Internal medicine - Disorders of the pancreas Flashcards

1
Q

INT - 9.1
Which enzyme gene mutation causes hereditary pancreatitis?

A) carbonic anhydrase
B) cationic trypsin
C) phospholipase
D) kallikrein
E) hexokinase

A

ANSWER
B) cationic trypsin

EXPLANATION
Cationic trypsin mutations are responsible for two-thirds of hereditary pancreatitis, mutations in other enzymes do not cause pancreatitis. Bile flow is blocked by the obstructed and compressed choledochus by a pancreas head cancer. The cholecyst is intact, stretching, but it cannot compensate to the obstructive icterus. In the other diseases the cholecyst does not expand, because it is inflamed and ill, or there is no distal choledochus obstruction.

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2
Q

INT - 9.2
The main functions of pancreatic ductal cells, except:
A) to guarantee a shell for th acinic cells
B) to excrete a liquid rich in bicarbonate
C) to bring the enzymes produced by the acini into the duodenum
D) to neutralize the protons produced by acini through bicarbonate secretion
E) to excrete a liquid rich in sodium and chloride ions

A

ANSWER
E) to excrete a liquid rich in sodium and chloride ions

EXPLANATION
The main functions of pancreatic ductal cells are to guarantee a shell for the acinic cells and to excrete a bicarbonate rich liquid, which neutralize the protons produced by acini and keep enzymes in an inactive state and bring them from the acinic cells into the duodenum. Sodium and chlorine-rich liquids are produced by acini.

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3
Q

INT - 9.3
It is true for the enzymes produced by pancreas:

A) Three different enzymes are produced by acini: amylase, trypsin and lipase
B) The enzymes are activated under physiological conditions in the pancreatic duct.
C) Lipase is activated by the enzyme enterokinase in the duodenum.
D) Enzymes are produced in inactive state in acini and under physiological conditions they only become activ in duodenum.
E) Most of the enzymes are produced by pancreatic ductal cells.

A

ANSWER
D) Enzymes are produced in inactive state in acini and under physiological conditions they only become activ in duodenum.

EXPLANATION
Pancreatic acini produce more than 20 types of enzymes, which get into the pancreatic duct in an inactive state. Under physiological conditions, enterokinase secreted by the duodenum activates trypsinogen, which turns into active trypsin. Activated trypsin then activates the other enzymes.

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4
Q

INT - 9.4
It is true for acute pancreatitis, except:

A) Antibiotic therapy should always be used due to the risk of infection.
B) The lipase level increases in the blood.
C) Usually it is induced by gallstone or excessive alcohol consumption.
D) It leads to abdominal pain.
E) The amylase level increases in the blood.
F) The inflammation can also spread to other organs in severe cases.

A

ANSWER
A) Antibiotic therapy should always be used due to the risk of infection.

EXPLANATION
Acute pancreatitis develops mainly due to gallstones or excessive alcohol consumption. Usually it is accompanied by abdominal pain, amylase and lipase elevations in the blood. In severe cases, the disease may affect several organs. It is clear, however, that antibiotic therapy should not be initiated in all cases.

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5
Q

INT - 9.5
In case of acute pancreatitis, the first thing to do is:

A) performing a CT scan
B) performing an ERCP test
C) starting fluid replacement
D) surgical console
E) performing an MRCP test

A

ANSWER
C) starting fluid replacement

EXPLANATION
In case of acute pancreatitis, the most important to do is to start fluid replacement immediately.

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6
Q

INT - 9.6
It is true for the distant complications of acute pancreatitis, except:

A) Lungs, kidneys and liver are the most common affected.
B) They are not related to the severity of the disease.
C) Migratory leukocytes, cytokines and free radicals are primarily responsible for their development.
D) The inflammation of organs may also lead to dysfunction and may cause multiple organ failure (MOF).
E) In severe cases, intensive therapy may be also needed.

A

ANSWER
B) They are not related to the severity of the disease.

EXPLANATION
During the progress of the inflammation, from the localized pancreatitis may develop a generalized multiple organ inflammation, which always refers to the severity of the inflammation. Lungs, kidneys and liver are the most common affected. Migratory leukocytes, cytokines and free radicals are primarily responsible for the spread of this inflammation to the whole body. The inflammation of organs may also lead to dysfunction and may cause multiple organ failure (MOF).

