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What is the most appropriate IV antibiotic of choice for treating infected necrosis in severe pancreatitis?
A pancreatic Balthazar grade score of 4 indicates severe pancreatitis.
True
What management step should be taken for a patient diagnosed with severe pancreatitis in the initial phase?
Nil per oral (NPO)
Biliary pancreatitis often requires ____________ and sphincterotomy for management.
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Match the following pancreatic necrosis scores with their corresponding descriptions:
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Which surgical procedure is typically used for a resectable distal CBD tumor?
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Bilhemia is caused by bile leaking into blood vessels.
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What is the most common site of metastasis in non-resectable gastrointestinal cancers?
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The tumor marker associated with gastrointestinal tumors is S. Ca _____.
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Match the biliary complications with their appropriate management:
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Which structure is associated with Whipple's surgery as indicated by the 'Tunnel of Love' line?
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Sphincter of Oddi consists of three sphincters.
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What complication can arise from poor functioning of the Sphincter of Oddi?
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Type 1 Sphincter of Oddi Dysfunction is characterized by biliary pain, CBD dilatation, and _____ derangement.
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Match the types of Sphincter of Oddi Dysfunction with their features:
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What is the recommended time frame for performing a CECT in benign pancreatic conditions?
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CECT stands for Contrast-Enhanced Computed Tomography.
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What does the abbreviation CECT refer to in medical imaging?
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In benign pancreatic conditions, CECT should ideally be done __________ hours after initial assessment.
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Match the following medical imaging types with their description:
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Which procedure is performed for Type I choledochal cysts?
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Choledochoceles belong to Type III choledochal cysts.
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What is one major clinical feature of choledochal cysts?
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The ___________ procedure is performed as a management step for Type II and III choledochal cysts.
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Match the types of choledochal cysts with their characteristics:
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What is the most common cause of liver transplant in children?
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CA 19-9 is used primarily for monitoring patients with extrahepatic biliary atresia.
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List one associated anomaly of extrahepatic biliary atresia.
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Type III atresia involves the right and left hepatic ducts and the entire __________ biliary tree.
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Match the types of extrahepatic biliary atresia with their descriptions:
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Which of the following is NOT a risk factor for cholangiocarcinoma?
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Sclerosing cholangitis is primarily an autoimmune disease associated with inflammatory bowel disease.
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What is the most common site for cholangiocarcinoma?
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The management procedure for Type I bile duct obstruction is __________.
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Match the following features with their corresponding descriptions:
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What is the most common cause of acute pancreatitis?
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Acinar cell death is a later stage in the pathophysiology of acute pancreatitis.
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Name one benign condition associated with pancreatitis.
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The activation of ____________ and other enzymes contributes to inflammation in pancreatitis.
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Which of the following symptoms is commonly experienced in acute pancreatitis?
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Match the following causes of acute pancreatitis with their descriptions:
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Low pH and activated trypsin are part of the early stages of pancreatitis.
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What is the risk percentage of developing pancreatitis after an ERCP procedure?
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Which sign is characterized by discoloration around the umbilicus in cases of acute hemorrhagic pancreatitis?
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Serum lipase levels rise gradually and decline late, making it less specific than serum amylase.
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What is one of the characteristic imaging findings associated with pancreatitis?
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The _____ sign indicates discoloration around the inguinal region in acute hemorrhagic pancreatitis.
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Match the conditions with their corresponding amylase levels:
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What is the most common congenital anomaly of the pancreas?
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Pancreas divisum is associated with an increased risk of pancreatitis due to ineffective drainage.
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What imaging technique is used to diagnose pancreas divisum?
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An annular pancreas is a condition arising from the malrotation of the ventral pancreatic bud, which encircles the __________.
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Match the following congenital pancreatic conditions with their clinical features:
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Which management strategy is preferred for treating annular pancreas?
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The double bubble sign is associated with annular pancreas.
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What is the clinical feature that associates annular pancreas with Down's syndrome?
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Study Notes
Modified Marshall Score
- Score ≥2 indicates severe pancreatitis.
CT Severity Index
- A CT severity score of 26 or higher indicates severe pancreatitis.
Balthazar Grade
- A score of 0 indicates a normal pancreas.
- Scores 1 and 2 represent mild abnormalities.
- Scores 3 and 4 indicate increasing severity of pancreatitis with fluid collections and/or gas.
Pancreatic Necrosis
- A score of 0 indicates no necrosis.
- A score of 2 indicates necrosis affecting 1/3rd of the pancreas.
- A score of 4 indicates necrosis affecting 1/2 of the pancreas.
- A score of 6 indicates necrosis affecting greater than 1/2 of the pancreas.
Pancreatitis Management
- Nil per oral (NPO) is recommended.
- Intravenous (IV) fluids, primarily Ringer's lactate, are the preferred choice.
- Analgesia is necessary to manage pain, with opioids being used for uncontrolled pain.
- Antibiotics are indicated in cases of severe pancreatitis or infected necrosis. Meropenem is the IV antibiotic of choice.
- Total parenteral nutrition is used during the initial phase of severe pancreatitis.
