What is an alternate bedside test, with the most number of clinical studies to support its use in the diagnosis of acute pancreatitis?

Urinary trypsinogen activation peptide (TAP)

What is the optimal timing for the initial intervention in a clinically stable patient with infected pancreatic necrosis? Choose the one best answer:

30 days after the onset of pancreatitis

10 days after the onset of pancreatitis

20 days after the onset of pancreatitis

30 days after the onset of pancreatitis

40 days or later after the onset of pancreatitis

You are caring for a patient with acute necrotizing pancreatitis who is developing worsening sepsis and organ failure despite maximal intensive care and broad spectrum antibiotic administration 12 days after the onset of pancreatitis. You obtain a percutaneous, CT-guided fine needle aspirate of his pancreatic necrosis that demonstrates bacterial infection. The optimal intervention at this time is:

Continued antibiotic administration and supportive therapy only

Endoscopic transluminal drainage

Video assisted retroperitoneal debridement

Which of the following patients with acute necrotizing pancreatitis are most likely to benefit from surgical intervention early in the course of disease?

Patients with colonic infarction

Patients with duodenal obstruction

Patients with colonic infarction

A 55 year old patient with acute necrotizing pancreatitis has been on the Intensive Care unit with multiple organ failure for approximately 4.5 weeks. Although his clinical situation improved over the last few days, the patient now deteriorates. There is fever up to 104 °F, a rising CRP of 398 and white blood cell count of 27 x 109/L. A contrast enhanced CT demonstrates a large, heterogeneous, walled off, peripancreatic collection with gas inside. What is your diagnosis based on clinical and radiological information?

SIRS as commonly seen in the acute phase of severe acute pancreatitis

A 55 year old patient with acute necrotizing pancreatitis has been on the Intensive Care unit with multiple organ failure for approximately 4.5 weeks. Although his clinical situation improved over the last few days, the patient now deteriorates. There is fever up to 104 °F, a rising CRP of 398 and white blood cell count of 27 x 109/L. A contrast enhanced CT demonstrates a large, heterogeneous, walled off, peripancreatic collection with gas inside. What is the preferred treatment strategy at this point?

Image-guided percutaneous or endoscopic catheter drainage

Primary minimally invasive surgical necrosectomy

Which statement is correct in patients with severe acute pancreatitis?

Lactate Ringer’s solution reduces systemic inflammation compared to saline

Transient organ failure is the key determinant of mortality in acute pancreatitis

Transient SIRS < 48 h results in a mortality of 25.4% compared to 8% in persistent SIRS.

Fluid resuscitation can prevent necrosis formation.

Lactate Ringer’s solution reduces systemic inflammation compared to saline

43 year old man with a history of severe alcohol induced necrotising pancreatitis in mid 2011 is readmitted with abdominal pain, normal serum lipase level, WBC 29 Gpt/l [4.3-10], platelets 444 Gpt/l [140-440], sodium 126 mmol/l [135-145], potassium 5.6 mm0l/l [3.5-4.6], creatinin 180 µmol/l [74-110], BUN 18 mmol/l [2.5-6.4], CRP 173 mg/l [<5 ], IL6 362 pg/ml [<10], <0.02 &permil; Ethanol. CT scan shows the following: ERP shows the following: What would be your treatment approach?

My suspicion would be an infected pancreatic collection resulting from a disrupted pancreatic duct and I would drain the collection transabdominally and via the papillary route. In addition I would give antibiotics.

My suspicion would spontaneous bacterial peritonitis and I would treat with antibiotics and ascites drainage.

My suspicion would be an infected pancreatic collection resulting from a disrupted pancreatic duct and I would drain the collection transabdominally

My suspicion would be an infected pancreatic collection resulting from a disrupted pancreatic duct and I would drain the collection transabdominally and via the papillary route. In addition I would give antibiotics.

My suspicion would be an infected pancreatic collection resulting from a disrupted pancreatic duct and I would immediately perform a pancreatic left resection.

A 47 year old patient with known alcohol abuse is admitted to the ER with sudden onset of abdominal belt like pain 10 hours before admission, lipase levels of 494 µkatal/l [1.59-6.36], leukocytosis of 17.4 Gpt/l [4.3-10], CRP <3.1 mg/dl [<5.0 ], ALAT 1.9 µkatal/l [0.22-0.77], ASAT 0.88 µkatal/l [<0.59], gamma-GT 4.5 µkatal/l [<0.96], Bilirubin 8.5 µmol/l [0-17]. Abdominal ultrasound shows gallbladder stones. The common bile duct cannot be visualized. HR 124/min. RR 90/60 mmHg. How should this patient be treated:

fluids, antibiotics, pain treatment

fluids, antibiotics, selective gut decontamination, pain treatment

fluids, antibiotics, selective gut decontamination, probiotics, pain treatment

Is prophylactic antibiotic therapy mandatory in acute pancreatitis?

Only in severe biliary pancreatitis with cholangitis

Only in severe cases with a CRP> 50 mg/dl

Only in severe biliary pancreatitis with cholangitis

What is the risk of probiotic therapy in severe pancreatitis?

Urinary tract infections with E.coli 1917 Nissle or Lactobacillus

What is the optimal timing of cholecystectomy in mild pancreatitis?

Never if ERC and endoscopic sphincterotomy is performed

After normalisation of CRP levels

Which statement is correct in patients with biliary pancreatitis?

Endoscopic sphincterotomy reduces recurrence of biliary pancreatitis

Only cholecystectomy prevents recurrence of biliary pancreatitis

Every patients should undergo cholecystectomy within index admission

There is no need for cholecystectomy in biliary pancreatitis as all stones pass within 48h hours

When would you schedule cholecystectomy? Ultrasound shows gall bladder stones and cholestasis, patients was admitted 6 days prior to the CT-scan below.