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7
Q

INT - 9.7
It refer to the severity of the acute necrotizing pancreatitits, except:
A) Ranson’s prognostic criteria
B) Glasgow prognostic criteria
C) Apache II. prognostic criteria
D) amylase elevation
E) markers of the inflammatory reaction (TNF-α, IL-6, CRP etc.)
F) CT findings (Balthazar-score) with contrast agent enhancement
G) clinical picture
H) infected necrosis

A

ANSWER
D) amylase elevation

EXPLANATION
Amylase elevation is not proportional to the severity of pancreatitis, in case of an extensive necrosis, enzyme levels may be low, because there is no more enzyme in the acinic cells, however, very high values can be found in case of mild pancreatitis with papillitis.

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8
Q

INT - 9.8
It is characteristic for the SPINK1 gene:

A) It is located on chromosome 8.
B) It encodes a protein called pancreatic secretory trypsin inhibitor.
C) The production of the protein that it encodes is essential for the activation of trypsin.
D) Its mutation leads in all cases to pancreatitis.
E) It often occurs in pancreatitis with hereditary or familial accumulation.

A

ANSWER
B) It encodes a protein called pancreatic secretory trypsin inhibitor.

EXPLANATION
The human SPINK1 gene is located on chromosome 5, it is 7.1 kilobases long, it contains 4 exons and it encodes a protein of 6.3 kilodaltons, a physiological inhibitor of trypsin named pancreatic secretory trypsin inhibitor. This genetic alteration is present in 16% of the idiopathic patients, but it rarely occurre in cases with hereditary or family accumulation. Unlike PRSS1 gene mutations, that can not be found in healthy people.

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9
Q

INT - 9.9
The most sensitive and specific imaging method is for the diagnosis of chronic pancreatitis:
A) transabdominal ultrasound
B) abdominal CT
C) endoscopic ultrasound
D) ERCP
E) native abdominal X-ray
F) irrigoscopy

A

ANSWER
D) ERCP

EXPLANATION
Endoscopic retrograd cholangiopancreatography is still the most sensitive and most specific of the listed imaging techniques in chronic pancreatitis, but it can be soon replaced by dynamic MRCP in this diagnostic function.

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10
Q

INT - 9.10
In the case of chronic pseudocysts, primarily selectable procedures are, excluded:
A) percutaneous drainage
B) endoscopic cystogastrostomy or cystoduodenostomy
C) transpapillar drainage of the pseudocyst
D) surgical cystogastrostomy posterior or cystoduodenostomy
E) surgical cystowirsungogastrostomy or cystowirsungo-jejunostomy

A

ANSWER
A) percutaneous drainage

EXPLANATION
Percutaneous drainage should not be selected for chronic pseudocysts, because the cyst comes back, since the cavity is usually connected with the pancreatic duct.

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11
Q

INT - 9.11
Mutations in the CFTR molecule in the pancreas can cause the following diseases or increase their risks, except:
A) cystic fibrosis
B) chronic pancreatitis
C) acute pancreatitis
D) pancreatic carcinoma
E) pancreatic division

A

ANSWER
E) pancreatic division

EXPLANATION
Mutations in the CFTR molecule can cause or increase the risk of pancreatitis or cystic fibrosis. The pancreatic division is an anatomical disorder, that is not related to the mutation of the CFTR gene.

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12
Q

INT - 9.12
In case of cystic fibrosis, the most endangering for the patient’s life is:
A) pancreatic insufficiency
B) gallstones
C) colonic stricture
D) pulmonary complications
E) meconium ileus
F) complications of diabetes mellitus
G) biliary cirrhosis

A

ANSWER
D) pulmonary complications

EXPLANATION
Lung complications endanger the life expectancy of a patient with mucoviscidosis the longest and most intense, the other complications cause the patient’s death rarely and only at a certain age.

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13
Q

INT - 9.13
It is valid for the endoscopic retrograde cholangiopancreatography (ERCP):
1) It is an unlimited repeatable, uncomplicated procedure.
2) The obstruction of the choledochus and the pancreas line can be solved by an additional intervention.
3) It is always diagnostic in mild chronic pancreatitis as well.
4) It has a high sensitivity and specificity in case of pancreatic head tumors.