- Early initiation of enteral nutrition reduces mortality and risk of infections.
- Nasojejunal tube is the preferred method for enteral nutrition.
ERCP & Sphincterotomy in Pancreatitis
- Indications include documented common bile duct (CBD) stone and biliary pancreatitis.
Cholecystectomy in Pancreatitis
- Indicated in gallstone-induced pancreatitis.
- Performed before discharge.
Hemobilia
- Bleeding from the biliary tree.
- Characteristics include pain, jaundice, Quincke's triad, and melena.
- Management typically involves CT angiography and embolization if bleeding persists.
Bilhemia
- Bile leaking into blood vessels.
- Often occurs after ERCP or trauma.
- Rapidly progressive jaundice is a feature.
- Management involves ERCP and stenting.
Tumor Marker for Pancreatic Cancer
- Serum CA 19-9 is a tumor marker.
Chemotherapy for Pancreatic Cancer
- Gemcitabine-based chemotherapy is commonly used.
Resectable Pancreatic Cancer
- Whipple's procedure is performed for distal CBD tumors.
- Choledochojejunostomy is used for supraduodenal tumors.
- Hepaticojejunostomy is employed for CHD tumors.
- Portoenterostomy is used for Klatskin tumors.
Non-Resectable Pancreatic Cancer
- Palliative management is required.
- ERCP with stenting and percutaneous transhepatic biliary drainage are common palliative interventions.
Surgical Anatomy
- The "Tunnel of Love" represents the area between the pancreatic head and the uncinate process, relevant during Whipple's surgery.
Sphincter of Oddi
- Composed of four sphincters: superior choledochal, inferior choledochal, ampullary, and pancreatic sphincter.
- Dysfunction of the Sphincter of Oddi leads to improper drainage of bile and pancreatic secretions.
Sphincter of Oddi Dysfunction Types
- Type 1: Biliary pain, CBD dilatation, and enzyme derangement.
- Type 2: Pain and CBD dilatation.
- Type 3: Biliary pain.
Diagnosis of Sphincter of Oddi Dysfunction
- Endoscopic retrograde cholangiopancreatography (ERCP) and manometry are used for diagnosis.
- Pressure above 40 mmHg indicates dysfunction.
Milwaukee Classification
- A classification system for pancreatitis.
CECT for Pancreatitis
- Computed tomography (CT) with contrast enhancement (CECT) is performed more than 72 hours after onset.
Acute Pancreatitis
- Gallstones are the most common cause of acute pancreatitis. Alcohol is the second most common cause.
- Trauma is a significant cause in children.
- Iatrogenic pancreatitis can occur as a complication of ERCP. The risk is around 5%.
- ERCP for therapeutic purposes carries a higher risk than diagnostic procedures.
- Females are more susceptible than males.
- Difficult cannulation during ERCP increases the risk.
Co-localization Theory of Pancreatitis
- Normal pancreatic acinar cells maintain proper function.
- Acinar cell death occurs during pancreatitis.
- The early stages involve leaky co-localized organelles, activated trypsin, and low pH.
- Zymogen activation leads to pancreatic destruction and pancreatitis.
Pathogenesis of Pancreatitis
- Inactive pancreatic enzymes (zymogens) are activated.
- Trypsinogen and other enzyme activation, increased calcium levels, and activation of NF-kB and PKC contribute to inflammation.
- Inflammatory mediators (IL-1, 6, 10,TNF-α) cause systemic inflammation.
Clinical Features of Pancreatitis
- Epigastric pain.
- Radiation to the back.
- Pain relief when bending forward.
- Symptoms often out of proportion to physical signs.
Benign Pancreatic Conditions
- Drug-induced pancreatitis: Thiazide diuretics, antiretrovirals, chemotherapeutic agents.
- Hyperparathyroidism and hypercalcemia.
- Elevated triglycerides.
- Pancreas divisum.
- Idiopathic pancreatitis.
- Scorpion bite.
Diagnosis of Benign Pancreatic Conditions
- Fasting ultrasound is the gold standard.
- MRCP is highly sensitive and specific.
- Liver biopsy confirms diagnosis and differentiates from neonatal hepatitis.
Differential Diagnosis of Benign Pancreatic Conditions
- Neonatal hepatitis.
- Alagille syndrome (characterized by biliary atresia, congenital heart disease, and skeletal abnormalities).
Management of Benign Pancreatic Conditions
- Hepaticojejunostomy is performed for Type I biliary atresia.
- Kasai procedure (portoenterostomy & jejunal anastomosis at the porta hepatis) is used for Type II and III biliary atresia.
Choledochal Cysts
- Dilatation of the biliary tree leads to ineffective drainage, resulting in jaundice.
- Increased risk (10%) of cholangiocarcinoma.
Choledochal Cyst Classification - Todani / Alonso-Lej Modification
- Type I: Diffuse dilatation of the CBD (most common).
- Type II: Diverticulum of the CBD.
- Type III: Dilatation of the intraduodenal portion of the CBD (Choledochocele).
- Type IVa: Intra- and extrahepatic biliary dilatation.
