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ABIM-GI November 16th, 2022 > Pancreas > Flashcards

Pancreas Flashcards

1
Q

What is the BEST treatment of a PANCREATIC DUCT LEAK (post-op, etc.) even if the ASCITES it created is SIGNIFICANT?

A

ERCP with PD STENT placement

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2
Q

What are the RISK factors for POST-ERCP pancreatitis?

A

CONTRAST injection, YOUNG age, SOD indication

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3
Q

What should be done for ALL pancreatic cysts whether or not they are thought to be pseudocysts or not?

A

EUS/FNA (CEA, lipase, cytology)

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4
Q

What is the recommended TREATMENT for LARGE BILOMAS?

A

PERCUTANEOUS DRAIN and BILIARY STENT

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5
Q

In a patient with CHRONIC PANCREATITIS and a BILIARY STRICTURE, what is the CRITERIA for ERCP treatment?

A

CBD >12 mm and ALP >3 X normal

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6
Q

What is the BEST association for SOD?

A

BILIARY PAIN post-CHOLECYSTECTOMY

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7
Q

In which SOD TYPE is the use of Sphincter of Oddi Manometry (SOM) predictive of good outcome with ERCP/Sphincterotomy?

A

SOD Type-II

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8
Q

When is EUS/FNA needed for a MALIGNANT BILIARY OBSTRUCTION?

A

If planning on PRE-OP NEOADJUVANT therapy or there is a DELAY in SURGERY

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9
Q

If a patient presents with a MALIGNANT BILIARY OBSTRUCTION and has SURGERY planned soon, do they require biliary DRAINAGE (T.Bili <14)?

A

NO

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10
Q

Wht MUST be done PRIOR to an ERCP when a HILAR MALIGNANCY is suspected?

A

MRCP

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11
Q

Besides biliary obstruction, what can AMPULLARY TUMORS and pancreatic ADENOCARCINOMA cause?

A

Idiopathic PANCREATITIS

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12
Q

Prior POST-ERCP pancreatitis, FEMALE, previous ACUTE RECURRENT pancreatitis, suspected SOD, young age <40, ABSENCE of CHRONIC PANCREATITIS, NORMAL BILIRUBIN are all risk factors for?

A

Post-ERCP PANCREATITIS

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13
Q

At what AGE should a patient with a LYNCH genetic mutation be SCREENED for COLON cancer?

A

At the age of 20-25 and every 1-2 years thereafter

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14
Q

During the FIRST WEEK of treatment of ACUTE PANCREATITIS, what determines SEVERITY and PROGNOSIS?

A

The presence of ORGAN FAILURE (renal, pulmonary, cardiovascular)

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15
Q

How elevated do the AMYLASE/LIPASE values need to be to diagnose ACUTE PANCREATITIS?

A

3 X upper limit of normal

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16
Q

If concerned for NECROSIS in a patient with ACUTE PANCREATITIS, when should a CT scan WITH CONTRAST be performed?

A

At least 3 DAYS AFTER the diagnosis of pancreatitis

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17
Q

What should be performed in ALL patients in whom GALLSTONE PANCREATITIS is suspected?

A

US

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18
Q

Acute pancreatitis grade WITHOUT ORGAN FAILURE (renal, pulmonary, cardiovascular) WITHOUT LOCAL COMPLICATIONS (fluid collection, necrosis) WITHOUT SYSTEMIC COMPLICATIONS (worsening of an uderlying medical condition)?

A

MILD

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19
Q

Acute pancreatitis grade WITH TRANSIENT ORGAN FAILURE <48 HOURS (renal, pulmonary, cardiovascular) WITH LOCAL COMPLICATIONS (fluid collection, necrosis) WITH SYSTEMIC COMPLICATIONS (worsening of an uderlying medical condition)?

A

MODERATE

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20
Q

Based on an ADMISSION CT, can MILD ACUTE PANCREATITIS be radiologically diagnosed within the first 48 HOURS?

A

NO

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21
Q

Acute pancreatitis grade WITH PERSISTENT ORGAN FAILURE >48 HOURS (renal, pulmonary, cardiovascular)?