I would perform a endoscopic sphincterotomy within the index admission and schedule cholecystectomy after the pseudocysts or fluid collections either resolve or persist beyond 6 weeks at

I would perform cholecystectomy within the next 72 hrs

I would perform a sphincterotomy within the next 72 hrs and never perform a cholecystectomy

I would wait for the resolution of the collection and then schedule for a laparoscopic cholecystectomy

I would perform a endoscopic sphincterotomy within the index admission and schedule cholecystectomy after the pseudocysts or fluid collections either resolve or persist beyond 6 weeks at

A 63-year old patient has been admitted for 2 weeks with acute biliary pancreatitis. Because of spiking fevers and positive blood cultures without organ failure a CT scan is made which demonstrates pancreatic necrosis without encapsulating wall and without impacted gas bubbles in the collection. What is probably the best strategy for this patient:

Antibiotics, initially conservative, monitor vitals

Fine needle aspiration, if positive intervention, if negative conservative, vitals

Emergency intervention (e.g. percutaneous drainage)

Regarding fine needle aspirations in necrotizing pancreatitis?

It should be performed routinely in all patients with necrotizing pancreatitis

It is mandatory prior to intervention for necrotizing pancreatitis

False negative outcome of FNA in necrotizing pancreatitis is rare, below 10%

Regarding interventions for sterile necrotizing pancreatitis

May be indicated in rare cases of ‘disconnected duct syndrome’

May be indicated in cases of ongoing gastric outlet obstruction

May be indicated in patients with pancreaticopleural fistula

A 73-year old patient has been admitted for 1 week with acute biliary pancreatitis and is in the intensive care unit with multisystem organ failure. Despite placing an NG tube and attempting to start elemental feeding, the patient has high tube feed residuals and tube feeding cannot be continued. What is probably the best strategy for this patient?

Initiate total parenteral nutrition

Switch tube feeding formulation

Place an NJ tube and begin elemental feeding

Initiate total parenteral nutrition

Acute Pancreatitis Post-test

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Total Contribution - 1 | Total attempts - 3,492

Questions: 36 | Attempts: 3,494 | Updated: Mar 22, 2023

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Questions and Answers

1.

What is an alternate bedside test, with the most number of clinical studies to support its use in the diagnosis of acute pancreatitis?
- A.
  
  Urinary trypsinogen activation peptide (TAP)
- B.
  
  Urinary trypsinogen-1
- C.
  
  Urinary trypsinogen-2
- D.
  
  Urinary elastase.
Correct Answer
C. Urinary trypsinogen-2

Explanation
Urinary trypsinogen-2 is the correct answer because it has the most number of clinical studies supporting its use in the diagnosis of acute pancreatitis. These studies have shown that urinary trypsinogen-2 levels are elevated in patients with acute pancreatitis, making it a reliable and useful bedside test for diagnosing the condition.

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2.

Which is the best first step in the evaluation of a patient with idiopathic recurrent acute pancreatitis?
- A.
  
  Secretin-stimulated MRCP
- B.
  
  Empiric cholecystectomy
- C.
  
  Endoscopic ultrasound
- D.
  
  ERCP
Correct Answer
C. Endoscopic ultrasound

Explanation
Endoscopic ultrasound is the best first step in the evaluation of a patient with idiopathic recurrent acute pancreatitis. This is because endoscopic ultrasound allows for direct visualization of the pancreas and surrounding structures, providing detailed information about any anatomical abnormalities or lesions that may be causing the recurrent pancreatitis. It also allows for the collection of tissue samples for further analysis, if necessary. Secretin-stimulated MRCP, empiric cholecystectomy, and ERCP are not the best first steps as they do not provide the same level of detailed imaging and diagnostic capabilities as endoscopic ultrasound.

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3.

Which biochemical test is an early predictor of biliary etiology of acute pancreatitis?
- A.
  
  Serum elastase
- B.
  
  Lipase
- C.
  
  Bilirubin
- D.
  
  G-Glutamyltransferase
- E.
  
  None of the above
Correct Answer
E. None of the above

Explanation
None of the above options are early predictors of the biliary etiology of acute pancreatitis. Serum elastase and lipase are enzymes that are elevated in pancreatitis, but they do not specifically indicate a biliary cause. Bilirubin and G-Glutamyltransferase are markers of liver function, but they are not specific to pancreatitis or its biliary etiology. Therefore, none of the given options are correct as an early predictor of the biliary etiology of acute pancreatitis.

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4.

What is the optimal timing for the initial intervention in a clinically stable patient with infected pancreatic necrosis? Choose the one best answer:
- A.
  
  10 days after the onset of pancreatitis
- B.
  
  20 days after the onset of pancreatitis
- C.
  
  30 days after the onset of pancreatitis
- D.
  
  40 days or later after the onset of pancreatitis
Correct Answer
C. 30 days after the onset of pancreatitis

Explanation
The optimal timing for initial intervention in a clinically stable patient with infected pancreatic necrosis is 30 days after the onset of pancreatitis. This allows for a period of observation and conservative management to determine if the patient's condition stabilizes or improves on its own. It also provides enough time for the necrotic tissue to demarcate and become well-defined, making subsequent interventions safer and more effective. Intervening too early may lead to unnecessary procedures and potential complications, while delaying intervention beyond 30 days may increase the risk of systemic infection and other complications.

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5.

