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1. A 74-year-old nursing home patient is brought to the emergency department with nausea, vomiting, and refusal to eat food. A complete medical history is difficult to ascertain as the patient has severe dementia. On physical examination, he is febrile and tachycardic and has mild epigastric tenderness. Which of the following is the next best step in the management of this patient?
A. Place nasogastric tube and start ciprofloxin and metronidazole.
B. Wait to speak to the patient’s family.
C. Obtain a CT of the abdomen/pelvis with or without contrast.
D. Obtain an ultrasound of the abdomen.
Correct answer : C
In many older patients, a full medical history is often difficult to obtain due to dementia, unclear symptoms, and decreased sensation of pain. Since the diagnosis is not clear and includes a number of diagnostic possibilities, a CT scan of the abdomen, with or without contrast, is important, along with other blood studies. If the diagnosis of pancreatitis is clear and no differential diagnosis is entertained, then CT is not required at this time. An initial CT will help exclude acute introabdominal conditions such as perforated small bowel, intestinal ischemia, and appendicitis.
2. A 68-year-old patient is brought to the hospital with fever, abdominal pain, and nausea. The serum amylase was 1,000 and lipase was 1,200. A diagnosis of acute pancreatitis was made based on the history of abdominal pain and elevated amylase and lipase more than 3 times normal. The most important step in the prevention of pancreatic necrosis is:
A. Adequate pain control.
B. Keep the patient NPO.
C. Intravenous proton pump inhibitors.
D. Aggressive intravenous hydration.
Correct answer : D
Although the mainstay of treatment for AP is intravenous fluid hydration, pain control, and NPO, fluid hydration should be aggressive. Maximum fluid volume should be replaced within the first 48 h. Dehydration and hypovolemia predispose to microcirculatory disturbance of the pancreas and result in pancreatic necrosis. While hydration is required, caution should be exercised in the elderly.
Proton pump inhibitors, however, do not play a role in the management of AP.
3. A 75-year-old patient is diagnosed with acute pancreatitis based on symptomatology and elevated amylase and lipase levels in the serum. The serum AST is 240 and ALT
320 and alkaline phosphatase of 260. The important biochemical studies on day 2 do not include which of the following?
A. Serum amylase and lipase levels
B. Serum creatinine
C. Hematocrit
D. Liver function tests
Correct answer : A
Once a diagnosis of acute pancreatitis is made based on elevated serum levels of amylase and lipase in the presence of abdominal pain, there is no need to repeat the levels again. Amylase and lipase levels do not indicate severity of acute pancreatitis. Serum creatinine level is a good marker of prognosis along with elevated hematocrit.
A normal hematocrit almost always indicates mild pancreatitis. If on admission, serum creatinine and hematocrit are elevated, adequate hydration should bring the levels back to normal within a day. Persistent elevation of creatinine and hematocrit indicate either inadequate hydration or worsening disease. Since on admission the liver function tests were abnormal, it is important to repeat the tests.
A CBD stone might be responsible for the elevated liver enzymes which would rapidly return to normal in most
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology ,
DOI 10.1007/978-1-4419-1623-5_43, © Springer Science+Business Media, LLC 2012
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464 C.S. Pitchumoni patients when the stone is passed into the duodenum.
Persistently elevated liver enzymes and bilurubin would suggest CBD obstruction which needs further evaluation with MRCP/EUS to decide the need for ERCP and papillotomy.
4. A 86-year-old patient is diagnosed with acute pancreatitis, secondary to a biliary etiology. He has been suffering from diabetes mellitus for 15 years and is on insulin therapy. His hypertension is being managed with ramipril
5 mg 2 times a day. The CBD size is 5 mm by abdominal ultrasound. Liver function tests are normal. The patient is asymptomatic. He and the family are reluctant to undergo surgery because of his age. The appropriate management is education of the patient with regard to the importance of which one of the following:
A. Cholecystectomy in the same admission
B. Cholecystectomy within 3 months after discharge
C. ERCP and papillotomy prior to discharge
D. Cholecystostomy
Correct answer : A
The appropriate management is removal of gall bladder in the same admission because of the high probability of recurrence of acute pancreatitis within a few months.
Laparoscopic surgery is appropriate in the same admission. Age alone is not a contraindication for surgery.
Cholesystectomy should not be postponed to 3 months for the above reason. There is no indication for ERCP and papillotomy since the CBD size is normal with no biochemical evidence of CBD obstruction. ERCP is not a diagnostic procedure. If there is evidence of persistent
CBD obstruction and ascending cholangitis, an emergency
ERCP with papillotomy is appropriate. Cholecystostomy is a procedure that is rarely performed in severely ill elderly patients who are not fit for an abdominal surgery as a palliative measure.
5. A 70-year-old otherwise healthy male who had recovered from pancreatitis 2 months ago on follow-up examination with an abdominal ultrasound showed a 3-cm cyst in the pancreas. His previous abdominal ultrasound and CT scan had shown mild pancreatitis, with a 3-cm cyst in the head of the pancreas. The repeat CT scan also confirmed the presence of the cyst in the head of the pancreas. The patient is asymptomatic. The appropriate management of this patient is:
A. Surgical removal of the cyst
B. Endoscopic drainage as treatment
C. EUS aspiration of the cyst, analysis of cyst fluid
D. Whipple’s procedure
Correct answer : C
Although a cyst in the head of the pancreas may be benign, it is important to exclude malignancy by EUS aspiration and analysis of cyst fluid. If his initial imaging studies had not shown the cyst, we may consider the cyst a consequence of acute pancreatitis and follow up the cyst size by repeated imaging studies. Whipple’s procedure is a drastic one when we do not have a diagnosis of malignancy. A cyst in the pancreas may be serous cystadenoma, mucinous cystadenoma, intrapapillary mucinproducing neoplasm, and/or pseudocyst.