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Acute pancreatitis
I/ Summary
Acute pancreatitis is an inflammatory condition of the pancreas most commonly caused by biliary tract disease or alcohol abuse. Damage
to the pancreas causes local release of digestive proteolytic enzymes that autodigest pancreatic tissue. Acute pancreatitis usually presents
with epigastric pain radiating to the back, nausea and vomiting, and epigastric tenderness on palpation. The diagnosis is made based on
the clinical presentation, elevated serum pancreatic enzymes, and findings on imaging (CT, MRI, ultrasound) that suggest
acute pancreatitis. Treatment is mostly supportive and includes bowel rest, fluid resuscitation, and painmedication. Enteral feeding is
usually quickly resumed once the pain and inflammatory markers begin to subside. Interventional procedures may be indicated for the
treatment of underlying conditions, such as ERCP or cholecystectomy in gallstone pancreatitis. Localized complications
of pancreatitis include necrosis, pancreatic pseudocysts, and abscesses. Systemic complications involve sepsis, ARDS, organ failure,
and shock and are associated with a considerable rise in mortality.
II/ Etiology
 Most common causes
1. Biliary pancreatitis (e.g., gallstones, constriction of the ampulla of Vater) ∼ 40% of cases
2. Alcohol-induced (∼ 30% of cases)
3. Idiopathic (∼ 15%–25% of cases)
 Other causes
 Hypertriglyceridemia, hypercalcemia
 Post-ERCP
 Toxic drugs (e.g., steroids, azathioprine, sulfonamides, furosemide, estrogen, protease inhibitors, NRTIs)
 Scorpion stings
 Viral infections (e.g., coxsackievirus B, mumps)
 Trauma
 Autoimmune and rheumatological disorders (e.g., Sjögren's syndrome)
 Pancreas divisum
 Hereditary (e.g., mutation of the trypsinogen gene, cystic fibrosis)
"I GET SMASHED": I = Idiopathic, G = Gall stones, E = Ethanol, T = Trauma, S = Steroids, M = Mumps, A = Autoimmune,
S = Scorpion poison, H = Hypercalcemia, Hypertriglyceridemia, E = ERCP, D = Drugs.
III/ Pathophysiology
1. Sequence of events leading to pancreatitis:
1. Intrapancreatic activation of pancreatic enzymes: secondary to pancreatic ductal outflow obstruction (e.g., gallstones, cystic

fibrosis) or direct injury to pancreatic acinar cells (e.g., alcohol, drugs)
2. Enzymatic autodigestion of pancreatic parenchyma
3. Attraction of inflammatory cells (neutrophils, macrophages) → release of
inflammatory cytokines → pancreatic inflammation (pancreatitis)
2. Sequelae of pancreatitis (depending on the severity of pancreatitis)
1. Capillary leakage: Release of inflammatory cytokines and vascular injury by pancreatic enzymes → vasodilation and increased
vascular permeability → shift of fluid from the intravascular space into the interstitial space (third space loss)
→ hypotension, tachycardia → distributive shock
2. Pancreatic necrosis: Uncorrected hypotension and third space loss → decreased organ perfusion → multiorgan
dysfunction (mainly renal) and pancreaticnecrosis
3. Hypocalcemia: Lipase breaks down peripancreatic and mesenteric fat → release of free fatty acids that bind calcium
→ hypocalcemia
3. Disease progression
 Mild acute pancreatitis: interstitial edema, no necrosis; no local and systemic complications, no organ failure
 Moderate acute pancreatitis: associated with local (e.g., necrosis, abscesses, pseudocysts) or systemic complications, such as
temporary organ failure (e.g., kidney failure), which improves within 48 hours
 Severe pancreatitis: associated with persistent pancreatic failure (> 48 hours), as well as single or multiple organ failure
IV/ Clinical features
 Constant, severe epigastric pain
 Classically radiating towards the back
 Worse after meals and when supine
 Improves on leaning forwards
 Nausea, vomiting
 General physical examination
 Signs of shock: tachycardia, hypotension, oliguria/anuria
 Possibly jaundice in patients with biliary pancreatitis
 Abdominal examination
 Abdominal tenderness, distention, guarding
 Ileus with reduced bowel sounds and tympany on percussion
 Ascites