You are caring for a patient with acute necrotizing pancreatitis who is developing worsening sepsis and organ failure despite maximal intensive care and broad spectrum antibiotic administration 12 days after the onset of pancreatitis. You obtain a percutaneous, CT-guided fine needle aspirate of his pancreatic necrosis that demonstrates bacterial infection. The optimal intervention at this time is:
- A.
  
  Continued antibiotic administration and supportive therapy only
- B.
  
  Percutaneous drainage
- C.
  
  Endoscopic transluminal drainage
- D.
  
  Video assisted retroperitoneal debridement
Correct Answer
B. Percutaneous drainage

Explanation
Percutaneous drainage is the optimal intervention at this time for a patient with acute necrotizing pancreatitis who is developing worsening sepsis and organ failure. This procedure involves inserting a catheter through the skin into the necrotic area of the pancreas to drain the infected fluid. This helps to remove the source of infection and allows for better control of sepsis. Continued antibiotic administration and supportive therapy alone may not be sufficient to address the worsening condition. Endoscopic transluminal drainage and video-assisted retroperitoneal debridement are not the recommended interventions in this scenario.

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6.

Which of the following patients with acute necrotizing pancreatitis are most likely to benefit from surgical intervention early in the course of disease?
- A.
  
  Patients with sterile necrosis
- B.
  
  Patients with duodenal obstruction
- C.
  
  Patients with hemorrhage
- D.
  
  Patients with colonic infarction
Correct Answer
D. Patients with colonic infarction

Explanation
Patients with colonic infarction are most likely to benefit from surgical intervention early in the course of acute necrotizing pancreatitis because colonic infarction is a severe complication that can lead to bowel perforation and sepsis. Surgical intervention can help remove the necrotic tissue, prevent further complications, and improve patient outcomes. Sterile necrosis, duodenal obstruction, and hemorrhage may also require surgical intervention in some cases, but colonic infarction is considered a more urgent indication for surgery.

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7.

A 55 year old patient with acute necrotizing pancreatitis has been on the Intensive Care unit with multiple organ failure for approximately 4.5 weeks. Although his clinical situation improved over the last few days, the patient now deteriorates. There is fever up to 104 °F, a rising CRP of 398 and white blood cell count of 27 x 10⁹/L. A contrast enhanced CT demonstrates a large, heterogeneous, walled off, peripancreatic collection with gas inside. What is your diagnosis based on clinical and radiological information?
- A.
  
  Acute pseudocyst
- B.
  
  Infected necrosis
- C.
  
  SIRS as commonly seen in the acute phase of severe acute pancreatitis
- D.
  
  Abdominal compartment syndrome
Correct Answer
B. Infected necrosis

Explanation
Based on the clinical and radiological information provided, the diagnosis is infected necrosis. The patient's deteriorating condition, along with the presence of fever, elevated CRP, and high white blood cell count, suggests an infection. The contrast-enhanced CT scan showing a large, heterogeneous, walled-off peripancreatic collection with gas inside further supports the diagnosis of infected necrosis. This is a serious complication of acute necrotizing pancreatitis and requires immediate medical intervention.

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8.

A 55 year old patient with acute necrotizing pancreatitis has been on the Intensive Care unit with multiple organ failure for approximately 4.5 weeks. Although his clinical situation improved over the last few days, the patient now deteriorates. There is fever up to 104 °F, a rising CRP of 398 and white blood cell count of 27 x 10⁹/L. A contrast enhanced CT demonstrates a large, heterogeneous, walled off, peripancreatic collection with gas inside. What is the preferred treatment strategy at this point?
- A.
  
  Conservative treatment
- B.
  
  Image-guided percutaneous or endoscopic catheter drainage
- C.
  
  Primary open necrosectomy
- D.
  
  Primary minimally invasive surgical necrosectomy
Correct Answer
B. Image-guided percutaneous or endoscopic catheter drainage

Explanation
The preferred treatment strategy at this point is image-guided percutaneous or endoscopic catheter drainage. This is because the patient has a large, walled off peripancreatic collection with gas inside, indicating the presence of infected necrotic tissue. Image-guided percutaneous or endoscopic catheter drainage allows for the drainage of the collection and removal of infected material, without the need for open surgery. This minimally invasive approach is preferred in cases of infected necrotizing pancreatitis as it reduces the risk of complications associated with open surgery.

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9.

A 55 year old patient with acute necrotizing pancreatitis has been on the Intensive Care unit with multiple organ failure for approximately 4.5 weeks. Although his clinical situation improved over the last few days, the patient now deteriorates. There is fever up to 104 °F, a rising CRP of 398 and white blood cell count of 27 x 10⁹/L. A contrast enhanced CT demonstrates a large, heterogeneous, walled off, peripancreatic collection with gas inside. If a patient with infected necrosis undergoes percutaneous catheter drainage, what is the chance the patient will need additional surgical necrosectomy?
- A.
  
  20%
- B.
  
  40%
- C.
  
  60%
- D.
  
  80%
Correct Answer
C. 60%

Explanation
The chance that the patient will need additional surgical necrosectomy after undergoing percutaneous catheter drainage is 60%. This is because the patient has infected necrosis, as indicated by the presence of fever, elevated CRP, and high white blood cell count. Infected necrosis often requires a combination of percutaneous drainage and surgical necrosectomy for effective treatment. Therefore, there is a 60% chance that the patient will require additional surgical intervention.

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10.

What is the best fluid type to use for resuscitation in acute pancreatitis?
- A.
  
  Normal saline
- B.
  
  Ringers lactate
- C.
  
  Dextrose saline
- D.
  