A

SEVERE

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22
Q

A patient who is >60 yo, BMI >30, first ACUTE PANCREATITIS attack, multiple COMORBIDITIES, PLEURAL EFFUSIONS, and SIRS have what type of prognosis?

A

MUCH HIGHER RISK for SEVERE PANCREATITIS

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23
Q

TWO or more of: Pluse >90 bpm; TEMP <36 C or >38 C; WBC <4,000 or >12,000; RESPIRATIONS >20 bpm; PCO2 <32 mm Hg is indicative of what?

A

Systemic Inflammatory Response Syndrome (SIRS)

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24
Q

Do the levels of AMYASE/LIPASE correlate with SEVERITY of ACUTE PANCREATITIS?

A

NO

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25
Q

What LABORATORY findings are SUGGESTIVE of SEVERE PANCREATITIS and likely the develoment of NECROSIS?

A

Hct >44, RISE in BUN after the FIRST 24 HOURS, ELEVATED Cr (>1.8)

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26
Q

In the setting of PERSISTENT MULTIORGAN FAILURE, what is the mortaity RISK for ACUTE PANCREATITIS?

A

50%

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27
Q

How does the presence of NECROSIS affect PROGNOSIS of ACUTE PANCREATITIS?

A

It does NOT, only if INFECTED NECROSIS

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28
Q

WHEN is HYDRATION the most important when treating ACUTE PANCREATITIS?

A

In the FIRST 6-12 HOURS (250 - 500 mL/hr)

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29
Q

How long CAN you wait in SEVERE PANCREATITIS before starting PO or TUBE FEEDS (preferred over parenteral)?

A

5 DAYS (only if PO not tolerated)

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30
Q

In MILD (no organ failure, no localized complications, no systemic complications) acute pancreatitis, WHEN should you FEED the patient and how?

A

EARLY ORAL (LOW FAT) when SYMPTOMS IMPROVE, without having to advance (for SEVERE, can wait 5 days but optional and via NGT if not tolerating PO)

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31
Q

A >3 X ELEVATION of ALT/AST in the presence of ACUTE PANCREATITIS is suggestive of what ETIOLOGY?

A

Gallstones

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32
Q

In a patient with ACUTE PANCREATITIS and COEXISTENT CHOLANGITIS, WHEN should the ERCP be performed?

A

WITHIN 24-72 HOURS

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33
Q

What DIFFERENTIATES a pancreatic PSEUDOCYST from WALLED-OFF PANCREATIC NECROSIS?

A

The LOCATION of the fluid collection (outside of the pancreas - pseudocyt, inside - necrosis)

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34
Q

What MUST be done when a pancreatic PSEUDOCYST becomes infected (abscess)?

A

DRAINAGE

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35
Q

What is it called when on a CONTRAST-ENHANCED CT in a patient with ACUTE PANCREATITIS, there is >30% of non-enhancement of the pancreas?

A

PANCREATIC NECROSIS (needs ICU monitoring) - avoid lines, parenteral nutrition to avoid infection

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36
Q

ACUTE PANCREATITIS, 7-14 DAYS after presentation, develops FEVER and LEUKOCYTOSIS?

A

INFECTED NECROSIS (biopsy to direct antibiotic choice)

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37
Q

WHEN is SURGICAL NECROSECTOMY (debridement) indicated for infected pancreatic necrosis?

A

4 WEEKS after initial hospital admission

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38
Q

WHEN is CHOLECYSTECTOMY indicated for a patient with ACUTE BILIARY PANCREATITIS?

A

SAME ADMISSION

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39
Q

Can PANCREATIC CANCER present as the FIRST ATTACK of PANCREATITIS?

A

YES (rarely)

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40
Q

What is the TIME frame for PREDICTING and for DEFINING severity in ACUTE PANCREATITIS?

A

48 HOURS (can predict before, can only define after)

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41
Q

Which CRYSTALLOID suspension is preferred but NOT MANDATORY for resusscitation of ACUTE PANCREATITIS?

A

Lactated Ringers (or NS)

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42
Q

Drinking ALCOHOL 4-5 drinks/day for 5-10 years with or without SMOKING (synergistic) can result in what CHRONIC condition of the PANCREAS?

