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Part 1: Five Basic-Level MCQs

MCQ 1

Question

Hypertriglyceridemia is a recognized cause of acute pancreatitis. At which minimum fasting serum triglyceride level is acute pancreatitis most commonly encountered?

Answer Choices

A. 150 mg/dL

B. 300 mg/dL

C. 800 mg/dL

D. 1000 mg/dL

Correct Answer: D. 1000 mg/dL

Explanation

  • Why D is correct: Most reported cases of hypertriglyceridemia-induced acute pancreatitis occur when fasting triglyceride levels exceed 1000 mg/dL (often cited as ≥10 mmol/L). This severe elevation leads to toxic free fatty acid release in the pancreatic microcirculation, triggering pancreatitis.
  • Why A, B, C are wrong:
    • A (150 mg/dL) and B (300 mg/dL) are below the threshold generally implicated in pancreatitis.
    • C (800 mg/dL) is high but still less commonly associated with pancreatitis compared to levels ≥1000 mg/dL.

Key Takeaways

  1. Hypertriglyceridemia is implicated in 1%–10% of acute pancreatitis cases.
  2. Triglyceride levels ≥1000 mg/dL markedly increase the risk, primarily due to the generation of free fatty acids that injure pancreatic cells.
  3. Co-factors like uncontrolled diabetes, obesity, pregnancy, and hypothyroidism can exacerbate hypertriglyceridemia-associated pancreatitis.
  4. Early recognition and management of severely elevated triglycerides can help prevent recurrent or severe pancreatic inflammation.
  5. Measuring triglyceride levels in unexplained acute pancreatitis is a critical part of the workup.

Reference: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 7th edition, Chapter 55 (pp. 787–792)

MCQ 2

Question

All of the following statements are true regarding hypercalcemia-induced acute pancreatitis EXCEPT:

Answer Choices

A. It can lead to calcium deposition in pancreatic ducts.

B. Hypercalcemia-induced cellular injury can occur via trypsin-mediated activation of pancreatic enzymes.

C. Hypercalcemia-induced pancreatitis always resolves spontaneously without treatment.

D. Elevated parathyroid hormone (PTH) may have direct toxic effects on the pancreas.

Correct Answer: C. Hypercalcemia-induced pancreatitis always resolves spontaneously without treatment

Explanation

  • Why C is correct (as the FALSE statement): Although treating the underlying hypercalcemia often helps resolve the pancreatitis, it is not true that it “always resolves spontaneously” without intervention. Aggressive correction of calcium levels and supportive care are typically necessary.
  • Why A, B, D are true:
    • A: Calcium deposition in the pancreatic ducts can contribute to ductal obstruction and injury.
    • B: Elevated calcium can prematurely activate pancreatic enzymes, leading to acinar cell damage.
    • D: Excess PTH may exert direct toxic and inflammatory effects on pancreatic tissue.

Key Takeaways

  1. Hypercalcemia is a relatively rare cause of acute pancreatitis, with a reported prevalence of 1%–4%.
  2. Mechanisms include calcium-mediated premature enzyme activation, ductal obstruction, and direct hormonal toxicity.
  3. Common causes of hypercalcemia include hyperparathyroidism, malignancies, and excessive Vitamin D intake, any of which can precipitate pancreatitis.
  4. Correction of hypercalcemia often alleviates pancreatic inflammation, highlighting the importance of treating the underlying cause.
  5. Hypercalcemia should remain on the differential for nonbiliary, nonalcoholic acute pancreatitis.

Reference: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 7th edition, Chapter 55 (pp. 787–792)

MCQ 3

Question

Which of the following statements is correct regarding drug-induced pancreatitis (DIP)?

Answer Choices

A. It accounts for more than half of acute pancreatitis cases.

B. It never occurs in pediatric patients.

C. Certain medications like angiotensin-converting enzyme (ACE) inhibitors have been implicated in DIP.

D. Drug-induced pancreatitis generally resolves without withdrawal of the offending agent.

Correct Answer: C. Certain medications like angiotensin-converting enzyme (ACE) inhibitors have been implicated in DIP

Explanation

  • Why C is correct: Multiple drugs, including ACE inhibitors, antibiotics, statins, and others, have been recognized as potential causes of acute pancreatitis. Vigilance in medication history is crucial.
  • Why A, B, D are wrong:
    • A: DIP only accounts for about 0.1%–2% of acute pancreatitis cases.
    • B: Pediatric patients can develop DIP, particularly if on known offending drugs.
    • D: Pancreatitis may persist or worsen unless the offending agent is discontinued.

