condition? A Hematocrit B Lipase C AST/ALT ratio D Alkaline phosphatase E Total bilirubin F Amylase Q3 A 55-year-old woman is brought to the emergency department because of worsening upper abdominal pain for hours She reports that the pain radiates to the back and is associated with nausea She has hypertension and hyperlipidemia, for which she takes enalapril, furosemide, and simvastatin Her temperature is 37.5°C (99.5 °F), blood pressure is 84/58 mm Hg, and pulse is 115/min The lungs are clear to auscultation Examination shows abdominal distention with epigastric tenderness and guarding Bowel sounds are decreased Extremities are warm Laboratory studies show: Hematocrit 48% Leukocyte count 13,800/mm3 Platelet count 175,000/mm3 Serum: Calcium 8.0 mg/dL Urea nitrogen 32 mg/dL Amylase 250 U/L An ECG shows sinus tachycardia Which of the following is the most likely underlying cause of this patient's vital sign abnormalities? A Decreased sympathetic tone B Hemorrhagic fluid loss C Decreased albumin concentration D Abnormal coagulation and fibrinolysis E Decreased cardiac output F Increased excretion of water G Pseudocyst formation H Capillary leakage Q4 A 50-year-old man comes to the emergency department because of severe lower chest pain for the past hour The pain radiates to the back and is associated with nausea He has had two episodes of non-bloody vomiting since the pain started He has a history of hypertension and type diabetes mellitus He has smoked one pack of cigarettes daily for 30 years He drinks five to six beers per day His medications include enalapril and metformin His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm Hg The lungs are clear to auscultation Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound; bowel sounds are decreased Laboratory studies show: Hemoglobin 14.5 g/dL Leukocyte count 5,100/mm3 Platelet count 280,000/mm3 Serum Na+ 133 mEq/L K+ 3.5 mEq/L Cl98 mEq/L Total bilirubin 1.0 mg/dL Amylase 160 U/L Lipase 380 U/L (N = 14–280) An ECG shows sinus tachycardia Which of the following is the most likely diagnosis? A Acute mesenteric ischemia B Boerhaave syndrome C Aortic dissection D Peptic ulcer disease E Pericarditis F Myocardial infarction G Acute pancreatitis Q5 A 65-year-old man with hypertension and type diabetes mellitus is brought to the emergency department hour after the onset of severe abdominal pain and nausea He has smoked one pack of cigarettes daily for 30 years and drinks alcoholic beverages occasionally His pulse is 110/min, respirations are 20/min, and blood pressure is 142/86 mm Hg The lungs are clear to auscultation Abdominal examination shows a pulsatile epigastric mass and diffuse tenderness Which of the following additional findings is most likely in this patient? A Increase in serum lipase concentration B Absence of the hepatojugular reflux C Filling defect in the superior mesenteric vein D Increase in jugular venous pressure E Decrease in ankle-brachial index Q6 A 52-year-old woman comes to the emergency department because of epigastric abdominal pain that started after her last meal and has become progressively worse over the past hours She has had intermittent pain similar to this before, but it has never lasted this long Her temperature is 39°C (102.2°F) Examination shows a soft abdomen with normal bowel sounds The patient has sudden inspiratory arrest during right upper quadrant palpation Her alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are within the reference ranges Abdominal imaging is most likely to show which of the following findings? A Dilated common bile duct with intrahepatic biliary dilatation B Gas in the gallbladder wall C Gallstone in the cystic duct D Fistula formation between the gallbladder and bowel E Decreased echogenicity of the liver F Enlargement of the pancreas with peripancreatic fluid Q7 One week after undergoing sigmoidectomy with end colostomy for complicated diverticulitis, a 67-year-old man has upper abdominal pain During the surgery, he was transfused two units of packed red blood cells His postoperative course was uncomplicated Two days ago, he