  Gelofusine
Correct Answer
B. Ringers lactate

Explanation
Ringers lactate is the best fluid type to use for resuscitation in acute pancreatitis. This is because Ringers lactate is a balanced crystalloid solution that closely resembles the electrolyte composition of plasma. It contains sodium, potassium, calcium, and lactate, which help to restore intravascular volume, correct electrolyte imbalances, and maintain acid-base balance. Normal saline, on the other hand, is a less ideal choice as it can lead to hyperchloremic acidosis. Dextrose saline and Gelofusine are not commonly used for resuscitation in acute pancreatitis.

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11.

What is the optimal rate for infusion of fluid in resuscitation of acute pancreatitis?
- A.
  
  10-15 ml/kg/h
- B.
  
  5-10 ml/kg/h
- C.
- D.
  
  >15 ml/kg/h
Correct Answer
B. 5-10 ml/kg/h

Explanation
The optimal rate for infusion of fluid in the resuscitation of acute pancreatitis is 5-10 ml/kg/h. This rate is recommended because it helps to maintain adequate hydration and prevent complications such as fluid overload. Infusing fluids at a higher rate (>15 ml/kg/h) may increase the risk of fluid overload and worsen the condition. Therefore, it is important to carefully monitor the fluid balance and adjust the infusion rate accordingly.

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12.

What is the best laboratory goal to use to guide fluid resuscitation in acute pancreatitis?
- A.
  
  Haematocrit
- B.
  
  Blood urea nitrogen
- C.
  
  Serum creatinine
- D.
  
  Amylase
Correct Answer
A. Haematocrit

Explanation
Haematocrit is the best laboratory goal to use to guide fluid resuscitation in acute pancreatitis because it measures the percentage of red blood cells in the total blood volume. In acute pancreatitis, there is often fluid shifting and third spacing, leading to intravascular volume depletion. Monitoring haematocrit levels helps determine the need for fluid resuscitation and assess the effectiveness of treatment. A decrease in haematocrit indicates ongoing fluid loss and the need for further resuscitation, while an increase suggests adequate fluid replacement. Therefore, haematocrit is a reliable marker for guiding fluid resuscitation in acute pancreatitis.

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13.

Who is not at high risk for rapid deterioration of acute pancreatitis and thus should be treated at ITU or HDU?
- A.
  
  Elderly
- B.
  
  Persistent SIRS
- C.
  
  Obese patients
- D.
  
  Drug induced pancreatitis
Correct Answer
D. Drug induced pancreatitis

Explanation
Drug induced pancreatitis refers to inflammation of the pancreas caused by certain medications. Unlike other risk factors such as being elderly, having persistent SIRS (systemic inflammatory response syndrome), or being obese, drug induced pancreatitis does not necessarily indicate a high risk for rapid deterioration of acute pancreatitis. Therefore, patients with drug induced pancreatitis may not require treatment at the intensive care unit (ITU) or high dependency unit (HDU) compared to those with other risk factors.

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14.

Which statement is correct in patients with severe acute pancreatitis?
- A.
  
  Transient organ failure is the key determinant of mortality in acute pancreatitis
- B.
  
  Transient SIRS < 48 h results in a mortality of 25.4% compared to 8% in persistent SIRS.
- C.
  
  Fluid resuscitation can prevent necrosis formation.
- D.
  
  Lactate Ringer’s solution reduces systemic inflammation compared to saline
Correct Answer
D. Lactate Ringer’s solution reduces systemic inflammation compared to saline

Explanation
Lactate Ringer's solution reduces systemic inflammation compared to saline.

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15.

43 year old man with a history of severe alcohol induced necrotising pancreatitis in mid 2011 is readmitted with abdominal pain, normal serum lipase level, WBC 29 Gpt/l [4.3-10], platelets 444 Gpt/l [140-440], sodium 126 mmol/l [135-145], potassium 5.6 mm0l/l [3.5-4.6], creatinin 180 µmol/l [74-110], BUN 18 mmol/l [2.5-6.4], CRP 173 mg/l [<5 ], IL6 362 pg/ml [<10], <0.02 ‰ Ethanol. CT scan shows the following: ERP shows the following: What would be your treatment approach?
- A.
  
  My suspicion would spontaneous bacterial peritonitis and I would treat with antibiotics and ascites drainage.
- B.
  
  My suspicion would be an infected pancreatic collection resulting from a disrupted pancreatic duct and I would drain the collection transabdominally
- C.
  
  My suspicion would be an infected pancreatic collection resulting from a disrupted pancreatic duct and I would drain the collection transabdominally and via the papillary route. In addition I would give antibiotics.
- D.
  
  My suspicion would be an infected pancreatic collection resulting from a disrupted pancreatic duct and I would immediately perform a pancreatic left resection.
Correct Answer
C. My suspicion would be an infected pancreatic collection resulting from a disrupted pancreatic duct and I would drain the collection transabdominally and via the papillary route. In addition I would give antibiotics.

Explanation
The patient's history of severe alcohol-induced necrotizing pancreatitis and the presence of abdominal pain, abnormal laboratory values (elevated WBC, low sodium, high potassium, high creatinine, high BUN, elevated CRP and IL6), and findings on CT scan suggest an infected pancreatic collection resulting from a disrupted pancreatic duct. The appropriate treatment approach would be to drain the collection transabdominally and via the papillary route to remove the infected fluid and relieve symptoms. Antibiotics would also be given to treat the infection.

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16.