A) the 1., 2. and 3. answers are correct
B) the 1. and 3. answers are correct
C) the 2. and 4. answers are correct
D) only the 4. answer is correct
E) all of the answers are correct

A

ANSWER
C) the 2. and 4. answers are correct

EXPLANATION
The great advantage of ERCP is that in case of blockage of pancreatic and / or bile duct, a practised endoscopic specialist can solve the stricture with drainage, expansion or other operative endoscopic procedures at the same time as the diagnosis. However, the diagnostic value of this examination is also outstanding in case of pancreatic head tumors, because the so-called. double channel signal (combined local stricture of the choledochus and the pancreatic duct) refers to cancer with 95% safety.

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14
Q

NT - 9.14
It is characteristic of cystic fibrosis:
1) CFTR gene mutations with autosomal recessive inheritance cause cystic fibrosis disease
2) CFTR protein is a cationic channel located on pancreatic acinic cells
3) mutations reduce the amount or inhibit the function of CFTR protein
4) Cystic fibrosis is the rarest anomaly with recessive inheritance in the Caucasian population

A) the 1., 2. and 3. answers are correct
B) the 1. and 3. answers are correct
C) the 2. and 4. answers are correct
D) only the 4. answer is correct
E) all of the answers are correct

A

ANSWER
B) the 1. and 3. answers are correct

EXPLANATION
The CFTR gene encodes a membrane protein called cystic fibrosis transmembrane conductance regulator with size of 168 kilodaltons, that catalyzes the transport of chloride ions in the apical membrane of the exocrine glands. The gene is located on the long arm of chromosome 7, it is 250 kilobases long and contains 27 exons. Mutations of the CFTR gene with autosomal recessive inheritance cause mucoviscidosis or cystic fibrosis. Mutations reduce the amount or inhibit the function of CFTR protein, and thereby lead to the thickening of the glandular secretion, that may cause first of all disturbances in the lungs, pancreas, skin, reproductive organs, intestines and liver. Cystic fibrosis is the most common recessive inherited disorder in the Caucasian population, there is one case for every 2500 births.

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15
Q

INT - 9.15
It is valid for transabdominal pancreatic ultrasound diagnostics:
1) unlimited repeatable, relatively cheap

2) suitable for detecting fluid collections and pseudocysts

3) meteorism is not an obstacle

4) the accompanying bile disease can be well proven

5) edema is well separated from necrosis

6) obesity is not an obstacle

7) ductal diatation can be well recognized

A) the 1., 2. and 3. answers are correct

B) the 4., 5., 6. and 7. answers are correct

C) the 1., 2., 3. and 4. answers are correct

D) the 1., 2., 4. and 7. answers are correct

E) all of the answers are correct

A

ANSWER
D) the 1., 2., 4. and 7. answers are correct

EXPLANATION
Ultrasound examination is not invasive, many patients can be examined in more shifts with one device. At the border of the liquid, the echo is sharply reflected, so the pseudocyst can be well defined, cholecysts can be examined, and a fluid-filled, expanded duct can be represented. However, meteorism and obesity make testing difficult, edema can not be confidently separated from necrosis.

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16
Q

INT - 9.16
It is valid for pancreatic computer tomography (CT):
1) unlimited repeatable, relatively cheap
2) suitable for detecting fluid collections and pseudocysts
3) obesity and meteorism are not obstacles
4) it also detects small parapapillary tumors
5) edema is well separated from necrosis
6) calcification and ductal diatation can be well recognized

A) the 1., 2., 3. and 6. answers are correct
B) the 3., 4. and 5. answers are correct
C) the 2., 3., 5. and 6. answers are correct
D) all of the answers are correct

A

ANSWER
C) the 2., 3., 5. and 6. answers are correct

EXPLANATION
CT also shows fluid collections well based on density differences. Obesity and meteorism do not disturb the contrast of the image. After administration of an intravenous contrast agent, the density of the live parenchyma increases, the „enhancement” of the non-living tissue is missing. The calcification is particularly piercingly visible, but the line expansion is also well represented. In contrast, it causes radiation strain and is more expensive than ultrasound, in addition, small papillary tumors are difficult to detect near the duodenum.

17
Q

INT - 9.17
It is characteristic of pancreatic tumors:
1) the five-year survival rate is below 5%
2) it usually begins with jaundice and severe spastic abdominal pain
3) it mainly origins from acinic cells
4) it never causes pancreatitis
5) it responds well to cytostatics

A) the 1., 2. and 3. answers are correct
B) the 1., 2. and 4. answers are correct
C) the 1., 2. and 5. answers are correct
D) only the 1. answer is correct
E) the 3. and 4. answers are correct

A

ANSWER
D) only the 1. answer is correct

EXPLANATION
Pancreatic tumors mainly origin from the ductal cells, their prognosis is not good at all. The five-year survival rate is below 5%. They usually develop silently and asymptomatic. The first symptom is often the jaundice of the patient. Cytostatic therapy can lengthen the survival time only minimal. In case of severe stricture of the pancreatic duct pancreatitis may be induced.