developed fever He is currently receiving parenteral nutrition through a central venous catheter He has type diabetes mellitus, hypertension, and hypercholesterolemia He is oriented to person, but not to place and time Prior to admission, his medications included metformin, valsartan, aspirin, and atorvastatin His temperature is 38.9°C (102.0°F), pulse is 120/min, and blood pressure is 100/60 mmHg Examination shows jaundice of the conjunctivae Abdominal examination shows tenderness to palpation in the right upper quadrant There is no rebound tenderness or guarding; bowel sounds are hypoactive Laboratory studies show: Leukocytes 13,500 /mm3 Segmented neutrophils 75 % Serum Aspartate aminotransferase 140 IU/L Alanine aminotransferase 85 IU/L Alkaline phosphatase 150 IU/L Bilirubin Total 2.1 mg/dL Direct 1.3 mg/dL Amylase 20 IU/L Which of the following is the most likely diagnosis in this patient? A Ischemic hepatitis B Acalculous cholecystitis C Small bowel obstruction D Anastomotic insufficiency E Cholecystolithiasis F Acute pancreatitis G Hemolytic transfusion reaction Q8 A 68-year-old man comes to the physician because of recurrent episodes of nausea and abdominal discomfort for the past months The discomfort is located in the upper abdomen and sometimes occurs after eating, especially after a big meal He has tried to go for a walk after dinner to help with digestion, but his complaints have only increased For the past weeks he has also had symptoms while climbing the stairs to his apartment He has type diabetes mellitus, hypertension, and stage peripheral arterial disease He has smoked one pack of cigarettes daily for the past 45 years He drinks one to two beers daily and occasionally more on weekends His current medications include metformin, enalapril, and aspirin He is 168 cm (5 ft in) tall and weighs 126 kg (278 lb); BMI is 45 kg/m2 His temperature is 36.4°C (97.5°F), pulse is 78/min, and blood pressure is 148/86 mm Hg On physical examination, the abdomen is soft and nontender with no organomegaly Foot pulses are absent bilaterally An ECG shows no abnormalities Which of the following is the most appropriate next step in diagnosis? A Esophagogastroduodenoscopy B CT scan of the abdomen C CT angiography of the abdomen D Hydrogen breath test E Cardiac stress test F Abdominal ultrasonography of the right upper quadrant G Endoscopic retrograde cholangiopancreatography Q9 A 46-year-old man is brought to the emergency department because of severe epigastric pain and vomiting for the past hours The pain is constant, radiates to his back, and is worse on lying down He has had 3–4 episodes of greenish-colored vomit He was treated for H pylori infection around months ago with triple-regimen therapy He has atrial fibrillation and hypertension He owns a distillery on the outskirts of a town The patient drinks 4–5 alcoholic beverages daily Current medications include dabigatran and metoprolol He appears uncomfortable His temperature is 37.8°C (100°F), pulse is 102/min, and blood pressure is 138/86 mm Hg Examination shows severe epigastric tenderness to palpation with guarding but no rebound Bowel sounds are hypoactive Rectal examination shows no abnormalities Laboratory studies show: Hematocrit 53% Leukocyte count 11,300/mm3 Serum Na+ 133 mEq/L Cl98 mEq/L K+ 3.1 mEq/L Calcium 7.8 mg/dL Urea nitrogen 43 mg/dL Glucose 271 mg/dL Creatinine 2.0 mg/dL Total bilirubin 0.7 mg/dL Alkaline phosphatase 61 U/L AST 19 U/L ALT 17 U/L γ-glutamyl transferase (GGT) 88 u/L (N=5–50 U/L) Lipase 900 U/L (N=14–280 U/L) Which of the following is the most appropriate next step in management? A CT angiography B Calcium gluconate therapy C Fomepizole therapy D Laparotomy E Endoscopic retrograde cholangio-pancreatography F Insulin infusion G Crystalloid fluid infusion Q10 A 67-year-old woman comes to the physician because of a 5-day history of episodic abdominal pain, nausea, and vomiting She has coronary artery disease and type diabetes mellitus She takes aspirin, metoprolol, and metformin She is 163 cm (5 ft in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2 Her