 Skin changes (rare)
 Cullen's sign: periumbilical ecchymosis and discoloration (bluish-red)
 Grey Turner's sign: flank ecchymosis with discoloration
 Fox's sign: ecchymosis over the inguinal ligament


V/ Diagnostics
Acute pancreatitis is diagnosed based on a typical clinical presentation, with abdominal pain radiating to the back, and either detection of
highly elevated pancreatic enzymes or characteristic findings on imaging. Serum hematocrit is an easy test that should be conducted to
help quickly predict disease severity.
1. Laboratory tests
 Tests to confirm clinical diagnosis
 ↑ Serum pancreatic enzymes
 Lipase: if ≥ 3 x the upper reference range → highly indicative of acute pancreatitis
 Amylase (nonspecific)
 The enzyme levels are not directly proportional to severity or prognosis!
 Tests to assess severity
 Hematocrit (Hct)
 Should be conducted at presentation as well as 12 and 24 hours after admissions
 ↑ Hct (due to hemoconcentration) indicates third space fluid loss and inadequate fluid resuscitation
 ↓ Hct indicates the rarer acute hemorrhagic pancreatitis
 WBC count
 Blood urea nitrogen
 ↑ CRP and procalcitonin levels
 ↑ ALT
 Tests to determine etiology
 Alkaline phosphatase, bilirubin levels (evidence of gallstone pancreatitis)
 Serum calcium levels
 Serum triglyceride levels (fasting)

!!! Determining calcium values is very important: Hypercalcemia may cause pancreatitis, which may then, in turn, cause hypocalcemia!
2. Imaging
 Ultrasound (most useful initial test): indicated in all patients with acute pancreatitis
 Main purpose: detection of gallstones and/or dilatation of the biliary tract (indicating biliary origin)
 Signs of pancreatitis
 Indistinct pancreatic margins (edematous swelling)
 Peripancreatic build-up of fluid ; evidence of ascites in some cases
 Evidence of necrosis, abscesses, pancreatic pseudocysts
 CT scan: not routinely indicated
 Indications
 At admission: only when the diagnosis is in doubt (e.g., not very highly elevated pancreatic enzymes, nonspecific symptoms)
 > 72 hours of symptom onset: if complications such as necrotizing pancreatitis or pancreatic abscess (e.g.,
persistent fever and leukocytosis, no clinical improvement or evidence of organ failure > 72 hours of therapy)
are suspected
 Findings
 Enlargement of the pancreatic parenchyma with edema; indistinct pancreatic margins with surrounding fat
stranding
 Necrotizing pancreatitis: lack of parenchymal enhancement or presence of air in the pancreatic tissue
 Pancreatic abscess: circumscribed fluid collection
 MRCP and ERCP
 Indications: suspected biliary or pancreatic duct obstructions
 MRCP is noninvasive but less sensitive than ERCP
 ERCP can be combined with sphincterotomy and stone extraction; but may worsen pancreatitis.
 Conventional x-ray
 Sentinel loop sign: dilatation of a loop of small intestine in the upper abdomen (duodenum/jejunum)
 Colon cut off sign: gaseous distention of the ascending and transverse colon that abruptly terminates at the splenic
flexure
 Evidence of possible complications: pleural effusions, pancreatic calcium stones; helps rule out intestinal perforation with
free air
VI/ Treatment