Key Takeaways

  1. Drug-induced pancreatitis makes up a small but significant percentage of AP cases.
  2. Over 500 medications are implicated, emphasizing a need for a thorough drug history.
  3. Mechanisms include toxic metabolites, hypersensitivity, and adverse metabolic effects.
  4. Prompt discontinuation of the causative agent is essential for management.
  5. The elderly and pediatric populations may be at higher risk due to multiple comorbidities or multidrug regimens.

Reference: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 7th edition, Chapter 55 (pp. 787–792)

MCQ 4

Question

A 54-year-old male with end-stage renal disease on peritoneal dialysis (PD) presents with severe epigastric pain and marked elevation of serum lipase. Which of the following best explains why patients on PD have a higher risk of acute pancreatitis compared to those on hemodialysis (HD)?

Answer Choices

A. Peritoneal dialysis solutions commonly contain high doses of alcohol.

B. Direct infusion of nonphysiologic fluid under increased intraabdominal pressure can lead to pancreatic injury and ischemia.

C. Peritoneal dialysis is associated with superior fluid balance, which paradoxically triggers pancreatitis.

D. Only hemodialysis-related intradialytic hypotension can cause pancreatitis.

Correct Answer: B. Direct infusion of nonphysiologic fluid under increased intraabdominal pressure can lead to pancreatic injury and ischemia

Explanation

  • Why B is correct: Peritoneal dialysis involves the infusion of large volumes of dialysate into the peritoneal cavity. Elevated intraabdominal pressure and potential chemical irritation can promote ischemia or direct injury to pancreatic tissue.
  • Why A, C, D are wrong:
    • A: Standard dialysate does not contain clinically significant alcohol.
    • C: Better fluid management is not typically a cause of pancreatitis.
    • D: Hemodynamic fluctuations in HD (particularly hypotension) can cause ischemic damage, but PD has its own distinct risk factors.

Key Takeaways

  1. Acute pancreatitis in dialysis patients has higher morbidity and mortality compared to the general population.
  2. Patients on peritoneal dialysis are at increased risk partly due to local mechanical and chemical factors in the peritoneal cavity.
  3. Both PD and HD patients may also have altered clearance of GI hormones, which could predispose to pancreatitis.
  4. Recognition of nonspecific symptoms in dialysis patients is challenging but crucial for early intervention.
  5. Managing PD settings to reduce intraabdominal pressure may lower the incidence of pancreatitis.

Reference: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 7th edition, Chapter 55 (pp. 787–792)

MCQ 5

Question

A 47-year-old patient develops painless obstructive jaundice and imaging reveals a diffusely enlarged, “sausage-shaped” pancreas. Laboratory tests show markedly elevated IgG4 levels. What is the most likely diagnosis?

Answer Choices

A. Pancreatic adenocarcinoma

B. Autoimmune pancreatitis

C. Chronic pancreatitis due to alcohol

D. Pancreatic pseudocyst

Correct Answer: B. Autoimmune pancreatitis

Explanation

  • Why B is correct: Autoimmune pancreatitis (AIP) is known for a characteristic imaging appearance described as a “sausage-shaped” pancreas and for significantly elevated serum IgG4. It often mimics malignancy but usually responds well to steroids.
  • Why A, C, D are wrong:
    • A: Pancreatic cancer may present with painless jaundice but is not associated with elevated IgG4 or the typical “sausage-shaped” pancreatic swelling.
    • C: Alcoholic chronic pancreatitis usually has a history of alcohol misuse and different imaging findings.
    • D: A pseudocyst is a complication of pancreatitis rather than a cause of painless obstructive jaundice with high IgG4.

Key Takeaways

  1. Autoimmune pancreatitis can mimic malignancy radiologically and clinically.
  2. Dramatic response to corticosteroids is a hallmark feature of AIP.
  3. Elevated IgG4 is often found in Type 1 autoimmune pancreatitis.
  4. Recognition and proper diagnosis can prevent unnecessary surgical interventions.
  5. Other autoimmune disorders may coexist in these patients.

Reference: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 7th edition, Chapter 55 (pp. 787–792)

End of Part 1.

Please let me know if you are satisfied with these 5 Basic-Level MCQs. Once you confirm (“I like that”), I will provide the 5 Advanced-Level MCQs followed by the Key Takeaways for the Entire Topic.