Chapter 37: Alterations in Function of the Gallbladder and Exocrine Pancreas

8. Chronic pancreatitis may lead to a. diabetes mellitus. b. Crohn disease. c. gallstones. d. celiac sprue.

ANS: A About 10% to 15% of patients will present not with pain, but rather with the sequelae of chronic pancreatitis, including diabetes mellitus, malabsorption, and weight loss. Chronic pancreatitis does not lead to Crohn disease. Increased incidence of gallstones is not the result of chronic pancreatitis. Celiac sprue is not related to chronic pancreatitis.

12. Untreated acute cholecystitis may lead to ________ of the gallbladder wall. a. gangrene b. infection c. distention d. inflammation

ANS: A If left untreated, the inflammatory process often escalates, and gangrene of the gallbladder wall with rupture may occur. Acute cholecystitis is defined as acute inflammation of the gallbladder wall. Distention of the gallbladder wall is not a risk factor related to untreated cholecystitis. Acute cholecystitis is defined as acute inflammation of the gallbladder wall.

1. Normal bile is composed of a. water, electrolytes, and organic solutes. b. proteins. c. bile acids. d. phospholipids.

ANS: A Normal bile is composed primarily of water, electrolytes, and organic solutes. Bile has a low protein content. The low amount of protein in bile contains bile acids, pigment, cholesterol, and phospholipids. Phospholipids are part of the low protein content in bile.

2. Chronic cholecystitis can lead to (Select all that apply.) a. biliary sepsis. b. calcified gallbladder. c. porcelain gallbladder. d. cirrhosis. e. diabetes mellitus.

ANS: A, B, C Chronic cholecystitis may lead to biliary sepsis, as well as a specific type of scarring known as a calcified or porcelain gallbladder. Chronic cholecystitis is associated with a higher risk of cancer, not cirrhosis which affects the liver. Diabetes mellitus is a predisposing factor of chronic cholecystitis. Chronic cholecystitis does not cause diabetes mellitus.

MULTIPLE RESPONSE 1. Patients who may be at risk for development of cholesterol gallstones include (Select all that apply.) a. high spinal cord injuries. b. patients receiving total parenteral nutrition. c. patients receiving chemotherapy. d. patients with rapid weight loss. e. pregnant women.

ANS: A, B, D, E A significant factor that promotes the continued growth of stones is hypomotility or stasis of bile within the gallbladder. Patients with high spinal cord injuries, patients receiving total parenteral nutrition, and persons who undergo prolonged fasting or rapid weight loss have impaired emptying and are at particular risk for development of cholesterol gallstones. Other risk factors for cholelithiasis include pregnancy, oral contraceptives, obesity, and diabetes mellitus. Patients receiving chemotherapy are not at greater risk for developing gallstones.

10. The finding of hypotension, rigid abdomen, and absent bowel sounds in a patient with pancreatitis a. is an expected finding and requires no specific intervention. b. indicates peritonitis with substantial risk for sepsis and shock. c. requires immediate surgical intervention. d. is an unusual finding in pancreatitis and indicates misdiagnosis.

ANS: B In acute pancreatitis, fever is common but is usually low-grade initially. In more severe pancreatitis, hypotension, rigid abdomen, and absent bowel sounds are present. Hypotension, rigid abdomen, and absent bowel sounds are unexpected findings. Pancreatic surgery is technically challenging and risky, and generally is only considered as a last resort. Findings indicative of peritonitis do occur and should be treated promptly.

2. Patients with acute pancreatitis are generally made NPO and may require continuous gastric suctioning in order to a. prevent abdominal distention. b. remove the usual stimuli for pancreatic secretion. c. prevent hyperglycemia associated with loss of insulin secretion. d. prevent mechanical obstruction of the intestine.

ANS: B Conservative management is indicated for mild to moderate cases of acute pancreatitis. In general, withholding oral feedings, providing nasogastric suction, and providing careful volume replacement with IV fluids are indicated. Gastric suctioning is not indicated for preventing abdominal distention. Hyperglycemia is not influenced by the presence of gastric suctioning. Continuous gastric suctioning may be used in the presence of a significant ileus.

11. It is true that gallstones are a. a minimal risk for Native Americans. b. more common in women. c. more common in men. d. at highest risk among Asians.

ANS: B Gallstones are twice as common in women as in men. Native Americans, particularly the Pima Indians of North America, are markedly susceptible to gallstones. Gallstones are twice as common in women than in men. European Caucasians are intermediate in prevalence, and persons of Asian descent are at the lowest risk.

3. Most gallstones are composed of a. bile. b. cholesterol. c. calcium. d. uric acid salts.

ANS: B The majority of gallstones among patients are cholesterol stones. Cholesterol eventually precipitates from supersaturated bile. Most gallstones are not composed of calcium. Uric acid salts are not the primary composition of gallstones.

16. The pain associated with chronic pancreatitis is generally described as ________ in nature. a. sharp and constant b. steady and boring c. intermittent and burning d. intermittent and stabbing

ANS: B The pain is often accompanied by nausea and is steady and boring in nature. The pain is usually located in the upper abdomen, particularly in the epigastrium, and radiates to the back in more than half of cases. Pain associated with pancreatitis is most often steady in nature. The pain of chronic pancreatitis is often the major form of debility. Nerve fibers from the pancreas pass to the celiac plexus and then to spinal sympathetic ganglia.