1. General measures
 Admission to hospital and assessment of disease severity (consider ICU admission)
 Fluid resuscitation: aggressive hydration with crystalloids (e.g., lactated Ringer's solution , normal saline)
 Analgesia: IV opioids (e.g., fentanyl)
 Bowel rest (NPO)and IV fluids are recommended until the pain subsides
 Nasogastric tube insertion: not routinely recommended; indicated in patients with vomiting and/or significant abdominal
distention
 Nutrition
 Begin enteral feeding (oral/nasogastric/nasojejunal) as soon as the pain subsides
 Total parenteral nutrition: only in patients who cannot tolerate enteral feeds (e.g., those with persistent ileus and
abdominal pain)


2. Drug therapy
 Analgesics: fentanyl or hydromorphone; consider pump administration (patient controlled analgesia = PCA)
 Antibiotics
 Prophylactic antibiotic therapy is not recommended.
 Antibiotics should only be used in patients with evidence of infected necrosis.
 Fenofibrates: in hyperlipidemia-induced acute pancreatitis
3. Procedures/surgery
 Biliary pancreatitis
 Urgent ERCP and sphincterotomy (within 24 hours): in patients with evidence of choledocholithiasis and/or cholangitis;
followed by cholecystectomy
 Cholecystectomy (preferably during same admission once the patient is stabilized; or within 6 weeks): in all patients with biliary
pancreatitis

!!! The most important therapeutic measure is adequate fluid replacement (minimum of 3–4 liters of crystalloids per day)!
"PANCREAS" - Perfusion (fluid replacement), Analgesia, Nutrition, Clinical (observation), Radiology (imaging), ERC (endoscopic
stone extraction), Antibiotics, Surgery (surgical intervention, if necessary).
VII/ Complications

1. Localized
 Bacterial superinfection of necrotic tissue → fever
 Diagnosis: CT-guided percutaneous drainage + culture of the aspirate
 Treatment: surgical debridement, antibiotics
 High mortality rate; multiple organ failure in ∼ 50% of cases
 Pancreatic pseudocysts
 Pancreatic abscess
 Walled-off infected necrotic tissue or pancreatic pseudocyst; typically develops > 4 weeks after an attack of
acute pancreatitis
 Abdominal CT: visible contrast-enhanced abscess capsule with evidence of fluid (pus)
 Ultrasound: complex cystic, fluid collection with irregular walls and septations
 Treatment: cannulation and drainage; necrosectomy if other measures are not effective
 Pleural effusion
 Abdominal compartment syndrome
 Blood vessel erosion with bleeding
2. Systemic
 SIRS, sepsis, DIC
 Pneumonia, respiratory failure, ARDS
 Shock
 Prerenal failure due to volume depletion
 Hypocalcemia
 Pleural effusion, pancreatic ascites
 Paralytic ileus
We list the most important complications. The selection is not exhaustive.
VIII/ Prognosis
 Mortality
 In patients without organ failure: < 1%
 In patients with organ failure: ∼ 30%
 Higher mortality in patients with biliary pancreatitis than in patients with alcoholic pancreatitis
 Important predictors of severity

 Age > 55
 Gastrointestinal bleeding
 Abnormal hematocrit within 48 hours
 Acute hemorrhagic pancreatitis: ↓ Hct
 Third space fluid loss: ↑ Hct
 Hypocalcemia and/or hyperglycemia
 Inflammatory markers: ↑↑ CRP, ↑ IL-6, ↑ IL-8
 Evidence of shock and/or organ failure
 ↑ AST, ↑ ALT
 ↑ BUN, creatinine
 ↑ LDH
 ABG: pO2 < 60 mmHg, metabolic acidosis with a base deficit > 4 mmol/L
 CT findings: pancreatic edema, peripancreatic fluid collection, and/or necrosis of > 33% of the pancreas

!!! Amylase and lipase, which are used for the diagnosis of pancreatitis, cannot be used to predict the prognosis!