temperature is 38.1°C (100.6°F) Physical examination shows dry mucous membranes, abdominal distension, and hyperactive bowel sounds Ultrasonography of the abdomen shows air in the biliary tract This patient's symptoms are most likely caused by obstruction at which of the following locations? A Third part of the duodenum B Distal ileum C Hepatic duct D Proximal jejunum E Pancreatic duct Q11 A 12-year-old girl is brought to the physician because of a 2-hour history of severe epigastric pain, nausea, and vomiting Her father has a history of similar episodes of abdominal pain and developed diabetes mellitus at the age of 30 years Abdominal examination shows guarding and rigidity Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized Which of the following is the most likely underlying cause of this patient's condition? A Defective bilirubin glucuronidation B Elevated serum amylase levels C Increased β-glucuronidase activity D Premature activation of trypsinogen E Defective elastase inhibitor F Impaired cellular copper transport Q12 A 42-year-old woman is brought to the emergency department because of intermittent sharp right upper quadrant abdominal pain and nausea for the past 10 hours She vomited three times There is no associated fever, chills, diarrhea, or urinary symptoms She has two children who both attend high school She appears uncomfortable She is 165 cm (5 ft in) tall and weighs 86 kg (190 lb); BMI is 32 kg/m2 Her temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 140/90 mm Hg She has mild scleral icterus The abdomen is soft and nondistended, with tenderness to palpation of the right upper quadrant without guarding or rebound Bowel sounds are normal Laboratory studies show: Hemoglobin count 14 g/dL Leukocyte count 9,000 mm3 Platelet count 160,000 mm3 Serum Alkaline phosphatase 238 U/L Aspartate aminotransferase 60 U/L Bilirubin Total 2.8 mg/dL Direct 2.1 mg/dL Which of the following is the most appropriate next step in diagnosis? A CT scan of the abdomen B Supine and erect x-rays of the abdomen C Transabdominal ultrasonography D Endoscopic retrograde cholangiopancreatography E HIDA scan of the biliary tract F Upper gastrointestinal series Q13 An otherwise healthy 28-year-old primigravid woman at 30 weeks' gestation comes to the physician with a 5-day history of epigastric pain and nausea that is worse at night Two years ago, she was diagnosed with a peptic ulcer and was treated with a proton pump inhibitor and antibiotics Medications include folic acid and a multivitamin Her pulse is 90/min and blood pressure is 130/85 mm Hg Pelvic examination shows a uterus consistent in size with a 30-week gestation Laboratory studies show: Hemoglobin 8.6 g/dL Platelet count 95,000/mm3 Serum Total bilirubin mg/dL Aspartate aminotransferase 80 U/L Lactate dehydrogenase 705 U/L Urine pH 6.2 Protein 2+ WBC negative Bacteria occasional Nitrates negative Which of the following best explains this patient's symptoms? A Inflammation of the gall bladder B Bacterial infection of the kidney C Inflammation of the lower esophageal mucosa D Stretching of Glisson capsule E Acute inflammation of the pancreas F Break in gastric mucosal continuity Q14 An otherwise healthy 56-year-old woman comes to the physician because of a 3-year history of intermittent upper abdominal pain She has had no nausea, vomiting, or change in weight Physical examination shows no abnormalities Laboratory studies are within normal limits Abdominal ultrasonography shows a hyperechogenic rim-like calcification of the gallbladder wall The finding in this patient's ultrasonography increases the risk of which of the following conditions? A Hepatocellular carcinoma B Pancreatic adenocarcinoma C Gallbladder empyema D Pyogenic liver abscess E Emphysematous cholecystitis F Gallbladder carcinoma G Gallstone ileus H Acute pancreatitis Q15 A previously healthy 31-year-old woman comes to the emergency department because of sudden, severe epigastric pain and vomiting for the past hours She reports that the pain radiates to the back and began when she was having dinner and drinks at a local brewpub Her