Acute pancreatitis

Question 1

Acute pancreatitis is the sudden inflammation and destruction of the pancreas. This is generally causes by injury to the acinar cells and impaired secretion of proenzymes from the acinar cells. What is the common surgical incidence of acute pancreatitis?

1 - 0.56/100,000
2 - 5/6/100,000
3 - 56/100,000
4 - 560/100,000

Answer 1

3 - 56/100,000

• 1/2000 hospital admissions in developed countries

Question 2

What is the mortality rate of acute pancreatitis?

1 - 0.5%
2 - 5%
3 - 25%
4 - 50%

Answer 2

2 - 5%

• others say it ranges between 2-6%
• 20% develop severe acute pancreatitis

Question 3

Are men or women more likely to develop acute pancreatitis?

Answer 3

• women

Question 4

At what age does the incidence of acute pancreatitis peak at?

1 - 20 y/o
2 - 30 y/o
3 - 40 y/o
4 - 50 y/o

Answer 4

4 - 50 y/o

Question 5

The mnemonic I GET SMASHED:

• I = idiopathic
• G = gallstones
• E = ethanol
• T = trauma
• S = steroids
• M = mumps virus
• A = autoimmune
• S = scorpion bite
• H = hypercalcaemia/ hypertriglyceraemia
• E = ERCP
• D = drugs

Which of 3 of these are the 3 most common causes in the correct order in the UK?

1 - I, G, E
2 - G, E, I
3 - G, I, E
4 - E, I, G

Answer 5

2 - G, E, I

1 - gallstones 50%
2 - ethanol 25%
3 - idiopathic 15-25%

Question 6

Which 2 of the following is how alcohol causes acute pancreatitis?

1 - increased zymogen secretion
2 - decreased zymogen secretion
3 - increased fluid and bicarbonate secretion
4 - decreased fluid and bicarbonate secretion

Answer 6

1 - increased zymogen secretion
4 - decreased fluid and bicarbonate secretion

• decreased fluid secretions causing thick solution and blockage of the pancreatic duct
• dysfunction in membrane trafficking, where lysosomes and zymogens may come into contact, and the pancreas undergoes autodigestion

Question 7

What is the primary pathophysiology of acute pancreatitis?

1 - membrane instability and early activation of zymogens
2 - blocked bile ducts
3 - inflamed pancreatic tissue
4 - trypsin activation

Answer 7

1 - membrane instability and early activation of zymogens

• closely followed by trypsin activation, which can then lead to interstitial oedematous pancreatitis

Question 8

At what age does the incidence of acute pancreatitis peak at?

1 - 20 y/o
2 - 30 y/o
3 - 40 y/o
4 - 50 y/o

Answer 8

4 - 50 y/o

Question 9

If a patient with acute pancreatitis undergoes a laparotomy, the surgeon may see white patches on the great omentum and mesentery, which is fat saponification (fat necrosis). This leads to what being sequestered in this area and a drop in blood levels?

1 - Na2+
2 - Ca2+
3 - Mg2+
4 - Cl-

Answer 9

2 - Ca2+

Question 10

If acute pancreatitis continues, there is activation of the complement and cytokine systems, which can subsequently lead to what?

1 - systemic inflammatory response syndrome (SIRS) and organ failure
2 - sepsis
3 - pancreatic pseudocyst formation
4 - perforation

Answer 10

1 - systemic inflammatory response syndrome (SIRS) and organ failure

• this can be detected on CT

Question 11

If the pancreas begins to become necrotic this can lead to what?

1 - perforation
2 - necrotising pancreatitis
3 - cholecystitis
4 - haemorrhage

Answer 11

2 - necrotising pancreatitis

• increased risk of mortality
• increased risk of infection with gram negative bacteria
• can lead to dark blood collection in abdominal cavity called acute haemorrhagic pancreatitis

Question 12

In a patient with acute pancreatitis, what is the description of the pain in which they present with?

1 - gradual onset of epigastric pain
2 - sudden onset of right hypochondriac pain
3 - sudden onset of epigastric pain
4 - intermittent epigastric pain

Answer 12

3 - sudden onset of epigastric pain

• often it is poorly localised
• some patients describe it as moving through to the back

Question 13

Which of the following is NOT a clinical feature of acute pancreatitis?

1 -sudden onset of epigastric pain
2 - vomiting
3 - only comfortable when lying down
4 - restless

Answer 13

3 - only comfortable when lying down

• this can occur as peritonitis sets in, other wise patients assume the pancreatic position (knees to chest)

Question 14

Amylase is often a blood test that is performed in a patient with suspected acute pancreatitis. What levels are generally confirmatory of acute pancreatitis?