Numerous scoring systems exist (e.g, Ranson criteria) for assessing the severity and predicting the prognosis of
acute pancreatitis


QUESTION
Q1. A previously healthy 32-year-old man comes to the emergency department because of a 2-day history of worsening abdominal pain
and vomiting. He has had chills but has not measured his temperature. He has not had diarrhea. He takes no medications. He drinks 4 to 5
beers daily but says that he drank more while on a recent vacation. He does not use illicit drugs. His temperature is 38.4°C (101.2°F),
pulse is 104/min, respirations are 18/min, and blood pressure is 132/82 mm Hg. Abdominal exam shows epigastric pain to palpation with
guarding but no rebound. Murphy sign is negative. He has no jaundice. Serum studies are most likely to show which of the following sets
of findings in this patient?

Q2. A 43-year-old man is brought to the emergency department because of severe epigastric pain and vomiting for 6 hours. The pain

radiates to his back and he describes it as 9 out of 10 in intensity. He has had 3–4 episodes of vomiting during this period. He admits to
consuming over 13 alcoholic beverages the previous night. There is no personal or family history of serious illness and he takes no
medications. He is 177 cm (5 ft 10 in) tall and weighs 55 kg (121 lb); BMI is 17.6 kg/m2. He appears uncomfortable. His temperature is
37.5°C (99.5°F), pulse is 97/min, and blood pressure is 128/78 mm Hg. Abdominal examination shows severe epigastric tenderness to
palpation. Bowel sounds are hypoactive. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin
13.5 g/dL
Hematocrit
62%
Leukocyte count
13,800/mm3
Serum
Na+
134 mEq/L
K+
3.6 mEq/L
Cl98 mEq/L
Calcium
8.3 mg/dL
Glucose
180 mg/dL
Creatinine
0.9 mg/dL
Amylase
150 U/L
Lipase
347 U/L (N = 14–280)
Total bilirubin
0.8 mg/dL
Alkaline phosphatase

66 U/L
AST
19 U/L
ALT
18 U/L
LDH
360 U/L
Which of the following laboratory studies is the best prognostic indicator for this patient's condition?
A. Hematocrit
B. Lipase
C. AST/ALT ratio
D. Alkaline phosphatase
E. Total bilirubin F Amylase
Q3. A 55-year-old woman is brought to the emergency department because of worsening upper abdominal pain for 8 hours. She reports
that the pain radiates to the back and is associated with nausea. She has hypertension and hyperlipidemia, for which she takes enalapril,
furosemide, and simvastatin. Her temperature is 37.5°C (99.5 °F), blood pressure is 84/58 mm Hg, and pulse is 115/min. The lungs are
clear to auscultation. Examination shows abdominal distention with epigastric tenderness and guarding. Bowel sounds are decreased.
Extremities are warm. Laboratory studies show:
Hematocrit
48%
Leukocyte count
13,800/mm3
Platelet count
175,000/mm3
Serum:
Calcium
8.0 mg/dL
Urea nitrogen
32 mg/dL
Amylase

250 U/L
An ECG shows sinus tachycardia. Which of the following is the most likely underlying cause of this patient's vital sign abnormalities?
A. Decreased sympathetic tone
B. Hemorrhagic fluid loss
C. Decreased albumin concentration


D. Abnormal coagulation and fibrinolysis
E. Decreased cardiac output
F. Increased excretion of water
G. Pseudocyst formation
H. Capillary leakage
Q4. A 50-year-old man comes to the emergency department because of severe lower chest pain for the past hour. The pain radiates to the
back and is associated with nausea. He has had two episodes of non-bloody vomiting since the pain started. He has a history of
hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 30 years. He drinks five to six beers per day.
His medications include enalapril and metformin. His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm
Hg. The lungs are clear to auscultation. Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound;
bowel sounds are decreased. Laboratory studies show:
Hemoglobin
14.5 g/dL
Leukocyte count
5,100/mm3
Platelet count
280,000/mm3
Serum
Na+
133 mEq/L
K+
3.5 mEq/L
Cl98 mEq/L