A

CHRONIC PANCREATITIS

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43
Q

Mutations in which GENES are implicated in HEREDITARY chronic pancreatitis?

A

PRSS1, SPINK1, CFTR, CTRC, and claudin-2

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44
Q

PANCREATITIS presenting in a patient with BILIARY STRICTURES, HILAR LYMPHADENOPATHY, SCLEROSING SIALADENITIS, RETROPERITONEAL FIBROSIS, PSEUDOTUMORS and TUBULOINTERSTITIAL NEPHRITIS is what type?

A

AUTOIMMUNE PANCREATITIS TYPE-I (AIP type I) - IgG4 (>2 X ULN)

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45
Q

>10 IgG4 PLASMA cells per HPF in PANCREATIC BIOPSY means what?

A

TYPE-I AIP

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46
Q

How does AIP TYPE-II differ from AIP TYPE-I?

A

AIP TYPE-II occurs ONLY in the PANCREAS and is ASSOCIATED with IBD

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47
Q

Which AIP TYPE is associated with IBD?

A

AIP TYPE-II (pancreas involvement only)

48
Q

PAINLESS JAUNDICE or ACUTE PANCREATITIS due to obstruction of the intra-pancreatic bile duct in a patient with NO OBSERVABLE pancreatic mass?

A

AIP

49
Q

SAUSAGE-SHAPED pancreas with LOW-DENSITY RIM around the pancreas seen on CT?

A

AIP

50
Q

Suggestive IMMAGING of the PANCREAS and pancreatic DUCT, SEROLOGY, OTHER ORGAN INVOLVEMENT, HISTOLOGY and response to STEROID THERAPY (the treatment) are the diagnostic criteria for what?

A

AUTOIMMUNE CHRONIC PANCRATITIS

51
Q

Which TYPE of AIP REQUIRES a PANCREATIC BIOPSY?

A

AIP TYPE-II

52
Q

What MUST be RULED OUT FIRST before initiating STEROIDS for presumed AIP?

A

PANCREATIC MALIGNANCY

53
Q

What is the TREATMENT and its DURATION for AIP?

A

PREDNISONE 40 mg PO daily, tapering off by 5-10 mg/week for a total of 10-12 WEEKS

54
Q

Which TYPE of AIP REPLAPSES (biliary strictures, jaundice) in 30-50% of patients and how is it treated?

A

AIP TYPE-I (repeat steroid taper) as azathioprine does not work and RITUXIMAB is used in REFRACTORY disease

55
Q

A patient from SOUTHWEST INDIA presents with mutations in SPINK1 and CTRC, youth to early adulthood, abdominal pain, severe MALNUTRITION, EXOCRINE and ENDOCRINE pancreatic dysfunction, LARGE PD and PD STONES?

A

TROPICAL PANCREATITIS

56
Q

What are the most SENSITIVE tests for diagnosing CHRONIC PANCREATITIS (can detect disease prior to developing exocrine/endocrine insufficiency)?

A

DIRECT HORMONAL STIMULATION TESTS (secretin stimulation test), a BICARBONATE concentration <80 meq/L after 60 min is ABNORMAL

57
Q

What do SERUM TRYPSIONGEN (<20 ng/mL) and FECAL ELASTASE (<200 µg/g) signify?

A

Pancreatic INSUFFICIENCY due to CHRONIC PANCREATITIS

58
Q

What are the RECOMMENDED initial IMAGING tests for dignosing CHRONIC PANCREATITIS?

A

MULTIDETECTOR-CT or MRI with MRCP

59
Q

What are the AGENTS to use with CHRONIC PANCREATITIS PAIN?

A

TRAMADOL, PREGABALIN, TCA or SSRI or combined SSRI/NRI (duloxetine)

60
Q

What is the DIFFERENCE between CELIAC PLEXUS BLOCK and CELIAC PLEXUS NEUROLYSIS?

A

BLOCK - BUPIVICANE only

NEUROLYSIS - addition of ABSOLUTE ALCOHOL

61
Q

What can be done for chronic pancretitis PAIN if pt does not respond to medical or endoscopic therapy?