18
Q

INT-9.18-9.21
Pair them.
A) acute pancreatitis
B) chronic pancreatitis
C) pancreatic tumor
D) cystic fibrosis

INT - 9.18 -
I can heal Restitutio ad integrum, plenty of fluid replacement, gallstone.

INT - 9.19 -
Weight loss, painless icterus.

INT - 9.20 -
Alcohol, fatty stool discharge, maldigestion.

INT - 9.21 -
Autosomal recessive inheritance, involvement of the lung.

A

ANSWER
INT - 9.18 -
I can heal Restitutio ad integrum, plenty of fluid replacement, gallstone. - A)

INT - 9.19 -
Weight loss, painless icterus. - C)

INT - 9.20 -
Alcohol, fatty stool discharge, maldigestion. - B)

INT - 9.21 -
Autosomal recessive inheritance, involvement of the lung. - D)

19
Q

INT-9.26-9.29
Pair them!
A) cationic trypsin (PRSS1)
B) chymotrypsin C (CTRC)
C) cystic fibrosis transregulator (CFTR)
D) pancreatic secretory trypsin inhibitor (SPINK1)

INT - 9.26 -
Apical Cl- channel, thickening of the glandular secretion, ∆F508-mutation.

INT - 9.27 -
p.N34S mutation, mainly idiopathic pancreatitis.

INT - 9.28 -
Control of trypsin breakdown, 4-5x risk increase in idiopathic and alcoholic patients.

INT - 9.29 -
Recurrent acute pancreatitis attacks, hereditary pancreatitis, 40-50x risk for the developement of pancreatic carcinoma, p.R122H-mutation.

A

ANSWER
INT - 9.26 -
Apical Cl- channel, thickening of the glandular secretion, ∆F508-mutation. - C)

INT - 9.27 -
p.N34S mutation, mainly idiopathic pancreatitis.- D)

INT - 9.28 -
Control of trypsin breakdown, 4-5x risk increase in idiopathic and alcoholic patients.- B)

INT - 9.29 -
Recurrent acute pancreatitis attacks, hereditary pancreatitis, 40-50x risk for the developement of pancreatic carcinoma, p.R122H-mutation. -A)

20
Q

INT - 9.30
Tactile, dilated, tight, painless gall bladder (Courvoisier-symptom) and icterus are characteristic of pancreatic tail tumors, because the tumors near the ducus choledochus are able to slowly compress the duct, blocking hereby the flow of the bile.

A) both are correct, there is a causal relationship between them
B) both are correct, but there is no causal relationship between them
C) the first is correct in itself, but the second is wrong
D) the first is wrong, the second is correct in itself
E) both are wrong

A

ANSWER
D) the first is wrong, the second is correct in itself

EXPLANATION
The bile flow is blocked by the choledochus obstructed and compressed by a pancreas head cancer. The cholecyst is intact, stretching, but it cannot compensate to the obstructive icterus. Cholecyst does not expand in case of pancreatic tail tumors, and there is no distal choledochus obstruction.

21
Q

INT - 9.31
It can occur in case of gallstone disease, that the gallstone impact into the hepatic duct, therefore, acute haemorrhagic pancreatic necrosis can occur as a complication of gallstone disease.

A) both are correct, there is a causal relationship between them
B) both are correct, but there is no causal relationship between them
C) the first is correct in itself, but the second is wrong
D) the first is wrong, the second is correct in itself
E) both are wrong

A

ANSWER
B) both are correct, but there is no causal relationship between them

EXPLANATION
Acute pancreatitis is caused by papillary injury due to the impactation or leaving of a gallstone in the ampull, however, impactation of a stone into the ductus hepaticus causes only cholangitis.

22
Q

INT - 9.32
Necrotizing pancreatitis usually requires prolonged, energy-intensive therapy, therefore, in these cases, jejunial nutrition should be chosen instead of parenteral therapy.