- Type IVb: Extrahepatic biliary tree dilatation.
- Type V: Extrahepatic biliary tree dilatation with intrahepatic biliary radial dilatation (Caroli's disease).
Clinical Features of Choledochal Cysts
- Lump, pain, and jaundice.
Investigation of Choledochal Cysts
- MRCP is the gold standard.
Management of Choledochal Cysts
- Type I: Roux-en-Y hepaticojejunostomy.
- Type IVb: Portoenterostomy.
- Type IVa & V: Liver transplantation.
- Type II: Cutting and repairing the CBD.
- Type III: ERCP and sphincterotomy.
Cholangiocarcinoma
- Carcinoma of the bile duct.
Risk Factors for Cholangiocarcinoma
- Obesity, diabetes mellitus (DM), HBV/HCV infection, choledochal cysts, thorotrast exposure.
- Abnormal pancreatobiliary duct junction.
- Sclerosing cholangitis (an autoimmune disease associated with inflammatory bowel disease).
- Females are more affected than males.
- Association with HLA DR3/B8.
- Presence of anti-smooth muscle antibodies and antinuclear antibodies.
Features of Cholangiocarcinoma
- Obstructive jaundice.
- Distal CBD tumor presents as periampullary cancer.
- Most common site: Hilum.
- Klatskin tumors: Hilar cholangiocarcinoma (classified using the Bismuth-Corlette classification).
Investigaton of Cholangiocarcinoma
- MRCP is used to diagnose.
Post-Cholangiocarcinoma Surgery
- Gemcitabine-based chemotherapy is used.
- Tumor depth and T-staging are important prognostic factors.
- CA 19-9 level is monitored.
Extrahepatic Biliary Atresia
- Inflammatory fibrosis of the biliary system seen in children.
- Most common cause of liver transplant in children.
- Classified based on the Japanese and Anglo-Saxon classifications.
Extrahepatic Biliary Atresia Classifications
- Type I: Atresia restricted to the CBD.
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Type II: Atresia of the CHD:
- IIa: Patent gallbladder with CBD.
- IIb: Obliterated gallbladder, cystic duct, and CBD.
- Type III: Atresia of the right and left hepatic ducts and the entire extrahepatic biliary tree.
Extrahepatic Biliary Atresia Associated Anomalies
- Cardiac lesions, polysplenia, and situs inversus.
Clinical Features of Extrahepatic Biliary Atresia
- Jaundice at birth.
- Rapidly progressive liver failure and cirrhosis.
Investigation of Extrahepatic Biliary Atresia
- Blood tests: Increased serum bilirubin and alkaline phosphatase.
Management of Extrahepatic Biliary Atresia
- Type I: Roux-en-Y hepaticojejunostomy.
- Type II: Cut and repair the CBD.
- Type III: ERCP + sphincterotomy.
- Type IVb: Portoenterostomy
- Type IVa & V: Liver transplantation.
Pancreatic Divisum
- The most common congenital anomaly of the pancreas.
- Failure of fusion of the dorsal and ventral pancreatic buds.
- Increased risk of pancreatitis due to ineffective drainage.
- Magnetic resonance cholangiopancreatography (MRCP) is used for diagnosis.
- Management: ERCP + Sphincterotomy.
Annular Pancreas
- Malrotation of the ventral pancreatic bud, encircling the second part of the duodenum.
- Commonly associated with Down syndrome.
- Clinical features: Non-bilious vomiting (may also be associated with duodenal atresia, presenting with bilious vomiting).
- Investigation: CECT and x-ray (double bubble sign).
- Management: Duodenoduodenostomy.
Signs of Acute Hemorrhagic Pancreatitis
- Cullen's sign (discoloration around the umbilicus).
- Grey Turner's sign (discoloration around the flanks).
- Fox's sign (discoloration around the inguinal region).
Signs of Severe Pancreatitis
- Peritonitis (deposition of chalky white material; no perforation).
Diagnosis of Acute Pancreatitis
- Two out of three criteria:
- Abdominal pain consistent with acute pancreatitis.
- Three-fold or high elevation of serum amylase or lipase levels.
- Characteristic imaging findings.
Serum Amylase and Lipase in Pancreatitis
- Amylase has a shorter half-life, rising early and declining early. It is sensitive but not specific for severity.
- Lipase has a longer half-life, with a gradual rise and late decline. It is more specific and does not predict pancreatitis severity.
Conditions with Raised Amylase
- Acute pancreatitis (3 to 4 times normal).
- Mesenteric ischemia.
- Bowel perforation.
X-ray Findings in Pancreatitis
- Gasless abdomen.
- Ileus.
- Colon cut-off sign (dilated colonic loop with incomplete haustrations).
- Sentinel loop (focal dilated proximal jejunal loop in the left upper quadrant).
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Description
This quiz covers the assessment and management strategies for severe pancreatitis, including scoring systems such as Modified Marshall Score, CT Severity Index, Balthazar Grade, and Pancreatic Necrosis. Understand the interventions and treatments typically recommended for managing this condition effectively.