Total bilirubin
1.0 mg/dL
Amylase
160 U/L
Lipase
380 U/L (N = 14–280)
An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis?
A. Acute mesenteric ischemia
B. Boerhaave syndrome
C. Aortic dissection
D. Peptic ulcer disease
E. Pericarditis
F. Myocardial infarction
G. Acute pancreatitis
Q5. A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 1 hour after the onset of
severe abdominal pain and nausea. He has smoked one pack of cigarettes daily for 30 years and drinks alcoholic beverages occasionally.
His pulse is 110/min, respirations are 20/min, and blood pressure is 142/86 mm Hg. The lungs are clear to auscultation. Abdominal
examination shows a pulsatile epigastric mass and diffuse tenderness. Which of the following additional findings is most likely in this
patient?
A. Increase in serum lipase concentration
B. Absence of the hepatojugular reflux
C. Filling defect in the superior mesenteric vein
D. Increase in jugular venous pressure
E. Decrease in ankle-brachial index
Q6. A 52-year-old woman comes to the emergency department because of epigastric abdominal pain that started after her last meal and
has become progressively worse over the past 6 hours. She has had intermittent pain similar to this before, but it has never lasted this
long. Her temperature is 39°C (102.2°F). Examination shows a soft abdomen with normal bowel sounds. The patient has sudden
inspiratory arrest during right upper quadrant palpation. Her alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase
levels are within the reference ranges. Abdominal imaging is most likely to show which of the following findings?
A. Dilated common bile duct with intrahepatic biliary dilatation

B. Gas in the gallbladder wall
C. Gallstone in the cystic duct
D. Fistula formation between the gallbladder and bowel
E. Decreased echogenicity of the liver
F. Enlargement of the pancreas with peripancreatic fluid


Q7. One week after undergoing sigmoidectomy with end colostomy for complicated diverticulitis, a 67-year-old man has upper
abdominal pain. During the surgery, he was transfused two units of packed red blood cells. His postoperative course was uncomplicated.
Two days ago, he developed fever. He is currently receiving parenteral nutrition through a central venous catheter. He has type 2 diabetes
mellitus, hypertension, and hypercholesterolemia. He is oriented to person, but not to place and time. Prior to admission, his medications
included metformin, valsartan, aspirin, and atorvastatin. His temperature is 38.9°C (102.0°F), pulse is 120/min, and blood pressure is
100/60 mmHg. Examination shows jaundice of the conjunctivae. Abdominal examination shows tenderness to palpation in the right
upper quadrant. There is no rebound tenderness or guarding; bowel sounds are hypoactive. Laboratory studies show:
Leukocytes
13,500 /mm3
Segmented neutrophils
75 %
Serum
Aspartate aminotransferase
140 IU/L
Alanine aminotransferase
85 IU/L
Alkaline phosphatase
150 IU/L
Bilirubin
Total
2.1 mg/dL
Direct
1.3 mg/dL

