Pancreas, Biliary Tract, Liver, Appendix,

Question 1

Most common abdominal surgical emergency

Answer 1

Appendicitis - affects 10% population

Question 2

Percentage of patients w appendicitis that progress to perforation / peritonitis

Answer 2

20%

Question 3

Pain timeline in appendicitis

Answer 3

12 hours - starts periumbilical and/or epigastric and intermittent, moves to Mcburney’s point and becomes constant.
Worse with movement, rebound tenderness.

Question 4

Patient with a retrocecal appendicitis likely to feel pain

Answer 4

On rectal exam

Question 5

Preferred method to confirm diagnosis of appendicitis

Answer 5

Abdominal CT

Question 6

Most common causes of pancreatitis

Answer 6

Cholelithiasis
Alcohol abuse

also 
Hyperlipidemia (hypertriglyceridemia)
Trauma
Drugs
Hypercalcemia 
Penetrating PUD

Question 7

Grave prognosis of pancreatitis indicated with

Answer 7

Shock!

Sever hypovolemia,
ARDS,
Tachy >130bpm

Question 8

Bruising of the flanks, known as ____ and indicative of ____

Answer 8

Grey Turner Sign, hemorrhagic pancreatitis (or other retroperitoneal hemorrhage)

Question 9

Superficial edema and bruising around the umbilicus is known as ____ and indicative of ____

Answer 9

Cullen’s sign, hemorrhagic pancreatitis (severe, acute)

Question 10

Most sensitive and specific lab for pancreatitis

Answer 10

Serum lipase, with elevations of threefold or greater

Question 11

Ranson Criteria for poor prognosis of pancreatitis

Answer 11

WBC count > 16,000
Glucose > 200mg
LDH > 350
AST >250
Arterial PO2 <60
Calcium Falling
BUN rising

Question 12

90% of chronic pancreatitis cases in US caused by

Answer 12

Alcohol abuse

Question 13

Classic triad of chronic pancreatitis

Answer 13

Pancreatic calcification
Steatorrhea
Diabetes mellitus

(only occurs in 20%)

Question 14

Clinical feature of chronic pancreatitis that’s different from acute

Answer 14

Fat malabsorption and steatorrhea (late in disease)

Question 15

Diagnosis of chronic pancreatitis

Answer 15

Abdominal plain film reveals calcification of 20-30% of pancreas

Question 16

5th leading cause of cancer death in US

Answer 16

pancreatic cancer

Question 17

Risk factors for pancreatic cancer

Answer 17

increased age
obesity
tobacco
chronic pancreatitis 
previous abdominal radiation
family history

Question 18

Jaundice and palpable gallbladder (Courvoisier sign) may be seen inpatients with

Answer 18

Cancer of the pancreatic hea

Question 19

palpable gallbladder is known as

Answer 19

Courvoisier sign

Question 20

Treatment for pancreatic cancer

Answer 20

Whipple surgery (if no metastases)

Question 21

Prevalence of gallstones

Answer 21

By age 75, 35% of women and 20% of men have gallstones

Question 22

percentage of ppl with gallstones that develop disease

Answer 22

30%

Question 23

Complications of choledocholithiasis

Answer 23

Cholecystitis, pancreatitis, acute cholangitis

Question 24

cause of acute cholecystitis

Answer 24

obstruction of bile duct by gallstone, causing inflammation

Question 25

What can identify cause, location, and extent of biliary obstruction - event treat

Answer 25

ERCP (endoscopic retrograde cholangiopancreatography)

Question 26

Treatment for cholecystitis

Answer 26

Surgical

Question 27

Potentially deadly condition of common bile duct obstruction combined with **ascending infection** - can lead to sepsis and death

Answer 27

Acute cholangitis

Question 28

Most common cause of infection in acute cholangitis

Answer 28

E. coli, | Enterococcus, Klebsiella, Enterobacter

Question 29

Charcot's triad, indicative of

Answer 29

RUQ tenderness, jaundice, fever (present in 50-70%) Indicative of Acute Cholangitis

Question 30

In addition to Charcot's triad, acute cholangitis may present with

Answer 30

Reynold's pentad: altered mental status hypotension (plus RUQ tenderness, jaundice, fever)

Question 31

Reynold's pentad

Answer 31

Presentation of acute cholangitis ``` RUQ tenderness Jaundice Fever Hypotension Altered mental status ```

Question 32

Initial test for acute cholangitis

Answer 32

RUQ ultrasonography will show biliary dilation or stones

Question 33

Labs to support diagnosis of cholangitis

Answer 33

Leukocytotis w left shift Increased bilirubin mildly increased Transaminase

Question 34

Optimal procedure for both diagnosis and treatment of acute cholangitis

Answer 34

ERCP | **should not be done unless patient is stable, unless urgent decompression is needed**

Question 35

Initial medical treatment for acute cholangitis

Answer 35

Antibiotics IV fluids Analgesics

Question 36

Chronic thickening of bile duct walls of unknown etiology - often associated with inflammatory bowel disease (UC)

Answer 36

Primary Sclerosing Cholangitis (PSC)