A) both are correct, there is a causal relationship between them
B) both are correct, but there is no causal relationship between them
C) the first is correct in itself, but the second is wrong
D) the first is wrong, the second is correct in itself
E) both are wrong

A

ANSWER
A) both are correct, there is a causal relationship between them

EXPLANATION
Necrotizing pancreatitis usually requires prolonged, energy-intensive therapy, therefore, in these cases, jejunic nutrition schould be chosen instead of parenteral therapy.

23
Q

INT - 9.33
In acute pancreatitis, a decrease in energy (ATP) levels can be observed in both the acini and ductal cells, resulting an increased enzyme and bicarbonate secretion.

A) both are correct, there is a causal relationship between them
B) both are correct, but there is no causal relationship between them
C) the first is correct in itself, but the second is wrong
D) the first is wrong, the second is correct in itself
E) both are wrong

A

ANSWER
C) the first is correct in itself, but the second is wrong

EXPLANATION
One of the main elements of the pathomechanism of pancreatitis is the damage of mitochondria and the consequent decrease in ATP levels. In the absence of energy, neither the enzymes nor the bicarbonate can be secreted, the pancreas is so-called “seizing up”. The process leads to enzyme activation, inflammation, and finally necrosis.

24
Q

INT - 9.34
Amylase elevation is a specific symptom of acute pancreatitis, because serum amylase originate only from the pancreas.

A) both are correct, there is a causal relationship between them
B) both are correct, but there is no causal relationship between them
C) the first is correct in itself, but the second is wrong
D) the first is wrong, the second is correct in itself
E) both are wrong

A

ANSWER
E) both are wrong

EXPLANATION
Elevation of amylase levels can also origin from the salivary gland, the intestine, the urogenital apparatus, and other organs, therefore it is not specific for pancreatitis.

25
Q

INT - 9.35
ERCP and EST are required in all cases of acute pancreatitis, because opening the papilla may be necessary in some cases to the racovery of the pancreatitis.

A) both are correct, there is a causal relationship between them
B) both are correct, but there is no causal relationship between them
C) the first is correct in itself, but the second is wrong
D) the first is wrong, the second is correct in itself
E) both are wrong

A

ANSWER
D) the first is wrong, the second is correct in itself

EXPLANATION
In case of biliary pancreatitis, ERCP and EST are required, because they ensure that the pancreatic juice and bile can flow uninterrupted. In other cases of acute pancreatitis, ERCP and EST are not indicated.

26
Q

INT - 9.37
In case of chronic pancreatitis with pain, a pancreatic preparation with high lipase activity should be given, to put pancreas rest through the pancreatoduodenal feedback system, and to reduce secretion pressure.

A) both are correct, there is a causal relationship between them
B) both are correct, but there is no causal relationship between them
C) the first is correct in itself, but the second is wrong
D) the first is wrong, the second is correct in itself
E) both are wrong

A

ANSWER
D) the first is wrong, the second is correct in itself

EXPLANATION
Pancreatic calmness and reduction of secretion can be achieved with high-protease pancreatin by inhibiting duodenal CCK release. The lipase has no effect on feedback, and on pancreatogenic pain.

27
Q

INT - 9.38
Combined adjuvant chemotherapy and radiotherapy of resecabile pancreatic cancers prolong the survival time, therefore, the five-year survival rate is improving worldwide.

A) both are correct, there is a causal relationship between them
B) both are correct, but there is no causal relationship between them
C) the first is correct in itself, but the second is wrong
D) the first is wrong, the second is correct in itself
E) both are wrong

A

ANSWER
C) the first is correct in itself, but the second is wrong

EXPLANATION
Although combined chemotherapy and radiotherapy delay the appearance of liver metastases and local recidivisms, but unfortunately, the five-year survival rate does not improve significantly.

28
Q

INT - 9.39
In the diagnosis of this case, which laboratory tests will provide a valuable help directly at the time of the enrollment of the patient?

A 35-year-old man complains of increased epigastric pain radiating under the left rib and to the back from early morning hours, after abundant food and alcohol consumption last night. He feels nausea, has vomited several times, but there is no relief. Blood pressure is 105/70 Hgmm, pulse is 120/min and easy to suppress. The abdomen of the patient is meteoristic, difficult to touch, but there is no pronounced defense, and in the epigastrium undetermined resistance can be detected.