A 47 year old patient with known alcohol abuse is admitted to the ER with sudden onset of abdominal belt like pain 10 hours before admission, lipase levels of 494 µkatal/l [1.59-6.36], leukocytosis of 17.4 Gpt/l [4.3-10], CRP <3.1 mg/dl [<5.0 ], ALAT 1.9 µkatal/l [0.22-0.77], ASAT 0.88 µkatal/l [<0.59], gamma-GT 4.5 µkatal/l [<0.96], Bilirubin 8.5 µmol/l [0-17]. Abdominal ultrasound shows gallbladder stones. The common bile duct cannot be visualized. HR 124/min. RR 90/60 mmHg. How should this patient be treated:
- A.
  
  Fluids, antibiotics, pain treatment
- B.
  
  Fluids, pain treatment
- C.
  
  Fluids, antibiotics, selective gut decontamination, pain treatment
- D.
  
  Fluids, antibiotics, selective gut decontamination, probiotics, pain treatment
Correct Answer
B. Fluids, pain treatment

Explanation
The patient is presenting with sudden onset of abdominal pain, elevated lipase levels, leukocytosis, and abnormal liver function tests. These findings suggest acute pancreatitis, which is commonly caused by gallstones. The absence of visualization of the common bile duct on ultrasound further supports this diagnosis. The treatment for acute pancreatitis includes fluid resuscitation to maintain hydration and pain management. Antibiotics and gut decontamination are not indicated unless there is evidence of infection. Probiotics are also not necessary in this case. Therefore, the correct treatment for this patient is fluids and pain treatment.

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17.

Is prophylactic antibiotic therapy mandatory in acute pancreatitis?
- A.
  
  Yes, always
- B.
  
  No, never
- C.
  
  Only in severe cases with a CRP> 50 mg/dl
- D.
  
  Only in severe biliary pancreatitis with cholangitis
Correct Answer
D. Only in severe biliary pancreatitis with cholangitis

Explanation
Prophylactic antibiotic therapy is not mandatory in all cases of acute pancreatitis. It is only recommended in severe cases of biliary pancreatitis with cholangitis. This is because cholangitis is a serious infection of the bile ducts that can occur in cases of biliary pancreatitis. In such cases, antibiotics are necessary to treat the infection and prevent further complications. However, in other cases of acute pancreatitis, prophylactic antibiotic therapy is not necessary.

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18.

What is the risk of probiotic therapy in severe pancreatitis?
- A.
  
  Severe fungal pneumonia
- B.
  
  Bowel ischemia
- C.
  
  Urinary tract infections with E.coli 1917 Nissle or Lactobacillus
- D.
  
  There is no risk of treatment
Correct Answer
B. Bowel ischemia

Explanation
Probiotic therapy, which involves the use of live bacteria or yeasts to improve gut health, has been suggested as a potential treatment for various conditions. However, in the case of severe pancreatitis, there is a risk of bowel ischemia associated with probiotic therapy. Bowel ischemia refers to a condition where there is a decrease in blood supply to the intestines, leading to tissue damage. This risk is important to consider when deciding on the use of probiotics in patients with severe pancreatitis.

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19.

What is the optimal timing of cholecystectomy in mild pancreatitis?
- A.
  
  Within the index admission
- B.
  
  Never if ERC and endoscopic sphincterotomy is performed
- C.
  
  After normalisation of CRP levels
- D.
  
  Within 6 weeks after discharge
Correct Answer
A. Within the index admission

Explanation
The optimal timing of cholecystectomy in mild pancreatitis is within the index admission. This means that the surgery should be performed while the patient is still in the hospital for their initial episode of pancreatitis. This is because early cholecystectomy has been shown to reduce the risk of recurrent pancreatitis and other complications associated with gallstones. Delaying the surgery may increase the risk of further episodes and complications.

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20.

Which statement is correct in patients with biliary pancreatitis?
- A.
  
  Endoscopic sphincterotomy reduces recurrence of biliary pancreatitis
- B.
  
  Only cholecystectomy prevents recurrence of biliary pancreatitis
- C.
  
  Every patients should undergo cholecystectomy within index admission
- D.
  
  There is no need for cholecystectomy in biliary pancreatitis as all stones pass within 48h hours
Correct Answer
A. Endoscopic sphincterotomy reduces recurrence of biliary pancreatitis

Explanation
Endoscopic sphincterotomy is a procedure that involves cutting the muscle of the sphincter of Oddi, which is the valve that controls the flow of bile and pancreatic juice into the small intestine. This procedure is commonly used to remove gallstones or to treat conditions such as biliary pancreatitis. By removing the obstruction in the biliary system, endoscopic sphincterotomy can help reduce the recurrence of biliary pancreatitis. Therefore, the statement "Endoscopic sphincterotomy reduces recurrence of biliary pancreatitis" is correct.

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21.

When would you schedule cholecystectomy? Ultrasound shows gall bladder stones and cholestasis, patients was admitted 6 days prior to the CT-scan below.
- A.
  
  I would perform cholecystectomy within the next 72 hrs
- B.
  
  I would perform a sphincterotomy within the next 72 hrs and never perform a cholecystectomy
- C.
  
  I would wait for the resolution of the collection and then schedule for a laparoscopic cholecystectomy
- D.
  
  I would perform a endoscopic sphincterotomy within the index admission and schedule cholecystectomy after the pseudocysts or fluid collections either resolve or persist beyond 6 weeks at
Correct Answer
D. I would perform a endoscopic sphincterotomy within the index admission and schedule cholecystectomy after the pseudocysts or fluid collections either resolve or persist beyond 6 weeks at
22.

A 63-year old patient has been admitted for 2 weeks with acute biliary pancreatitis. Because of spiking fevers and positive blood cultures without organ failure a CT scan is made which demonstrates pancreatic necrosis without encapsulating wall and without impacted gas bubbles in the collection. What is probably the best strategy for this patient:
- A.
  
  Conservative, monitor vitals
- B.
  