A

SURGERY (lateral pancreaticojejunostomy - modified PUSTEOW procedure) - with Roux-en-Y and immediate pain relief in 80% of patients

62
Q

What are the TWO most significant causes of CHRONIC PANCREATITIS?

A

ALCOHOL and SMOKING

63
Q

What should be considered in ALL patients after SUBTOTAL PANCREATECTOMY performed for chronic pancreatitis or otherwise?

A

Pancreatic ENZYME supplementation for likely sublte exocrine pancreatic defficiency

64
Q

How many UNITS of LIPASE are delivered by the pancreas with a meal?

A

~900,000 USP (90,000 are required to eliminate steatorrhea)

65
Q

What is IMPORTANT to keep in mind when prescribing pancreatic ENZYME supplementation?

A

Pancreatic ENZYMES MUST BE ENTERICALLY COATED or patient must be PRESCRIBED H2-blockers or PPIs

66
Q

What ELSE must be done in patients with pancreatic exocrine insufficiency with STEATORRHEA besides ENZYME supplementation?

A

Supplementation of the FAT-SOLUBLE vitamins (D, E, K, A) as well as BONE DENSITY to prevent osteopenia and osteoporosis

67
Q

What is DM Type 3C?

A

It is DIABETES MELLITUS associated DIRECTLY with ISLET CELL LOSS due to CHRONIC PANCREATITIS or other pancreatic diseases

68
Q

What is the PREFERRED medication to use in patients with DM due to chronic pancreatitis?

A

METFORMIN (prevents adenocarcinoma)

69
Q

The development on an ACUTE GIB in the presence of a PANCREATIC PSEUDOCYST is idicative of what?

A

PSEUDOANEURYSM (erosion of the pseudocyst into a vessel) 40% MORTALITY - emergent CT with IV contrast (high-density material) after negative EGD - small sentinel bleed followed days to weeks later by massive bleed

70
Q

Which PANCREATIC CYSTS require SURGICAL removal?

A

MUCINOUS CYSTIC NEOPLASMS and IPMNs (>3 cm , growth of >3 mm/year, or if PD is >10 mm) or SOLID COMPONENT

71
Q

SPLENIC VEIN thrombosis, SIBO, GASTROPARESIS are all complications of this condition?

A

Chronic Pancreatitis

72
Q

Which AIP type is associated with IgG4?

A

TYPE-I (systemic and not just involving the pancreas)

73
Q

In a patient with CHRONIC PANCREATITIS PAIN, if no stricture, no stone, s/p surgery but still with pain, why?

A

CNS sensitization, a nerve problem

74
Q

Which pancreatic CYSTS have an OVARIAN-LIKE stroma?

A

MUCINOUS CYSTIC NEOPLASMS (MCN, not ipmn)

75
Q

A CEA value of WHAT is considered elevated for a pancreatic CYST?

A

CEA >192

76
Q

What is the recommendation for SURVEILLANCE (CT, MRI, EUS) of pancreatric CYSTS?

A

<10 mm, every 12 MONTHS

10 - 20 mm, 6-12 MONTHS

>20 mm, 3-6 MONTHS

IF NO CHANGE after 2 YEARS, lengthen the interval

77
Q

What follow-up is required for a PANCREATIC REST?

A

NONE, its a benign lesion

78
Q

In a patient with IDIOPATHIC PANCREATITIS, if EVERYTHING including EUS has been done without explanation, what would be the recommended next step?

A

EMPIRIC CHOLECYSTECTOMY

79
Q

What should be done as far as FEEDING for a patient with NECROTIZING PANCREATITIS even if hypoactive bowel sounds?

A

TRIAL of PO FEEDING

80
Q

In a patient with ACUTE NECROTIZING PANCREATITIS, with a FEVER and LEUKOCYTOSIS, when should you think of INFECTED NERCOSIS?

A

With ORGAN FAILURE and ~1 WEEK out, NOT EARLY in the process

81
Q

Which GENE is MOSTLY associated with HEREDITARY (family members) CHRONIC PANCREATITIS?

