Clin Med II_Gallbladder & Pancreas

Sudden steady pain localized in the epigastrium or RUQ radiating to the R. shoulder or scapula is a classical presentation of : a. Acute Cholecystitis b. Choledocholithiasis c. Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

a. Acute Cholecystitis

What is Murphy's sign and what is it associated with? a. Acute Cholecystitis b. Choledocholithiasis c. Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

a. Acute Cholecystitis - Acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration

Which of the following imaging tests is not recommended in pancreatic cancer? a. Ultrasonography b. Helical CT c. MRI d. PET e. Endoscopic Ultrasound

a. Ultrasonography ** Bowel gases may affect image

Excess fecal fat is found in: a. Acute Pancreatitis b. Chronic Pancreatitis c. Pancreatic Cancer

b. Chronic Pancreatitis

What is Charcot's Triad & what is it associated with? a. Acute Cholecystitis b. Chronic Cholecystitis c. Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

c. Cholangitis 1. Severe Pain 2. Fever & Chills 3. Jaundice

______________ is increased more than twofold over 5 years for patients with acute pancreatitis. a. Peptic Ulcer Disease b. Paralytic Ileus c. Diabetes Mellitus d. Encephalopathy e. Hyperlipidemia

c. Diabetes Mellitus

ARDS may present in which of the following: a. Acute Cholecystitis b. Chronic Cholecystitis c. Choledocholithiasis & Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

d. Acute Pancreatitis

Assessments such as Ranson Criteria, SOFA, APACHE II, & HAPS are used for which of the following? a. Acute Cholecystitis b. Chronic Cholecystitis c. Choledocholithiasis & Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

d. Acute Pancreatitis

Fever, tachycardia, hypotension (even shock), pallor, & cool clammy skin are present in severe cases of ____________________. a. Acute Cholecystitis b. Chronic Cholecystitis c. Choledocholithiasis & Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

d. Acute Pancreatitis

Gallstones, a sentinel loop (adynamic ileus), & linear atelectasis of lung lower lobes may present on a plain radiograph of : a. Acute Cholecystitis b. Chronic Cholecystitis c. Choledocholithiasis & Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

d. Acute Pancreatitis

Which of the following is consistent with acute cholangitis? A. Jaundice B. Caput medusa C. Bilateral flank bruising D. An enlarged, palpable nontender gallbladder

(c) A. Jaundice is part of Charcot's triad associated with cholangitis along with fever and biliary colic. (u) B. Caput medusa is associated with ascites and cirrhosis. (u) C. Bilateral flank bruising is associated with hemorrhagic pancreatitis. (u) D. An enlarged, nontender, palpable gallbladder is associated with cancer of the head of the pancreas.

Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct or A. cystic duct. B. pancreatic duct. C. duodenal ampulla. D. common hepatic duct.

(c) A. Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed thegallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis. (u) B. Obstruction of the pancreatic duct leads to development of acute pancreatitis. (u) C. The duodenal ampulla is the area where the pancreatic duct and the common bile duct empty into the duodenum. Gallstones do not cause obstruction at this distal site. (u) D. The common hepatic duct from the liver joins the cystic duct from the gallbladder to form the common bile duct.Stone migration occurs along the pathway of the cystic duct to the common bile duct, not along the common hepatic duct.

The initial manifestation of acute pancreatitis is often A. generalized pruritus B. epigastric pain C. epigastric mass D. anorexia

(u) A. Pruritus presents as a symptom only when acute pancreatitis occurs as a result of obstruction of the distal common bile duct. (c) B. The typical findings in acute pancreatitis include nausea, vomiting, and abdominal pain. Epigastric pain,generally abrupt in onset, is steady and severe. (u) C. Epigastric mass is more common in pancreatic cancer. (u) D. Anorexia is a common finding with chronic pancreatitis, but uncommon with acute pancreatitis.