  Antibiotics, initially conservative, monitor vitals
- C.
  
  Fine needle aspiration, if positive intervention, if negative conservative, vitals
- D.
  
  Emergency intervention (e.g. percutaneous drainage)
Correct Answer
B. Antibiotics, initially conservative, monitor vitals

Explanation
Given the patient's presentation of acute biliary pancreatitis with pancreatic necrosis but without encapsulating wall and impacted gas bubbles in the collection, the best strategy would be to start with antibiotics and initially take a conservative approach while monitoring the patient's vital signs. This approach aims to manage the infection and inflammation with antibiotics, while closely monitoring the patient's condition to assess for any signs of organ failure or worsening of symptoms. This strategy allows for potential intervention if necessary, while also avoiding unnecessary invasive procedures such as fine needle aspiration or emergency interventions like percutaneous drainage.

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23.

Regarding fine needle aspirations in necrotizing pancreatitis?
- A.
  
  It should be performed routinely in all patients with necrotizing pancreatitis
- B.
  
  It is mandatory prior to intervention for necrotizing pancreatitis
- C.
  
  False negative outcome of FNA in necrotizing pancreatitis is rare, below 10%
- D.
  
  None of the above
Correct Answer
D. None of the above

Explanation
Fine needle aspiration (FNA) is not routinely performed in all patients with necrotizing pancreatitis. It is not mandatory prior to intervention for necrotizing pancreatitis. Additionally, false negative outcomes of FNA in necrotizing pancreatitis are not rare, as they can occur in more than 10% of cases. Therefore, the correct answer is "None of the above".

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24.

Regarding interventions for sterile necrotizing pancreatitis
- A.
  
  May be indicated in rare cases of ‘disconnected duct syndrome’
- B.
  
  May be indicated in cases of ongoing gastric outlet obstruction
- C.
  
  May be indicated in patients with pancreaticopleural fistula
- D.
  
  All of the above
Correct Answer
D. All of the above

Explanation
Interventions for sterile necrotizing pancreatitis may be indicated in rare cases of 'disconnected duct syndrome', which refers to a situation where the main pancreatic duct is disconnected from the rest of the pancreas. These interventions may also be indicated in cases of ongoing gastric outlet obstruction, which occurs when the flow of food from the stomach to the small intestine is blocked. Additionally, interventions may be indicated in patients with pancreaticopleural fistula, which is an abnormal connection between the pancreas and the pleural space in the lungs. Therefore, the correct answer is "All of the above."

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25.

A 73-year old patient has been admitted for 1 week with acute biliary pancreatitis and is in the intensive care unit with multisystem organ failure. Despite placing an NG tube and attempting to start elemental feeding, the patient has high tube feed residuals and tube feeding cannot be continued. What is probably the best strategy for this patient?
- A.
  
  Switch tube feeding formulation
- B.
  
  Place an NJ tube and begin elemental feeding
- C.
  
  Initiate total parenteral nutrition
- D.
  
  Initiate probiotics
Correct Answer
C. Initiate total parenteral nutrition

Explanation
Initiating total parenteral nutrition (TPN) is the best strategy for this patient. The patient has high tube feed residuals and is unable to tolerate tube feeding, indicating that the gastrointestinal tract is not functioning properly. TPN provides essential nutrients directly into the bloodstream, bypassing the gastrointestinal tract, and is therefore suitable for patients who cannot tolerate enteral feeding. In this case, TPN would ensure that the patient receives the necessary nutrition despite the inability to tolerate tube feeding.

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26.

Regarding the type of enteral feeding that should be used in acute pancreatitis:
- A.
  
  Elemental or polymeric feeding should be the treatment of choice
- B.
  
  High fat formulations are acceptable to use in acute pancreatitis
- C.
  
  There is no role for “trickle” feeding to prevent translocation of gut flora
- D.
  
  None of the above
Correct Answer
A. Elemental or polymeric feeding should be the treatment of choice

Explanation
The correct answer is that elemental or polymeric feeding should be the treatment of choice in acute pancreatitis. This means that enteral feeding formulas that contain either partially or fully broken down nutrients should be used. These formulas are easier for the body to digest and absorb, which can help reduce the workload on the pancreas and promote healing. High fat formulations, on the other hand, may be harder for the pancreas to handle and could potentially worsen the condition. Additionally, there is no evidence to support the use of "trickle" feeding to prevent the translocation of gut flora in acute pancreatitis.

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27.

A 45-year old patient has been hospitalized with interstitial alcoholic pancreatitis for five days and feels that she would like to begin eating.
- A.
  
  Initiate clear liquid diet and advance as tolerated
- B.
  
  Initiate low-fat diet and advance as tolerated
- C.
  
  Initiate regular diet and advance as tolerated
- D.
  
  A or b
Correct Answer
D. A or b

Explanation
The correct answer is a or b. This is because in cases of interstitial alcoholic pancreatitis, it is important to start with a clear liquid diet and advance as tolerated. This allows the pancreas to rest and gradually introduces solid foods as the patient's condition improves. Both a low-fat diet and a regular diet can be considered as the patient progresses, depending on their tolerance and recovery.

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28.

Case History •A 62year old man with long-standing history of chronic alcohol consumption and congestive heart failure presents with sharp epigastric pain. He is diagnosed with acute pancreatitis. Initial vital signs in the emergency ward are as follows: temperature of 101.8F, pulse 106, blood pressure 115/70, respirations of 24 breaths/minute. •On examination, patient has tenderness in the epigastrium without rebound or guarding. He is confused during the course of the medical interview. •Laboratory studies are notable for lipase of 7000, WBC 12,000/mm3, hematocrit of 50%, blood urea nitrogen 30 mg/dL, creatinine 2.0 mg/dL. Which of the following factors in this patient’s presentation has not been linked to increased risk of mortality in acute pancreatitis?
- A.
  