A

PRSS1 (autosomal dominant)

82
Q

In a patient with IDIOPATHIC PANCREATITIS but NO FAMILY HISTORY of heredity, which GENE is most likely mutated?

A

CFTR

83
Q

HOW are GASTRIC VARICES (fundic) caused by SPLENIC VEIN THROMBOSIS treated?

A

These RARELY BLEED if caused by splenic vein thrombosis, and unless they do, NO INTERVENTION is required. If they do bleed, treat with SPLENECTOMY

84
Q

4 cm CYST in TOP, with SEPTATIONS and scattered CALCIFICATIONS?

A

MUCINOUS CYSTIC NEOPLASM (MCN)

85
Q

3 cm SIMPLE (no INTERNAL NODULES or SEPTATIONS) pancreatic CYST with ELEVATED CEA and MILD PD DILATION, what should be done NEXT?

A

IMAGING in 1 YEAR (SIMPLE cyst, even if mucinous)

86
Q

Which IVF is the BEST for preventing ORGAN FAILURE and MORTALITY in a patient with ACUTE PANCREATITIS?

A

NONE, all the same (NS or LR)

87
Q

Which FINDINGS on IMAGING of the pancreas correlate best with PANCREATIC PAIN?

A

NONE

88
Q

What is the RECOMMENDED TREATMENT for a HEMORRHAGIC pancreatic PSEUDOCYST?

A

ANGIOGRAPHY with embolization

89
Q

In ACUTE PANCREATITIS, which ENZYME (amylase or lipase) decreases to the reference range MUCH FASTER because that enzyme comes from MULTIPLE SOURCES and which of the TWO is SPECIFIC for PANCREATITIS?

A

AMYLASE normalizes MUCH FASTER (multiple sources)

LIPASE is SPECIFIC to the PANCREAS

90
Q

At which LEVEL of HYPERTRIGLYCERIDEMIA is PANCREATITIS POSSIBLE?

A

>1,000 (with suppression of the rise amylase)

91
Q

ACUTE LFT (ALT) elevations in a patient with PAIN, are STRONGLY INDICATIVE of what etiology of ACUTE PANCREATITIS?

A

BILIARY (stones, sludge)

92
Q

What are the RISK FACTORS for SEVERE PANCREATITIS?

A

A pt’s AGE (>55), WEIGHT (BMI >30), HEMOCONCENTRATION and RESIRATORY COMPROMISE (organ failure at admission i.e. renal or pulm)

93
Q

What is the RECOMMENDED INITIAL management of ACUTE PANCREATITIS?

A

AGGRESSIVE FLUID HYDRATION and CLOSE MONITORING

94
Q

The DEGREE of HEMOCONCENTRATION is predictive of what in ACUTE PANCREATITIS?

A

HIGHER RISK for SEVERE COURSE

95
Q

The HARMLESS ACUTE PANCREATITIS SCORE (HAPS) consists of WHAT values that can predict with 98% certainty that the pancreatitis course will be MILD to MODERATE?

A

ABSENCE of REBOUND, NORMAL Hct and NORMAL Cr

96
Q

CT CHARACTERIZATION of ACUTE PANCREATITIS IF ACTUALLY NEEDED, should be done WHEN after presentation?

A

48-72 HOURS

97
Q

WHEN should NUTRITION be instituted in ACUTE PANCREATITIS?

A

EARLY, within the FIRST 24-48 HOURS to maintain GUT INTEGRITY

98
Q

HOW should ANALGESIA be administered for a patient with ACUTE PANCREATITIS?

A

(PATIENT-CONTROLLED ANALGESIA) PCA PUMP

99
Q

In a patient with ACUTE PANCREATITIS who develops FEVER, LEUKOCYTOSIS, RESPIRATORY COMPROMISE, RENAL FAILURE (elevated Cr), HYPOTENSION, TACHYCARDIA, with CT demonstrating NECROSIS and FLUID CONSOLIDATION, what should be done?

A

ICU CARE and CT-GUIDED ASPIRTATION of PANCREAS (rule out infection) and ANTIBIOTIC therapy

100
Q

YOUNG pt with ABDOMINAL PAIN, OBSTRUCTIVE JAUNDICE, and a DIFFUSELY ENLARGED PANCREAS on IMAGING, with NORMAL IgG4, no other organ involvement, NO STONES, NO ALCOHOL?