1 - >100IU/ml
2 - >300IU/ml
3 - >700IU/ml
4 - >1000IU/ml

Answer 14

4 - >1000IU/ml

• often this is 3 times the normal level
• need to use caution as amylase levels can dip following an acute presentation

Question 15

Although serum amylase is used to try and diagnose patients with acute pancreatitis, but it has a poor association with disease severity. What other marker is more useful?

1 - CRP
2 - LDH
3 - troponin
4 - CK

Answer 15

1 - CRP

Question 16

What is the most sensitive measure used to diagnose a patient with acute pancreatitis?

1 - CRP
2 - amylase
3 - LDH
4 - plasma lipase

Answer 16

4 - plasma lipase

• also has a longer half life than amylase, so easier to detect later in the disease
• not widely used due to accessibility

Question 17

When trying to diagnose a patient with acute pancreatitis we need to rule out the most common cause. What is the first line imaging used for this?

1 - MRI
2 - CT
3 - X-ray
4 - ultrasound

Answer 17

4 - ultrasound

• reliably identifies gallstones and biliary dilation

Question 18

CT scan has limited for diagnosing acute pancreatitis. When is it generally used?

1 - when patient is terminally unwell
2 - clinical and biochemical findings are equivocal
3 - patient has a large BMI
4 - patient has chronic pancreatitis

Answer 18

2 - clinical and biochemical findings are equivocal

• can be helpful in severe pancreatitis
• needs to be performed at 72-96 hours

Question 19

If a patient has acute pancreatitis and the cause has been confirmed due to gallstones. How soon should an ERCP be performed with a sphincterotomy?

1 - <12 hours
2 - <48 hours
3 - <72 hours
4 - <96 hours

Answer 19

3 - <72 hours

Question 20

If a patient has acute pancreatitis and the cause has not been confirmed the patient may have an MRCP. Which of the following is the MRCP not great at identifying in a patient with acute pancreatitis?

1 - ductal stones
2 - CBD/PD anatomy
3 - pancreatic anatomy
4 - aetiology not related to gallstones

Answer 20

3 - <72 hours

• 4 - aetiology not related to gallstones

Question 21

Patients with acute pancreatitis are graded either mild or severe. To do this we can use the Ranson score or the modified version of the Ranson score, called the modified Glasgow score. The modified Glasgow score can be remembered using the mnemonic PANCREAS. What does the P stand for?

1 - Pao2
2 - pancreas inflammation
3 - polyuria
4 - PaCo2

Answer 21

1 - Pao2

• levels <8 kPA or 60mmHg

Question 22

Patients with acute pancreatitis are graded either mild or severe. To do this we can use the Ranson score or the modified version of the Ranson score, called the modified Glasgow score. The modified Glasgow score can be remembered using the mnemonic PANCREAS. What does the A stand for?

1 - Alzheimer’s
2 - acute onset
3 - age
4 - acidity

Answer 22

3 - age

• > 55 years

Question 23

Patients with acute pancreatitis are graded either mild or severe. To do this we can use the Ranson score or the modified version of the Ranson score, called the modified Glasgow score. The modified Glasgow score can be remembered using the mnemonic PANCREAS. What does the N stand for?

1 - pneumonia
2 - necrosis
3 - new onset
4 - neutrophil count

Answer 23

4 - neutrophil count

• > 15 x 109/L

Question 24

Patients with acute pancreatitis are graded either mild or severe. To do this we can use the Ranson score or the modified version of the Ranson score, called the modified Glasgow score. The modified Glasgow score can be remembered using the mnemonic PANCREAS. What does the C stand for?

1 - cancer
2 - calcium
3 - creatinine
4 - cough

Answer 24

2 - calcium

• <2mmol/L

Question 25

Patients with acute pancreatitis are graded either mild or severe. To do this we can use the Ranson score or the modified version of the Ranson score, called the modified Glasgow score. The modified Glasgow score can be remembered using the mnemonic PANCREAS. What does the R stand for? 1 - rigor mortis 2 - raynauds 3 - raised plasma urea 4 - raised creatinine

Answer 25

3 - raised plasma urea

Question 26

Patients with acute pancreatitis are graded either mild or severe. To do this we can use the Ranson score or the modified version of the Ranson score, called the modified Glasgow score. The modified Glasgow score can be remembered using the mnemonic PANCREAS. What does the E stand for? 1 - enzymes 2 - elevated urea 3 - exudate 4 - extrusion