Question 37

Most common presenting features of PSC

Answer 37

Jaundice and pruritis - with fatigue, malaise, weight loss

Question 38

Treatment for PSC

Answer 38

Balloon dilation and stent placement for localized strictures Liver transplant only treatment with a known survival benefit

Question 39

first and second most common causes of hepatitis

Answer 39

1. virus | 2. alcohol

Question 40

Lab value which is elevated in all types of acute hepatitis, indicating hepatocellular damage

Answer 40

Aminotransferase (AST, ALT)

Question 41

Bilirubin level associated w scleral icterus and/or frank jaundice

Answer 41

3.0 >

Question 42

Hep A incubation period, after which HAV IgM is detectable

Answer 42

15-40 days

Question 43

HAV IgG indicates

Answer 43

resolved Hep A

Question 44

HBsAg positive, indicates

Answer 44

Ongoing infection of any duration (Hep B)

Question 45

anti-HBs indicates

Answer 45

Heb B immunity, via vaccination or past infection

Question 46

anti-HBc indicates

Answer 46

Acute hepatitis - present between disappearance of HBsAg and appearance of anti-HBs

Question 47

HBeAg indicates

Answer 47

Active infection, highly contagious

Question 48

anti-HBe

Answer 48

Indicates lower viral titer

Question 49

Indications of late stage cirrhosis

Answer 49

``` Ascites Pleural effusion Ecchymoses Esophageal varices Hepatic encephalopathy ```

Question 50

Asterixis, tremor, dysarthria, delirium, eventually coma

Answer 50

hepatic encephalopathy

Question 51

Patient with advanced cirrhosis presents with Fever, chills, worsening ascites, abdominal pain. May lead to diarrhea and renal failure

Answer 51

Spontaneous bacterial peritonitis

Question 52

A significant complicating feature of decompensated cirrhosis and is responsible for the development of ascites and bleeding from esophagogastric varices

Answer 52

Portal hypertension

Question 53

two complications that signify decompensated cirrhosis

Answer 53

Ascites and esophageal varices

Question 54

liver biopsy in alcoholic cirrhosis

Answer 54

Liver biopsy can be helpful to confirm a diagnosis, but generally when patients present with alcoholic hepatitis and are still drinking, liver biopsy is withheld until abstinence has been maintained for at least 6 months to determine residual, nonreversible disease.

Question 55

inherited disorder of iron metabolism that results in a progressive increase in hepatic iron deposition, which, over time, can lead to a portal-based fibrosis progressing to cirrhosis, liver failure, and hepatocellular cancer.

Answer 55

Hemochromatosis

Question 56

Diagnosis and treatment of Hemochromatosis

Answer 56

Diagnosis is made with serum iron studies showing an elevated transferrin saturation and an elevated ferritin level, along with abnormalities identified by HFE mutation analysis. Treatment is straightforward, with regular therapeutic phlebotomy.

Question 57

inherited disorder of copper homeostasis with failure to excrete excess amounts of copper, leading to an accumulation in the liver. Wilson’s disease typically affects adolescents and young adults.

Answer 57

Wilson's disease

Question 58

Diagnosis and treatment of Wilson's disease

Answer 58

Diagnosis requires determination of ceruloplasmin levels, which are low; 24-h urine copper levels, which are elevated; typical physical examination findings, including Kayser-Fleischer corneal rings; and characteristic liver biopsy findings. Treatment consists of copper-chelating medications.

Question 59

inherited disorder that causes abnormal folding of the α1AT protein, resulting in failure of secretion of that protein from the liver. Patients are at greatest risk for developing chronic liver disease have the ZZ phenotype, but only about 10–20% of such individuals will develop chronic liver disease.

Answer 59

Alpha 1 antitrypsin deficiency

Question 60

Diagnosis and treatment of alpha 1 antitrypsin deficiency

Answer 60

Diagnosis is made by determining α1AT levels and phenotype. Characteristic periodic acid–Schiff (PAS)-positive, diastase-resistant globules are seen on liver biopsy. The only effective treatment is liver transplantation, which is curative.

Question 61

Prehepatic causes of portal hypertension

Answer 61

Splenic vein thrombosis | Portal vein thrombosis

Question 62

Post hepatic causes of portal hypertension

Answer 62

Affects hepatic veins and venous drainage to heart Budd Chiari syndrome Venocclusive disease Chronic right heart congestive failure

Question 63

Intrahepatic causes of portal hypertension

Answer 63

**account for 95% of portal hypertension** Cirrhosis presinusoidal, sinusoidal, and postsinusoidal causes. Postsinusoidal causes include venoocclusive disease, whereas presinusoidal causes include congenital hepatic fibrosis and schistosomiasis. Sinusoidal causes are related to cirrhosis from various causes.

Question 64

The three primary complications of portal hypertension

Answer 64

gastroesophageal varices with hemorrhage, ascites hypersplenism

Question 65

Benign liver neoplasms

Answer 65

Cavernous hemangioma Hepatocellular adenoma Infantile hemangioendothelioma

Question 66

Cancers that commonly metastasize to liver

Answer 66

Lung | Breast