3. Which digestive enzyme is secreted from the intestinal mucosa during a meal? (Select all that apply.) a. Amylase b. Cholecystokinin c. Trypsinogen d. Lecithin e. Lipase f. Secretin

ANS: B, F The release of digestive enzymes during a meal is controlled by hormones secreted from the small intestinal mucosa: cholecystokinin (CCK) and secretin. The juices themselves are composed of both active digestive enzymes (e.g., amylase, lipase) and precursor or proenzymes (e.g., trypsinogen). Trypsinogen is a proenzyme. Lecithin is unrelated to hormone release during meals.

4. Elevated serum lipase and amylase levels are indicative of a. gallbladder disease. b. appendicitis. c. pancreatitis. d. peritonitis.

ANS: C The laboratory evaluation of acute pancreatitis begins with measurements of serum pancreatic enzymes. Serum lipase and amylase levels rise more or less in tandem. Elevated serum lipase and amylase levels are not indicative of gallbladder disease. Appendicitis is not related to lipase and amylase levels. Peritonitis is not caused by elevated serum lipase or amylase levels.

15. Narcotic administration should be administered carefully in patients with acute pancreatitis related to potential for a. respiratory depression. b. narcotic dependency. c. sphincter of Oddi dysfunction. d. allergic reaction.

ANS: C All narcotics should be used carefully because of the potential of sphincter of Oddi dysfunction, although recent studies show that no single agent is contraindicated. Respiratory failure related to adult respiratory distress syndrome is a risk factor with severe pancreatitis. Narcotic dependency should not be a concern with acute pancreatitis. While patients should always be assessed for allergies, this is not the primary concern.

7. A patient with pancreatitis may experience muscle cramps secondary to a. alkalosis. b. hyperglycemia. c. hypocalcemia. d. hypermagnesemia.

ANS: C Associated laboratory findings of acute pancreatitis include leukocytosis, hyperlipidemia, and hypocalcemia. Alkalosis is not associated with pancreatitis. Hyperglycemia would not be a cause for muscle cramps. Hypermagnesemia is not generally related to pancreatitis.

14. More than half of the initial cases of pancreatitis are associated with a. trauma. b. stones. c. alcoholism. d. high cholesterol.

ANS: C Up to 66% of first cases of pancreatitis are associated with alcoholism. Trauma is a possible mechanism for acinar cell injury. A prominent factor in pancreatitis is obstruction of the pancreatic duct by a stone. Hypertriglyceridemia is a predisposing factor for pancreatitis in the United States.

6. A biliary cause of acute pancreatitis is suggested by an elevation in which serum laboratory results? a. Lipase b. Amylase c. Glucose d. Alkaline phosphatase

ANS: D Marked elevation of the alkaline phosphatase and bilirubin levels suggest the possibility of biliary disease or obstruction, particularly by gallstones. Elevated serum lipase levels and elevated glucose levels do not suggest a biliary cause of pancreatitis. Acute pancreatitis is evidenced by elevated serum amylase and lipase levels, but does not indicate biliary disease.

13. It is true that biliary cancer a. is most often cured by surgery. b. respond well to chemotherapy. c. are identifiable and treatable when diagnosed early. d. tend to be asymptomatic and progress insidiously.

ANS: D Biliary cancers tend to be asymptomatic and progress insidiously until well advanced. Surgery for cure is a treatment option in fewer than 10% of cases. Chemotherapy and radiation therapy are indicted for palliation, and certain patients may benefit from stenting and other procedures to alleviate biliary obstruction. Cancers of the biliary system are relatively rare, accounting for only 1 to 2 cases per 100,000 per year. Unfortunately, they tend to be asymptomatic and progress insidiously until well advanced.

5. The definitive treatment for cholecystitis is a. lithotripsy of stones. b. chemical dissolution of stones. c. antibiotics and anti-inflammatories. d. cholecystectomy.

ANS: D Surgical removal of the gallbladder is the definitive treatment for cholecystitis. Laparoscopic cholecystectomy is now the treatment of choice for symptomatic gallstones. Extracorporeal shock wave lithotripsy (ESWL), which involves the breaking up of gallstones using shock waves, is a nonsurgical approach which could lead to recurrence of stones. Chemodissolution of stones has a low overall efficacy. Antibiotics are generally used with acute cholecystitis if infection is involved.

9. The most challenging aspect of treatment for chronic pancreatitis is a. pancreatectomy. b. strict dietary avoidance of fats. c. abstinence from alcohol. d. pain control.

ANS: D The treatment for chronic pancreatitis is directed toward pain control, exocrine and endocrine insufficiency, and management of complications. By far the most challenging is the management of pain. If endoscopic management fails or is not appropriate in a given patient, surgery may be indicated. Management of exocrine insufficiency can usually be accomplished with low-fat diets. Absolute abstention from alcohol is paramount to prevent worsening of symptoms.