temperature is 37.9°C (100.2°F), pulse is 98/min, respirations are 19/min, and blood pressure is 110/60 mm Hg Abdominal examination shows epigastric tenderness and guarding but no rebound Bowel sounds are decreased Laboratory studies show: Hematocrit 43% Leukocyte count 9000/mm3 Serum Na+ 140 mEq/L K+ 4.5 mEq/L Ca2+ 9.0 mg/dL Lipase 170 U/L (N = < 50 U/L) Amylase 152 U/L Alanine aminotransferase (ALT, GPT) 140 U/L Intravenous fluid resuscitation is begun Which of the following is the most appropriate next step in management? A Esophagogastroduodenoscopy B Contrast-enhanced abdominal CT scan C Right upper quadrant abdominal ultrasound D Plain x-ray of the abdomen E Endoscopic retrograde cholangiopancreatography F Measure serum triglycerides G Blood alcohol level assay Q16 A 45-year-old woman comes to the emergency department because of right upper abdominal pain and nausea that have become progressively worse since eating a large meal hours ago She has had intermittent pain similar to this before, but it has never lasted this long She has a history of hypertension and type diabetes mellitus She does not smoke or drink alcohol Current medications include metformin and enalapril Her temperature is 38.5°C (101.3°F), pulse is 90/min, and blood pressure is 130/80 mm Hg The abdomen is soft, and bowel sounds are normal The patient has sudden inspiratory arrest during right upper quadrant palpation Laboratory studies show a leukocyte count of 13,000/mm3 Serum alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are within the reference ranges Imaging is most likely to show which of the following findings? A Dilated common bile duct with intrahepatic biliary dilatation B Enlargement of the pancreas with peripancreatic fluid C Gas in the gallbladder wall D Fistula formation between the gallbladder and bowel E Gallstone in the cystic duct F Decreased echogenicity of the liver Q17 A 42-year-old woman is brought to the emergency department because of a 5-day history of epigastric pain, fever, nausea, and malaise Five weeks ago she had acute biliary pancreatitis and was treated with endoscopic retrograde cholangiopancreatography and subsequent cholecystectomy Her maternal grandfather died of pancreatic cancer She does not smoke She drinks 1–2 beers daily Her temperature is 38.7°C (101.7°F), respirations are 18/min, pulse is 120/min, and blood pressure is 100/70 mm Hg Abdominal examination shows epigastric tenderness and three well-healed laparoscopy scars The remainder of the examination shows no abnormalities Laboratory studies show: Hemoglobin 10 g/dl Leukocyte count 15,800/mm3 Serum Na+ 140 mEq/L Cl− 103 mEq/L K+ 4.5 mEq/L HCO325 mEq/L Urea nitrogen 18 mg/dL Creatinine 1.0 mg/dL Alkaline phosphatase 70 U/L Aspartate aminotransferase (AST, GOT) 22 U/L Alanine aminotransferase (ALT, GPT) 19 U/L γ-Glutamyltransferase (GGT) 55 U/L (N=5-50 U/L) Bilirubin mg/dl Glucose 105 mg/dL Amylase 220 U/L Lipase 105 U/L (N=3-43 U/L) Abdominal ultrasound shows a complex cystic fluid collection with irregular walls and septations in the pancreas Which of the following is the most likely diagnosis? A Pancreatic abscess B Pancreatic pseudocyst C Pancreatic cancer D Acute cholangitis E ERCP-induced pancreatitis Q18 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 Perform a pilocarpine-induced sweat test B Measure serum mumps IgM titer C Perform an esophagogastroduodenoscopy D Obtain an upright x-ray of the abdomen E Measure serum lipid levels F Measure stool elastase level ... pancreatitis than in patients with alcoholic pancreatitis  Important predictors of severity  Age > 55  Gastrointestinal bleeding  Abnormal hematocrit within 48 hours  Acute hemorrhagic pancreatitis: ... evidence of infected necrosis  Fenofibrates: in hyperlipidemia-induced acute pancreatitis Procedures/surgery  Biliary pancreatitis  Urgent ERCP and sphincterotomy (within 24 hours): in patients... indicated in all patients with acute pancreatitis  Main purpose: detection of gallstones and/or dilatation of the biliary tract (indicating biliary origin)  Signs of pancreatitis  Indistinct pancreatic