Amylase
20 IU/L
Which of the following is the most likely diagnosis in this patient?
A. Ischemic hepatitis
B. Acalculous cholecystitis
C. Small bowel obstruction
D. Anastomotic insufficiency
E. Cholecystolithiasis
F. Acute pancreatitis
G. Hemolytic transfusion reaction
Q8. A 68-year-old man comes to the physician because of recurrent episodes of nausea and abdominal discomfort for the past 4 months.
The discomfort is located in the upper abdomen and sometimes occurs after eating, especially after a big meal. He has tried to go for a
walk after dinner to help with digestion, but his complaints have only increased. For the past 3 weeks he has also had symptoms while
climbing the stairs to his apartment. He has type 2 diabetes mellitus, hypertension, and stage 2 peripheral arterial disease. He has smoked
one pack of cigarettes daily for the past 45 years. He drinks one to two beers daily and occasionally more on weekends. His current
medications include metformin, enalapril, and aspirin. He is 168 cm (5 ft 6 in) tall and weighs 126 kg (278 lb); BMI is 45 kg/m2. His
temperature is 36.4°C (97.5°F), pulse is 78/min, and blood pressure is 148/86 mm Hg. On physical examination, the abdomen is soft and
nontender with no organomegaly. Foot pulses are absent bilaterally. An ECG shows no abnormalities. Which of the following is the most
appropriate next step in diagnosis?
A. Esophagogastroduodenoscopy
B. CT scan of the abdomen
C. CT angiography of the abdomen
D. Hydrogen breath test
E. Cardiac stress test
F. Abdominal ultrasonography of the right upper quadrant
G. Endoscopic retrograde cholangiopancreatography
Q9. A 46-year-old man is brought to the emergency department because of severe epigastric pain and vomiting for the past 4 hours. The
pain is constant, radiates to his back, and is worse on lying down. He has had 3–4 episodes of greenish-colored vomit. He was treated for
H. pylori infection around 2 months ago with triple-regimen therapy. He has atrial fibrillation and hypertension. He owns a distillery on
the outskirts of a town. The patient drinks 4–5 alcoholic beverages daily. Current medications include dabigatran and metoprolol. He

appears uncomfortable. His temperature is 37.8°C (100°F), pulse is 102/min, and blood pressure is 138/86 mm Hg. Examination shows
severe epigastric tenderness to palpation with guarding but no rebound. Bowel sounds are hypoactive. Rectal examination shows no
abnormalities. Laboratory studies show:
Hematocrit
53%
Leukocyte count
11,300/mm3
Serum
Na+
133 mEq/L
Cl98 mEq/L
K+
3.1 mEq/L
Calcium
7.8 mg/dL
Urea nitrogen
43 mg/dL
Glucose
271 mg/dL


Creatinine
2.0 mg/dL
Total bilirubin
0.7 mg/dL
Alkaline phosphatase
61 U/L
AST
19 U/L
ALT

17 U/L
γ-glutamyl transferase (GGT)
88 u/L (N=5–50 U/L)
Lipase
900 U/L (N=14–280 U/L)
Which of the following is the most appropriate next step in management?
A. CT angiography
B. Calcium gluconate therapy
C. Fomepizole therapy
D. Laparotomy
E. Endoscopic retrograde cholangio-pancreatography
F. Insulin infusion
G. Crystalloid fluid infusion
Q10. A 67-year-old woman comes to the physician because of a 5-day history of episodic abdominal pain, nausea, and vomiting. She has
coronary artery disease and type 2 diabetes mellitus. She takes aspirin, metoprolol, and metformin. She is 163 cm (5 ft 4 in) tall and
weighs 91 kg (200 lb); her BMI is 34 kg/m2. Her temperature is 38.1°C (100.6°F). Physical examination shows dry mucous membranes,
abdominal distension, and hyperactive bowel sounds. Ultrasonography of the abdomen shows air in the biliary tract. This patient's
symptoms are most likely caused by obstruction at which of the following locations?
A. Third part of the duodenum
B. Distal ileum
C. Hepatic duct
D. Proximal jejunum
E. Pancreatic duct
Q11. A 12-year-old girl is brought to the physician because of a 2-hour history of severe epigastric pain, nausea, and vomiting. Her father
has a history of similar episodes of abdominal pain and developed diabetes mellitus at the age of 30 years. Abdominal examination shows
guarding and rigidity. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. Which of
the following is the most likely underlying cause of this patient's condition?
A. Defective bilirubin glucuronidation
B. Elevated serum amylase levels
C. Increased β-glucuronidase activity