Answer 26

1 - enzymes - plasma lactate dehydrogenase (LDH)

Question 27

Patients with acute pancreatitis are graded either mild or severe. To do this we can use the Ranson score or the modified version of the Ranson score, called the modified Glasgow score. The modified Glasgow score can be remembered using the mnemonic PANCREAS. What does the A stand for? 1 - albumin 2 - acetate 3 - aminoglutinase 4 - amylase

Answer 27

1 - albumin - <32g/L

Question 28

Patients with acute pancreatitis are graded either mild or severe. To do this we can use the Ranson score or the modified version of the Ranson score, called the modified Glasgow score. The modified Glasgow score can be remembered using the mnemonic PANCREAS. What does the S stand for? 1 - serum CRP 2 - sugar (plasma glucose) 3 - serial acute episodes

Answer 28

2 - sugar (plasma glucose) - >10 mmol/L

Question 29

Using the modified Glasgow score for acute pancreatitis, how many of the PANCREAS mnemonic criteria does a patient need to be classed as severe pancreatitis? 1 - >2 2 - >3 3 - >4 4 - >5

Answer 29

2 - >3

Question 30

In a patient with acute pancreatitis that is mild in severity, they can often present as: - well with minimal systemic features - epigastric pain - diffusely tender distended abdomen - absent or minimal bowel sounds (ileus) - mild jaundice (periampullary odema) Taking these into account, which of the following is NOT a common differential for this type of pain, excluding acute pancreatisis? 1 - biliary colic 2 - acute cholecystitis 3 - peptic ulcer 4 - bowel obstruction

Answer 30

4 - bowel obstruction

Question 31

In a patient with acute pancreatitis that is severe in severity, they can often present as: - apathetic (lethargy) - grey and shocked - abdominal signs of peritonitis - extreme guarding and tenderness Taking these into account, which of the following is NOT a common differential for this type of pain, excluding acute pancreatitis? 1 - biliary colic 2 - faecal peritonitis 3 - concealed haemorrhage (AAA) 4 - bowel infarction/ischaemia

Answer 31

1 - biliary colic - an early and dangerous complication of severe pancreatitis is Acute respiratory distress syndrome (ARDS)

Question 32

All of the following are treatments for a patient with mild pancreatitis. In addition to trying to treat the underlying cause, which one of the following should NOT be used, unless infected necrosis is confirmed? 1 - analgesia 2 - prophylactic antibiotics 3 - IV fluid resuscitation 4 - normal dietary intake

Answer 32

2 - prophylactic antibiotics - if cannot eat then use NG tubes - alcohol should be discouraged

Question 33

If a patient has severe pancreatitis, is the main conservative management of air, resuscitation fluids, analgesia and NG feeding any different?

Answer 33

- no - if feeding tubes are not tolerated then total parental nutrition may be needed

Question 34

If a patient has severe pancreatitis, they are likely to have electrolytes disturbances and lose large volumes of protein rich fluid into the peritoneal cavity. These patients need to be monitored carefully. Which of the following is not one of these measures? 1 - cardiac monitoring with transoesophageal doppler 2 - fluid output (mainly urine) 3 - sepsis 4 - adrenal function

Answer 34

4 - adrenal function

Question 35

Which of the following is NOT a scoring system for staging pancreatitis? 1 - Ranson score 2 - Apache score 3 - Modified Glasgow score 4 - Parklands grading

Answer 35

4 - Parklands grading

Question 36

In pancreatitis CRP is not specific, but once levels reach above 150 mg/L this is a good marker of disease severity, necrosis and inflammation. What time period is this effective in measuring? 1 - <12 hours 2 - <24 hours 3 - 48 hours 4 - 72 hours

Answer 36

3 - 48 hours

Question 37

Mortality is a complication of pancreatitis. What is the mortality of patients with severe pancreatitis? 1 - 2-3% 2 - 10-15% 3 - 10-30% 4 - >50%

Answer 37

3 - 10-30% - obese patients have a higher mortality

Question 38

Mortality is a complication of pancreatitis. The mortality of patients with severe pancreatitis is between 10-30%. What do these patient generally die from? 1 - pancreatic organ failure 2 - acute respiratory syndrome or pulmonary failure 3 - cardiac failure 4 - renal failure