  Age 62 years
- B.
  
  Altered mental status
- C.
  
  Hematocrit of 50
- D.
  
  Blood urea nitrogen of 30 mg/dL
Correct Answer
C. Hematocrit of 50

Explanation
In acute pancreatitis, an elevated hematocrit level is associated with increased mortality. This is because hemoconcentration, which leads to an elevated hematocrit, is a sign of severe dehydration and hypovolemia. Dehydration can worsen the inflammatory response and lead to organ failure. Therefore, a hematocrit of 50% in this patient's presentation is a factor that has been linked to increased risk of mortality in acute pancreatitis.

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29.

Which of the following clinical scoring system was specifically developed for assessment at the time of admission?
- A.
  
  Ranson
- B.
  
  Glasgow-Imrie
- C.
  
  Bedside Index of Severity in Acute Pancreatitis (BISAP)
- D.
  
  Harmless Acute Pancreatitis Score (HAPS)
Correct Answer
D. Harmless Acute Pancreatitis Score (HAPS)

Explanation
The Harmless Acute Pancreatitis Score (HAPS) is specifically developed for assessment at the time of admission for patients with acute pancreatitis. It is a clinical scoring system that helps in predicting the severity of the disease and the risk of complications. The other scoring systems mentioned, such as Ranson, Glasgow-Imrie, and BISAP, may also be used for assessing pancreatitis, but they are not specifically designed for assessment at the time of admission.

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30.

Which scoring system has the highest sensitivity for prediction of severe acute pancreatitis during initial 24 hours of hospitalization?
- A.
  
  APACHE II score with threshold of 12
- B.
  
  SIRS with a threshold of 2
- C.
  
  Glasgow-Imrie Score with threshold of 3
- D.
  
  BISAP score with threshold of 3
Correct Answer
B. SIRS with a threshold of 2

Explanation
The SIRS scoring system with a threshold of 2 has the highest sensitivity for predicting severe acute pancreatitis during the initial 24 hours of hospitalization. This means that it is the most effective in correctly identifying patients who have severe acute pancreatitis. The SIRS criteria include abnormal body temperature, heart rate, respiratory rate, and white blood cell count. A threshold of 2 means that if a patient meets 2 or more of these criteria, they are classified as having SIRS.

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31.

A 25-year-old patient is admitted to the hospital with severe epigastric pain radiating to the back since 26 hours, nausea and vomiting. At presentation there are no clinical signs of organ failure. Laboratorium investigation shows amylase and lipase level of 280 and 340 U/L, respectively (normal institutional values are 70 and 60 U/L, respectively). There is fever up to 100°F, a CRP level of 105 and white blood cell count of 15 x 10⁹/L. A justified reason to perform a contrast-enhanced CT (CECT) at admission in this patient is:
- A.
  
  To definitively assess necrosis of pancreatic parenchyma.
- B.
  
  B) To confirm the diagnosis of acute pancreatitis because of uncertainty.
- C.
  
  To exclude a surgical condition.
- D.
  
  To stage the severity of disease for prognostic purposes.
Correct Answer
C. To exclude a surgical condition.

Explanation
The patient's presentation with severe epigastric pain radiating to the back, nausea, vomiting, and elevated amylase and lipase levels are consistent with acute pancreatitis. However, the presence of fever, elevated CRP level, and high white blood cell count raises concern for a potential surgical condition, such as infected pancreatic necrosis or pancreatic abscess. Performing a contrast-enhanced CT scan at admission can help exclude a surgical condition by identifying any complications or signs of infection in the pancreas, such as necrosis or abscess formation. This information is crucial for determining the appropriate management and surgical intervention if necessary.

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32.

A 25-year-old patient is admitted to the hospital with severe epigastric pain radiating to the back since 26 hours, nausea and vomiting. At presentation there are no clinical signs of organ failure. Laboratorium investigation shows amylase and lipase level of 280 and 340 U/L, respectively (normal institutional values are 70 and 60 U/L, respectively). There is fever up to 100°F, a CRP level of 105 and white blood cell count of 15 x 10⁹/L. At what time point is CT best performed to reliably diagnose acute necrotizing pancreatitis?
- A.
  
  At admission (day 1)
- B.
  
  At day 2
- C.
  
  Option A and B
- D.
  
  At day > 3
Correct Answer
D. At day > 3

Explanation
CT is best performed at day > 3 to reliably diagnose acute necrotizing pancreatitis. This is because it takes at least 72 hours for necrosis to develop in the pancreas. Performing CT before this time point may not accurately detect necrotizing pancreatitis, as the necrotic areas may not be fully developed. Therefore, waiting until day > 3 allows for a more reliable diagnosis of acute necrotizing pancreatitis.

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33.

A 25-year-old patient is admitted to the hospital with severe epigastric pain radiating to the back since 26 hours, nausea and vomiting. At presentation there are no clinical signs of organ failure. Laboratorium investigation shows amylase and lipase level of 280 and 340 U/L, respectively (normal institutional values are 70 and 60 U/L, respectively). There is fever up to 100°F, a CRP level of 105 and white blood cell count of 15 x 10⁹/L. What CT scan protocol is recommended in this patient for assessing the morphologic type of pancreatitis?
- A.
  
  Contrast-enhanced CT in the pancreatic or portal venous phase (50-70 seconds delay)
- B.
  
  Multiphasic contrast-enhanced CT (unenhanced, arterial and portal venous phase)
- C.
  