A patient presents to the emergency department with right upper quadrant pain over eight hours, nausea, and vomiting. On exam there is a fever of 101.2 degrees F. Ultrasound shows a distended gallbladder. What is the mostappropriate management of this patient? A. Oral analgesics B. Diagnostic peritoneal lavage C. Proton pump inhibitors D. Laparoscopic cholecystectomy

(u) A. See D for explanation. (u) B. Diagnostic peritoneal lavage is used to detect intraabdominal bleeding from trauma and not to treat acute cholecystitis and may delay appropriate treatment. (u) C. Proton pump inhibitors are used to treat GERD or PUD. (c) D. The proper treatment for acute cholecystitis is IV fluids, antibiotics, pain control, and surgery. Cholecystectomy is the definitive treatment for acute cholecystitis and laparoscopic cholecystectomy is the procedure of choice.

A 62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwiseunremarkable. Which of the following is the most likely diagnosis? A. Viral hepatitis B. Pancreatic cancer C. Acute cholecystitis D. Gilbert's syndrome

(u) A. While viral hepatitis may cause jaundice, the liver is enlarged and tender. (c) B. Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer. (u) C. While acute cholecystitis may present with jaundice and an enlarged gallbladder, the pain is classically colicky and located in the right upper quadrant. On physical examination with deep inspiration and palpation of the right subcostal area increased pain and respiratory arrest (Murphy's sign) is usually seen. (u) D. Gilbert's syndrome is the most common of the hereditary hyperbilirubinemias. It is most often diagnosed near puberty or adult life based on results of a comprehensive metabolic panel.

Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis? A.Weight loss B. Intractable pain C. Exocrine deficiency D. To decrease risk of cancer

(u) A. While weight loss is common with chronic pancreatitis, it is not an indication for surgical intervention. (c) B. Indications for surgical treatment of chronic pancreatitis include severe pain that limits the patient's functioning or intractable pain despite the use of non-narcotic analgesics and absence of alcohol intake. (u) C. While the majority of patients go on to develop diabetes mellitus 25 years after the clinical onset of chronic pancreatitis, this is not an indication for surgical intervention as it would lead to more severe exocrinedeficiency. (u) D. While the possible presence of pancreatic cancer is an indication for surgery, there is no indication forprophylactic surgery to decrease the risk of cancer.

What do each of the following tests show for choledocholithiasis & cholangitis? - US & CT - Nuclear Imaging - CT & MRI Cholangiography - ERCP or Percutaneous Transhepatic Cholangiography

- US & CT → shows dilated bile ducts - Nuclear Imaging → shows impaired bile flow - CT & MRI Cholangiography → shows bile duct stones - ERCP or Percutaneous Transhepatic Cholangiography → most direct view of bile ducts

Tumors of the ampulla have a _____________ (worse/better) prognosis in pancreatic cancer.

Better

Why is there prolonged PT in choledocholithiasis & cholangitis?

Bile is necessary for Vitamin K → obstruction causes bile to to backup & never reach small intestines

Why might acute pancreatitis present with hyperglycemia & glycosuria?

Effects of insulin/glucagon production/release in the pancreas

Endoscopic Stenting is a curative treatment for pancreatic cancer. (T/F)

False → palliative care

ERCP is indicated in ___________ (acute/chronic) pancreatitis & contraindicated in ___________ (acute/chronic) pancreatitis.

Indicated → Chronic Contraindicated → Acute ** Invasive test, not needed for acute pancreatitis

Why are serum amylase/lipase high in acute pancreatitis?

Inflammation of the pancreas affects the production/release of digestive enzymes

_____________ may improve survival in diabetic patients with pancreatic cancer.

Metformin

Are post-operative antibiotics administered after biliary tract surgery?

No

Which medication is advise to be avoided if possible in chronic pancreatitis?

Opioids

What is Courvoisier's Sign & what may it indicate?

Palpable gallbladder due to obstruction → Pancreatic Cancer

What is Whipple Resection used to treat?

Pancreatic Cancer (The Head)

HIDA (Hepatic Iminodiacetic Acid Scan) is recommended for which of the following? a. Acute Cholecystitis b. Choledocholithiasis c. Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

a. Acute Cholecystitis

Perforation & Gangrene are complications of which of the following? a. Acute Cholecystitis b. Choledocholithiasis c. Cholangitis d. Acute Pancreatitis e. Pancreatic Cancer

a. Acute Cholecystitis