D. Premature activation of trypsinogen
E. Defective elastase inhibitor
F. Impaired cellular copper transport
Q12. A 42-year-old woman is brought to the emergency department because of intermittent sharp right upper quadrant abdominal pain
and nausea for the past 10 hours. She vomited three times. There is no associated fever, chills, diarrhea, or urinary symptoms. She has
two children who both attend high school. She appears uncomfortable. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32
kg/m2. Her temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 140/90 mm Hg. She has mild scleral icterus. The
abdomen is soft and nondistended, with tenderness to palpation of the right upper quadrant without guarding or rebound. Bowel sounds
are normal. Laboratory studies show:
Hemoglobin count
14 g/dL
Leukocyte count
9,000 mm3
Platelet count
160,000 mm3
Serum
Alkaline phosphatase
238 U/L
Aspartate aminotransferase
60 U/L
Bilirubin
Total 2.8 mg/dL
Direct 2.1 mg/dL
Which of the following is the most appropriate next step in diagnosis?


A. CT scan of the abdomen
B. Supine and erect x-rays of the abdomen
C. Transabdominal ultrasonography
D. Endoscopic retrograde cholangiopancreatography

E. HIDA scan of the biliary tract
F. Upper gastrointestinal series
Q13. An otherwise healthy 28-year-old primigravid woman at 30 weeks' gestation comes to the physician with a 5-day history of
epigastric pain and nausea that is worse at night. Two years ago, she was diagnosed with a peptic ulcer and was treated with a proton
pump inhibitor and antibiotics. Medications include folic acid and a multivitamin. Her pulse is 90/min and blood pressure is 130/85 mm
Hg. Pelvic examination shows a uterus consistent in size with a 30-week gestation. Laboratory studies show:
Hemoglobin
8.6 g/dL
Platelet count
95,000/mm3
Serum
Total bilirubin
5 mg/dL
Aspartate aminotransferase
80 U/L
Lactate dehydrogenase
705 U/L
Urine
pH
6.2
Protein
2+
WBC
negative
Bacteria
occasional
Nitrates
negative
Which of the following best explains this patient's symptoms?
A. Inflammation of the gall bladder

B. Bacterial infection of the kidney
C. Inflammation of the lower esophageal mucosa
D. Stretching of Glisson capsule
E. Acute inflammation of the pancreas
F. Break in gastric mucosal continuity
Q14. An otherwise healthy 56-year-old woman comes to the physician because of a 3-year history of intermittent upper abdominal pain.
She has had no nausea, vomiting, or change in weight. Physical examination shows no abnormalities. Laboratory studies are within
normal limits. Abdominal ultrasonography shows a hyperechogenic rim-like calcification of the gallbladder wall. The finding in this
patient's ultrasonography increases the risk of which of the following conditions?
A. Hepatocellular carcinoma
B. Pancreatic adenocarcinoma
C. Gallbladder empyema
D. Pyogenic liver abscess
E. Emphysematous cholecystitis
F. Gallbladder carcinoma
G. Gallstone ileus
H. Acute pancreatitis
Q15. A previously healthy 31-year-old woman comes to the emergency department because of sudden, severe epigastric pain and
vomiting for the past 4 hours. She reports that the pain radiates to the back and began when she was having dinner and drinks at a local
brewpub. Her temperature is 37.9°C (100.2°F), pulse is 98/min, respirations are 19/min, and blood pressure is 110/60 mm Hg. Abdominal
examination shows epigastric tenderness and guarding but no rebound. Bowel sounds are decreased. Laboratory studies show:
Hematocrit
43%
Leukocyte count
9000/mm3
Serum
Na+
140 mEq/L
K+
4.5 mEq/L

Ca2+
9.0 mg/dL
Lipase
170 U/L (N = < 50 U/L)