Answer 38

2 - acute respiratory syndrome or pulmonary failure - other can also kill patients, including hypotension and disseminated intravascular coagulation

Question 39

In patients with severe pancreatitis, they can develop pancreatic and peripancreatic (around the pancreas) necrosis as a complication of pancreatitis. What time frame does this generally occur in? 1 - <48 hours 2 - <72 hours 3 - <1 week 4 - <2 weeks

Answer 39

4 - <2 weeks - best diagnosed using a CT with contrast

Question 40

In patients with severe pancreatitis, they can develop pancreatic and peripancreatic (around the pancreas) necrosis as a complication of pancreatitis, which generally occurs in <2 weeks. What are these patients at an increased risk of? 1 - transverse colon perforation 2 - stomach abscess 3 - infection 4 - pneumoperitoneum

Answer 40

3 - infection - gas bubbles may be seen in the pancreas - infections can often be fatal in these patients

Question 41

In a patient with severe pancreatitis, they can develop fluid collections around the pancreas as a complication of pancreatitis. This is normally self resolving within 6 weeks, but if not what can be done to treat this? 1 - CT guided percutaneous drain 2 - steroids and antibiotics 3 - antibiotics 4 - Whipple operation

Answer 41

1 - CT guided percutaneous drain - >6 weeks it is called a pancreatic pseudocyst - can also develop into a pancreatic abscess

Question 42

A pseudocyst is a walled off collection of pancreatic enzymes, inflammatory fluid and necrotic tissue. How common is this as a complication? 1 - 0.1-0.8% 2 - 1-8% 3 - 11-18% 4 - 21-38%

Answer 42

2 - 1-8% - not a true cyst as it does not contain an epithelial lining

Question 43

What is the imaging modality of choice to identify if a patient has a pancreatic pseudocyst? 1 - ultrasound 2 - MRI 3 - X-ray 4 - CT

Answer 43

4 - CT

Question 44

A pancreatic abscess is a complication of pancreatitis. What is the incidence of pancreatic abscess? 1 - 0.1-0.4% 2 - 1-4% 3 - 11-14% 4 - 21-34%

Answer 44

2 - 1-4% - this is a pus filled collection that can be lined by multiple cell types

Question 45

A pancreatic abscess is a complication of pancreatitis with an incidence of 1-4%. What is the tell tale sign that a patient has a pancreatic abscess? 1 - constant fever 2 - rise in amylase >1000 3 - swinging fever 4 - raised LFTs

Answer 45

3 - swinging fever

Question 46

A haemorrhagic psuedoaneurysm can form as a complication of severe acute pancreatitis. Why do these form? 1 - necrotic pancreas damages blood vessels 2 - pancreatic enzymes are acid and can damage surrounding blood vessels 3 - fistula with blood vessels can form 4 - hypotension causes abnormal blood flow

Answer 46

2 - pancreatic enzymes are acid and can damage surrounding blood vessels - enzymes have a low pH and can damage surrounding blood vessels

Question 47

Which of the following 2 are late complications of acute pancreatitis? 1 - liver failure 2 - diabetes 3 - malabsorption 4 - peptic ulcers

Answer 47

2 - diabetes 3 - malabsorption - pancreas cannot function properly anymore, can also occur in chronic pancreatitis

Question 48

Patients with pancreatitis can develop recurrent and chronic pancreatitis. Chronic pancreatitis is defined as the irreversible morphological changes that cause loss of pancreatic function. Are all the pancreatic attacks severe?

Answer 48

- no - first 2 generally, and the rest are mild, with the patient fit and well in between

Question 49

What is the incidence of chronic pancreatitis, defined as the irreversible morphological changes that cause loss of pancreatic function? 1 - 0.6-0.7 / 100,000 2 - 6-7 / 100,000 3 - 60-70 / 100,000 4 - 600 - 700 / 100,000

Answer 49

2 - 6-7 / 100,000

Question 50

What % of patients with acute pancreatitis will go on to develop chronic pancreatitis? 1 - 0.1% 2 - 1% 3 - 10% 4 -30%

Answer 50

3 - 10%

Question 51

Chronic pancreatitis is most likely to lead to which 2 of the following conditions? 1 - Diabetes Mellitus 2 - Splenomegaly 3 - Fat malabsorption 4 - Appendicitis

Answer 51

1 - Diabetes Mellitus 3 - Fat malabsorption - essentially this is pancreatic endocrine (T1DM) and exocrine insufficiency (malabsorption) - treatment of PI is with Pancreatin which is exogenous faecal elastase