2) 1) white blood cell count
2) hematocrit
3) LDH
4) urea nitrogen
5) blood sugar
6) calcium
7) SGOT
8) arterial pO2
9) bicarbonate
10) albumin
11) C-reactive protein
12) serum amylase, lipase

A) 2., 4., 6., 8. and 9. answers are correct
B) 1., 3., 5. and 7. answers are correct
C) 2., 4., 6., 8., 9., 10. and 11. answers are correct
D) 1., 3., 5., 7. and 12. answers are correct

A

ANSWER
D) 1., 3., 5., 7. and 12. answers are correct

EXPLANATION
Based on the Ranson’s criteria, it means a serious prognosis at the time of patients registration, if the white blood cell count is above 16,000, LDH is more than 350 U/l, blood sugar is more than 200 mg/dl (11 mmol/l) and SGOT is more than 250 U/l. The slip of enzymes increases the specificity of laboratory abnormalities. The other parameters can be evaluated after 48 hours.

29
Q

INT - 9.40
Which laboratory tests will provide a valuable help in evaluation of the prognosis of this case at the 48. hour of the observation?

A 35-year-old man complains of increased epigastric pain radiating under the left rib and to the back from early morning hours, after abundant food and alcohol consumption last night. He feels nausea, has vomited several times, but there is no relief. Blood pressure is 105/70 Hgmm, pulse is 120/min and easy to suppress. The abdomen of the patient is meteoristic, difficult to touch, but there is no pronounced defense, and in the epigastrium undetermined resistance can be detected.

1) white blood cell count
2) hematocrit
3) LDH
4) urea nitrogen
5) blood sugar
6) calcium
7) SGOT
8) arterial pO2
9) bicarbonate
10) albumin
11) C-reactive protein
12) serum amylase,-lipase

A) 2., 4., 6., 8. and 9. answers are correct
B) 1., 3., 5. and 7. answers are correct
C) 2., 4., 6., 8., 9., 10. and 11. answers are correct
D) 1., 3., 5., 7. and 12. answers are correct

A

ANSWER
C) 2., 4., 6., 8., 9., 10. and 11. answers are correct

EXPLANATION
It does not means a good prognosis at the 48. hour of the observation, if hematocrit, urea nitrogen, calcium, arterial pO2, bicarbonate, albumin and C-reactive protein are significantly impaired.

30
Q

INT - 9.41
Which imaging procedures would you use to clarify the diagnosis of this case?

A 35-year-old man complains of increased epigastric pain radiating under the left rib and to the back from early morning hours, after abundant food and alcohol consumption last night. He feels nausea, has vomited several times, but there is no relief. Blood pressure is 105/70 Hgmm, pulse is 120/min and easy to suppress. The abdomen of the patient is meteoristic, difficult to touch, but there is no pronounced defense, and in the epigastrium undetermined resistance can be detected.

1) native abdominal X-ray
2) transabdominal ultrasound
3) irrigoscopy
4) abdominal CT
5) a. coeliaca angiography

A) 1., 2., 3. and 5. answers are correct
B) 1., 2. and 4. answers are correct
C) 3., 4. and 5. answers are correct
D) 3. and 5. answers are correct
E) all of the answers are correct

A

ANSWER
B) 1., 2. and 4. answers are correct

EXPLANATION
Native abdominal X-ray is a standard imaging method for the separation from perforation and other abdominal disasters, ultrasound is essential in the diagnosis of biliary pancreatitis, abdominal CT is fundamental for the determination of the severity of necrosis and pancreatitis.

31
Q

INT - 9.42
What can be the diagnosis?

A 35-year-old man complains of increased epigastric pain radiating under the left rib and to the back from early morning hours, after abundant food and alcohol consumption last night. He feels nausea, has vomited several times, but there is no relief. Blood pressure is 105/70 Hgmm, pulse is 120/min and easy to suppress. The abdomen of the patient is meteoristic, difficult to touch, but there is no pronounced defense, and in the epigastrium undetermined resistance can be detected.

A) perforated duodenal ulcus
B) mesenterial thrombosis
C) esophageal perforation
D) alcoholic acute pancreatitis
E) diabetic ketoacidosis

A

ANSWER
D) alcoholic acute pancreatitis

EXPLANATION
Anamnesis and laboratory findings indicate alcoholic acute pancreatitis.

32
Q

INT - 9.43
Which therapy would you use based on the correct diagnosis?