A

TYPE-2 AIP (GRANULOCYTE EPITHELIAL LESION with NEUTROPHILIC INFILTRATE in the PANCREATIC DUCT epithelium, OBLITERATING the LUMEN)

101
Q

MUTATION in WHICH of the HEREDITARY CHRONIC PANCREATITIS GENES is most SPECIFIC for this CONDITION?

A

PRSS1 (R117H and N21I)

102
Q

MUTATIONS in SPINK1 and CFTR are associated with what TYPE of PANCREATITIS?

A

IDIOPATHIC PANCREATITIS

103
Q

PERSISTENT, MILD increase in serum AMYLASE levels may indicate WHAT if the LIPASE is normal?

A

MACROAMYLASEMIA (BENIGN)

104
Q

WHAT ONE IMAGING FINDING of the PANCREAS (CT, EUS, ETC) is HIGHLY-SUGGESTIVE for CHRONIC PANCRETITIS?

A

INTRA-DUCTAL STONES

105
Q

HOW MUCH of the PANCREATIC EXOCRINE FUNCTION must be LOST in order to have STEATORRHEA?

A

>90%

106
Q

WHEN SHOULD PANCREATIC ENZYMES be taken when eating?

A

THROUGHOUT the MEAL, NOT BEFORE or AFTER (30,000 to 45,000 units of LIPASE per meal)

107
Q

CORRECTION of STEATORRHEA with ORAL ENZYME SUPPLEMENTS is associated with CORRECTION of WHAT else?

A

CORRECTION of CARBOHYDRATE and PROTEIN MALABSORPTION

108
Q

For patients who have PAIN due to CHRONIC CALCIFIC (pancreatic duct STONES) PANCREATITIS with a DILATED DUCT, what is the RECOMMENDED INTERVENTION?

A

LATERAL PANCREATICO-JEJUNOSTOMY

109
Q

What is the RECOMMENDED management for a GALLBLADDER ADENOMA >18 mm (fixed, hyperechoic lesion, protruding into the GB lumen without shadowing)?

A

OPEN CHOLECYSTECTOMY (HIGH-LIKELIHOOD of ADVANCED CANCER)

110
Q

In a patient who presents with ALCOHOLIC ACUTE PANCREATITIS and GB microlithiasis is found, what is done for the MICROLITHIASIS?

A

NOTHING, unless SECOND episode of acute pancreatitis occurs WITHOUT ALCOHOL involvement or another etiologic factor

111
Q

What is the RECOMMENDATION for management of a PREGNANT woman with SYMTOMATIC GB disease?

A

CHOLECYSTECTOMY (laparoscopic, when possible)

112
Q

Which PARASITES cause RECURRENT PYOGENIC CHOLANGITIS?

A

ASCARIS and OPISTHORCHIS

113
Q

What COLORED BILIARY STONES are seen in patients with CYSTIC FIBROSIS, CHRONIC HEMOLYSIS, MECHANICAL HEART VALVES, CIRRHOSIS and GILBERT’s SYNDROME or who are on TPN?

A

BLACK - colored stones

114
Q

What COLORED BILIARY STONES are seen in patients with BACTERIAL or PARASITIC infestation of the BILIARY SYSTEM?

A

BROWN - colored stones

115
Q

What is a MICRO GALLBLADDER (2-3 cm in size) ASSOCIATED with?

A

CYSTIC FIBROSIS and NEONATAL HEPATITIS

116
Q

What CONGENITAL GALLBLADDER TYPE is associated with risk of TORSION?

A

WANDERING GALLBLADDER (long mesentery, no firm attachment to the liver)

117
Q

PHARYGIAN CAP, HOURGLASS GALLBLADDER, WANDERING GALLBLADDER and GALBLADDER AGENESIS are all which TYPE of variants?

A

CONGENITAL ANOMALIES (macro-galbladder is NOT congenital)

ABIM-GI November 16th, 2022 (8 decks)

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