Question 52

Chronic pancreatitis, defined as the irreversible morphological changes that cause loss of pancreatic function is NOT associated with which one of the following factors (those that may cause chronic pancreatitis)? 1 - smoking 2 - cystic fibrosis 3 - kidney failure 4 - autoimmune disease

Answer 52

3 - kidney failure

Question 53

Patients with pancreatitis can develop recurrent and chronic pancreatitis, where the first 2 attacks are normally bad, but the rest are less lethal. What are the 2 most common causes of these recurrent attacks? 1 - infection 2 - alcohol relapse 3 - gallstones 4 - trauma

Answer 53

2 - alcohol relapse 3 - gallstones

Question 54

Some patients with pancreatitis can develop pancreatic attacks that are similar to acute pancreatitis, but they are prolonged. Although the initial symptoms are similar, there is one constant in chronic pancreatitis, what is it? 1 - raised amylase 2 - raised CRP 3 - severe and unrelenting pain 4 - raised WCC

Answer 54

3 - severe and unrelenting pain - generally no other abdominal signs - so severe it can drive patients to suicide (up to 8%)

Question 55

Chronic pancreatitis, defined as the irreversible morphological changes that cause loss of pancreatic function. What is the best marker for diagnosis of chronic pancreatitis (insufficiency of pancreas)? 1 - amylase 2 - pancreatic lipase 3 - faecal calprotectin 4 - faecal elastase

Answer 55

4 - faecal elastase - enzyme produced by the liver, low levels suggest chronic insufficiency - can also be used to identify cancer risk

Question 56

When suspecting a patient with chronic pancreatitis, defined as the irreversible morphological changes that cause loss of pancreatic function. what 2 other conditions must be ruled out? 1 - carcinoma of the pancreas 2 - abdominal aortic aneurysm 3 - chronic pancreatic inflammation 4 - mesenteric ischaemia

Answer 56

1 - carcinoma of the pancreas 3 - chronic pancreatic inflammation - diagnosis needs to be made to provide analgesia

Question 57

Chronic pancreatitis, defined as the irreversible morphological changes that cause loss of pancreatic function. Which of the following is NOT a symptom of chronic pancreatitis? 1 - weight loss 2 - anaemia 3 - abdominal pain 4 - diarrhoea

Answer 57

2 - anaemia - diarrhoea is due to pancreatic exocrine failure

Question 58

Although the following all provide measures of diagnosing chronic pancreatitis. Rank the following in order of sensitivity? 1 - endoscopic ultrasound (EUS) 2 - faecal elastase 3 - CT scan 4 - MRCP

Answer 58

1 - endoscopic ultrasound (EUS) 4 - MRCP 3 - CT scan 2 - faecal elastase - EUS using the Rosemont criteria to diagnose the patient

Question 59

If a patient with chronic pancreatitis has malabsorption due to impaired exocrine function, what can they be prescribed? 1 - analgesia 2 - creon 3 - diabetes medication 4 - dietician support

Answer 59

2 - creon - mixture of pancreatic enzymes

Question 60

If a patient with chronic pancreatitis has malabsorption due to impaired endocrine function, what can they be prescribed? 1 - analgesia 2 - creon 3 - diabetes medication 4 - dietician support

Answer 60

3 - diabetes medication

Question 61

Chronic pancreatitis can cause duodenal stenosis, how? 1 - narrowing of duodenum due to weight loss 2 - fistula formation narrowing duodenum 3 - pancreatic enzymes degrade duodenum 4 - head of pancreas increase in side due to abscess or inflammation

Answer 61

4 - head of pancreas increase in side due to abscess or inflammation

Question 62

What is the tumour marker the pancreas? 1 - carcinoembryonic antigen (CEA) 2 - Alpha Fetoprotein (AFP) 3 - Beta-2-microglobulin (B2M) 4 - carbohydrate antigen (CA) 19-9

Answer 62

4 - carbohydrate antigen (CA) 19-9

Question 63

Which condition can lead to a thickening of the pancreatic secretions, that subsequently leads to blocked ducts and an inflamed pancreas? 1 - type 1 diabetes 2 - cystic fibrosis 3 - malignancy 4 - alpha Fetoprotein (AFP)

Answer 63

2 - cystic fibrosis - digestive are enzymes are secreted into the pancreatic duct - bicarbonate and chloride are transported across to the duct via CFTR, with water following creating a soluble alkaline fluid - cystic fibrosis leads to thickening and a blockage