A 35-year-old man complains of increased epigastric pain radiating under the left rib and to the back from early morning hours, after abundant food and alcohol consumption last night. He feels nausea, has vomited several times, but there is no relief. Blood pressure is 105/70 Hgmm, pulse is 120/min and easy to suppress. The abdomen of the patient is meteoristic, difficult to touch, but there is no pronounced defense, and in the epigastrium undetermined resistance can be detected.

1) low calorie containing total parenteral nutrition with fractional insulin
2) jejunial nutrition
3) immediately surgery
4) fluid replacement, ion replacement, cardiorespiratoric assistance as occasion requires
5) analgesia, reduction of inflammation

A) 1., 3., 4. and 5. answers are correct
B) 1. and 4. answers are correct
C) 2., 4. and 5. answers are correct
D) all of the answers are correct

A

ANSWER
C) 2., 4. and 5. answers are correct

EXPLANATION
In the treatment of acute pancreatitis, early jejunial nutrition, supportive intensive care as occasion requires, pain relief, and mitigation of inflammatory cascade are important.

33
Q

INT - 9.44
Which tests will help to find the diagnosis of this case most quickly?

A 38-year-old obese woman is brought to the hospital with a pain under the right rib radiating to the shoulder. She used to eat a scrambled eggs made with bacon previous day. Her abdomen is meteoristic, diffuse sensitive, bowel movements are reduced, tachycardia can be detected (120/min).

1) blood tests (WBC, platelet counts, blood sinking)
2) liver function (bilirubin, AP, γGT, SGOT, prothrombin)
3) serum amylase
4) EKG, chest X-ray
5) transabdominal ultrasound
6) echocardiography

A) 1., 2., 3. and 5. answers are correct
B) 1., 4. and 6. answers are correct
C) 4. and 6. answers are correct
D) all of the answers are correct

A

ANSWER
A) 1., 2., 3. and 5. answers are correct

EXPLANATION
Among the laboratory findings, WBC, blod sinking, bilirubin, γ-GT, SGOT are pathognomic due to the biliary pancreatitis associated cholangitis and cholestasis (platelet counts and prothrombin should be checked for papillotomy), serum amylase makes pancreatitis probable, ultrasound is mainly needed to confirm gallstones and biliary dilatation.

34
Q

INT - 9.45
What can be the diagnosis?

A 38-year-old obese woman is brought to the hospital with a pain under the right rib radiating to the shoulder. She used to eat a scrambled eggs made with bacon previous day. Her abdomen is meteoristic, diffuse sensitive, bowel movements are reduced, tachycardia can be detected (120/min).

A) myocardial infarction
B) pleuropneumonia
C) pulmonary embolism
D) biliary acute pancreatitis
E) lung tuberculosis

A

ANSWER
D) biliary acute pancreatitis

EXPLANATION
Based on the history and the positivity of early studies, it may be a biliary acute pancreatitis.

35
Q

INT - 9.46
Which therapy should be used after the quick diagnosis?

A 38-year-old obese woman is brought to the hospital with a pain under the right rib radiating to the shoulder. She used to eat a scrambled eggs made with bacon previous day. Her abdomen is meteoristic, diffuse sensitive, bowel movements are reduced, tachycardia can be detected (120/min).

A) antibiotic therapy + analgesia
B) anticoagulant treatment + bed rest
C) ERCP + papillotomy
D) antituberculotic therapy

A

ANSWER
C) ERCP + papillotomy

EXPLANATION
After the rapid diagnosis, ERCP and papillotomy should be performed, if the examination confirm a mark of stone removal in the papilla, or cholangitis, or stone in the choledochus.

36
Q

NT - 9.47
What is your diagnosis?

A 56-year-old man turned to the family doctor due to an insecure, deep epigastric pain. The pain occurs before 15-20 minutes after meal, but recently, it occurs regardless of meals. The patient has been drinking 4-5 bottles of beer a day for 20 years. His body weight has been gradually decreasing in the recent years, because he does not dare to eat due to the pain. Recently, she reports about loose stools. Diarrhea occurs after fatty meals. His urine is normal.

A) functional dyspepsia
B) spondylosis
C) dyskinesia of the major duodenal papilla
D) chronic pancreatitis
E) gastric ulcer

A

ANSWER
D) chronic pancreatitis

EXPLANATION
The case presentation is typical for chronic pancreatitis. The assumed diagnosis is confirmed by imaging (ERCP, abdominal ultrasound) or pancreatic functional test. We recommend initially frequent, low-volume meals, low-fat diets, total alcohol abstinence, and lipase accentual enzyme replacement therapy. Angiography is not recommended for diagnostic or therapeutic purposes. In contrast, ERCP is performed, and we try to solve the progression causing stenosis, stone or other complication with operative endoscopy technique. If the pain does not ease up, we recommend surgery for the patient.