Amylase
152 U/L
Alanine aminotransferase (ALT, GPT)
140 U/L
Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
A. Esophagogastroduodenoscopy
B. Contrast-enhanced abdominal CT scan
C. Right upper quadrant abdominal ultrasound
D. Plain x-ray of the abdomen
E. Endoscopic retrograde cholangiopancreatography
F. Measure serum triglycerides
G. Blood alcohol level assay
Q16. A 45-year-old woman comes to the emergency department because of right upper abdominal pain and nausea that have become
progressively worse since eating a large meal 8 hours ago. She has had intermittent pain similar to this before, but it has never lasted this
long. She has a history of hypertension and type 2 diabetes mellitus. She does not smoke or drink alcohol. Current medications include
metformin and enalapril. Her temperature is 38.5°C (101.3°F), pulse is 90/min, and blood pressure is 130/80 mm Hg. The abdomen is
soft, and bowel sounds are normal. The patient has sudden inspiratory arrest during right upper quadrant palpation. Laboratory studies
show a leukocyte count of 13,000/mm3. Serum alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are
within the reference ranges. Imaging is most likely to show which of the following findings?
A. Dilated common bile duct with intrahepatic biliary dilatation
B. Enlargement of the pancreas with peripancreatic fluid
C. Gas in the gallbladder wall
D. Fistula formation between the gallbladder and bowel
E. Gallstone in the cystic duct

F. Decreased echogenicity of the liver
Q17. A 42-year-old woman is brought to the emergency department because of a 5-day history of epigastric pain, fever, nausea, and
malaise. Five weeks ago she had acute biliary pancreatitis and was treated with endoscopic retrograde cholangiopancreatography and
subsequent cholecystectomy. Her maternal grandfather died of pancreatic cancer. She does not smoke. She drinks 1–2 beers daily. Her
temperature is 38.7°C (101.7°F), respirations are 18/min, pulse is 120/min, and blood pressure is 100/70 mm Hg. Abdominal examination
shows epigastric tenderness and three well-healed laparoscopy scars. The remainder of the examination shows no abnormalities.
Laboratory studies show:
Hemoglobin
10 g/dl
Leukocyte count
15,800/mm3
Serum
Na+
140 mEq/L
Cl−
103 mEq/L
K+
4.5 mEq/L
HCO325 mEq/L
Urea nitrogen
18 mg/dL
Creatinine
1.0 mg/dL
Alkaline phosphatase
70 U/L
Aspartate aminotransferase (AST, GOT)
22 U/L
Alanine aminotransferase (ALT, GPT)
19 U/L
γ-Glutamyltransferase (GGT)

55 U/L (N=5-50 U/L)
Bilirubin
1 mg/dl
Glucose
105 mg/dL
Amylase
220 U/L
Lipase
105 U/L (N=3-43 U/L)
Abdominal ultrasound shows a complex cystic fluid collection with irregular walls and septations in the pancreas. Which of the following
is the most likely diagnosis?
A. Pancreatic abscess
B. Pancreatic pseudocyst
C. Pancreatic cancer
D. Acute cholangitis
E. ERCP-induced pancreatitis


Q18. A 21-year-old college student comes to the emergency department because of a two-day history of vomiting and epigastric pain that
radiates to the back. He has a history of atopic dermatitis and Hashimoto thyroiditis. His only medication is levothyroxine. He has not
received any routine vaccinations. He drinks 1–2 beers on the weekends and occasionally smokes marijuana. The patient appears
distressed and is diaphoretic. His temperature is 37.9°C (100.3°F), pulse is 105/min, respirations are 16/min, and blood pressure is 130/78
mm Hg. Physical examination shows abdominal distention with tenderness to palpation in the epigastrium. There is no guarding or
rebound tenderness. Skin examination shows several clusters of yellow plaques over the trunk and extensor surfaces of the extremities.
Hemoglobin concentration is 15.2 g/dL and serum calcium concentration is 7.9 mg/dL. Which of the following is the most appropriate
next step in evaluation?
A. Perform a pilocarpine-induced sweat test
B. Measure serum mumps IgM titer
C. Perform an esophagogastroduodenoscopy
D. Obtain an upright x-ray of the abdomen

E. Measure serum lipid levels
F. Measure stool elastase level