  Contrast-enhanced CT in the arterial phase (30 seconds delay)
- D.
  
  Non-contrast CT
Correct Answer
A. Contrast-enhanced CT in the pancreatic or portal venous phase (50-70 seconds delay)

Explanation
Contrast-enhanced CT in the pancreatic or portal venous phase (50-70 seconds delay) is recommended in this patient for assessing the morphologic type of pancreatitis. This is because contrast-enhanced CT allows for better visualization of the pancreas and surrounding structures, helping to identify any abnormalities or inflammation. The pancreatic or portal venous phase is specifically chosen as it provides optimal enhancement of the pancreas, allowing for accurate assessment of the morphologic type of pancreatitis.

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34.

The definition of acute pancreatitis is based on which of the following criteria?
- A.
  
  Laboratory (serum amylase > 3x upper limit of normal)
- B.
  
  Imaging (ultrasound, CT, MRI) criteria as reported by the AGA 2007 review
- C.
  
  Clinical (typical upper abdominal pain, nausea, ...)
- D.
  
  2 out of the 3 criteria mentioned above
- E.
  
  Only if all criteria mentioned are met.
Correct Answer
D. 2 out of the 3 criteria mentioned above

Explanation
Acute pancreatitis is defined based on 2 out of the 3 criteria mentioned above. These criteria include laboratory criteria (serum amylase > 3x upper limit of normal), imaging criteria as reported by the AGA 2007 review (ultrasound, CT, MRI), and clinical criteria (typical upper abdominal pain, nausea, etc.). Therefore, for a diagnosis of acute pancreatitis, a patient must meet at least two of these criteria.

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35.

Under which circumstances is ERCPand sphincterotomy indicated early in the course of pancreatitis?
- A.
  
  Mild biliary pancreatitis.
- B.
  
  Biliary pancreatitis with co-existing cholangitis.
- C.
  
  Biliary pancreatitis with no co-existing biliary obstruction
- D.
  
  In severe biliary pancreatitis
Correct Answer
B. Biliary pancreatitis with co-existing cholangitis.

Explanation
ERCP (Endoscopic Retrograde Cholangiopancreatography) and sphincterotomy are indicated early in the course of pancreatitis when there is biliary pancreatitis with co-existing cholangitis. Cholangitis is an infection of the bile ducts, which can occur as a result of biliary obstruction. In this case, the obstruction may be causing the pancreatitis, and it is important to relieve the obstruction as soon as possible to prevent further complications. ERCP allows for visualization and intervention in the bile ducts, while sphincterotomy involves cutting the sphincter muscle to facilitate the flow of bile. This combination of procedures can effectively treat the underlying cause of the pancreatitis and prevent its progression.

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36.

If ERCP is indicated, what is the optimal timing in biliary pancreatitis?
- A.
  
  Within 24 hours after onset of the disease.
- B.
  
  Within 72 hours after onset of the disease.
- C.
  
  Within 24 hours after admission to the hospital.
- D.
  
  Within 72 hours after admission to the hospital.
- E.
  
  No recommendation can be given regarding the optimal timing.
Correct Answer
E. No recommendation can be given regarding the optimal timing.

Explanation
The question asks about the optimal timing for ERCP (endoscopic retrograde cholangiopancreatography) in biliary pancreatitis. The answer states that no recommendation can be given regarding the optimal timing. This suggests that there is no specific guideline or consensus on when exactly ERCP should be performed in biliary pancreatitis. The optimal timing may vary depending on the individual patient's condition and other factors, and therefore, it is not possible to provide a definitive recommendation.

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Acute Pancreatitis Post-test

What is an alternate bedside test, with the most number of clinical studies to support its use in the diagnosis of acute pancreatitis?

Which is the best first step in the evaluation of a patient with idiopathic recurrent acute pancreatitis?

Which biochemical test is an early predictor of biliary etiology of acute pancreatitis?

What is the optimal timing for the initial intervention in a clinically stable patient with infected pancreatic necrosis? Choose the one best answer:

Which of the following patients with acute necrotizing pancreatitis are most likely to benefit from surgical intervention early in the course of disease?

What is the best fluid type to use for resuscitation in acute pancreatitis?

What is the optimal rate for infusion of fluid in resuscitation of acute pancreatitis?

What is the best laboratory goal to use to guide fluid resuscitation in acute pancreatitis?

Who is not at high risk for rapid deterioration of acute pancreatitis and thus should be treated at ITU or HDU?

Which statement is correct in patients with severe acute pancreatitis?

Is prophylactic antibiotic therapy mandatory in acute pancreatitis?

What is the risk of probiotic therapy in severe pancreatitis?

What is the optimal timing of cholecystectomy in mild pancreatitis?

Which statement is correct in patients with biliary pancreatitis?

When would you schedule cholecystectomy? Ultrasound shows gall bladder stones and cholestasis, patients was admitted 6 days prior to the CT-scan below.

Regarding fine needle aspirations in necrotizing pancreatitis?

Regarding interventions for sterile necrotizing pancreatitis

Regarding the type of enteral feeding that should be used in acute pancreatitis:

A 45-year old patient has been hospitalized with interstitial alcoholic pancreatitis for five days and feels that she would like to begin eating.

Which of the following clinical scoring system was specifically developed for assessment at the time of admission?

Which scoring system has the highest sensitivity for prediction of severe acute pancreatitis during initial 24 hours of hospitalization?

The definition of acute pancreatitis is based on which of the following criteria?

Under which circumstances is ERCPand sphincterotomy indicated early in the course of pancreatitis?

If ERCP is indicated, what is the optimal timing in biliary pancreatitis?