37
Q

INT - 9.48
Which test methods would you use to certify the suspected diagnosis?

A 56-year-old man turned to the family doctor due to an insecure, deep epigastric pain. The pain occurs before 15-20 minutes after meal, but recently, it occurs regardless of meals. The patient has been drinking 4-5 bottles of beer a day for 20 years. His body weight has been gradually decreasing in the recent years, because he does not dare to eat due to the pain. Recently, she reports about loose stools. Diarrhea occurs after fatty meals. His urine is normal.

1) gastroscopy
2) irrigiscopy
3) ERCP
4) abdominal ultrasound
5) abdominal MR
6) starch load

A) 1., 2. and 3. answers are correct
B) 3., 4. and 6. answers are correct
C) 1., 5. and 6. answers are correct
D) all of the answers are correct

A

ANSWER
B) 3., 4. and 6. answers are correct

EXPLANATION
The case presentation is typical for chronic pancreatitis. The assumed diagnosis is confirmed by imaging (ERCP, abdominal ultrasound) or pancreatic functional test. We recommend initially frequent, low-volume meals, low-fat diets, total alcohol abstinence, and lipase accentual enzyme replacement therapy. Angiography is not recommended for diagnostic or therapeutic purposes. In contrast, ERCP is performed, and we try to solve the progression causing stenosis, stone or other complication with operative endoscopy technique. If the pain does not ease up, we recommend surgery for the patient.

38
Q

NT - 9.49
Which treatment is recommended primarily?

A 56-year-old man turned to the family doctor due to an insecure, deep epigastric pain. The pain occurs before 15-20 minutes after meal, but recently, it occurs regardless of meals. The patient has been drinking 4-5 bottles of beer a day for 20 years. His body weight has been gradually decreasing in the recent years, because he does not dare to eat due to the pain. Recently, she reports about loose stools. Diarrhea occurs after fatty meals. His urine is normal.

1) low fat diet
2) total alcohol abstinence
3) proton pump inhibitor
4) physiotherapy
5) spasmolytics, painkillers
6) pancreatic enzyme replacement

A) 1., 2., 3. and 4. answers are correct
B) 2., 3. and 6. answers are correct
C) 1., 2., 5. and 6. answers are correct
D) all of the answers are correct

A

ANSWER
C) 1., 2., 5. and 6. answers are correct

EXPLANATION
The case presentation is typical for chronic pancreatitis. The assumed diagnosis is confirmed by imaging (ERCP, abdominal ultrasound) or pancreatic functional test. We recommend initially frequent, low-volume meals, low-fat diets, total alcohol abstinence, and lipase accentual enzyme replacement therapy. Angiography is not recommended for diagnostic or therapeutic purposes. In contrast, ERCP is performed, and we try to solve the progression causing stenosis, stone or other complication with operative endoscopy technique. If the pain does not ease up, we recommend surgery for the patient

39
Q

INT - 9.50
The complaints of the patient do not disappear after 3 to 4 months of treatment. What would you suggest, except:

A 56-year-old man turned to the family doctor due to an insecure, deep epigastric pain. The pain occurs before 15-20 minutes after meal, but recently, it occurs regardless of meals. The patient has been drinking 4-5 bottles of beer a day for 20 years. His body weight has been gradually decreasing in the recent years, because he does not dare to eat due to the pain. Recently, she reports about loose stools. Diarrhea occurs after fatty meals. His urine is normal.

A) increase the enzyme replacement dose
B) ERCP with intervention as needed
C) pancreatic resection surgery
D) angiography

A

ANSWER
D) angiography

EXPLANATION
The case presentation is typical for chronic pancreatitis. The assumed diagnosis is confirmed by imaging (ERCP, abdominal ultrasound) or pancreatic functional test. We recommend initially frequent, low-volume meals, low-fat diets, total alcohol abstinence, and lipase accentual enzyme replacement therapy. Angiography is not recommended for diagnostic or therapeutic purposes. In contrast, ERCP is performed, and we try to solve the progression causing stenosis, stone or other complication with operative endoscopy technique. If the pain does not ease up, we recommend surgery for the patient.