Which ONE of the following is NOT a clinical predictor in acute pancreatitis?
Answer: B: Ranson criteria is a clinical prediction tool frequently used for predicting the severity of acute pancreatitis (table below).
RANSON CRITERIA FOR ACUTE PANCREATITIS AT PRESENTATION:
At 48 hours combine the total number of criteria present (Table Below).
RANSON CRITERIA FOR ACUTE PANCREATITIS AT 48 HOURS:
The criteria for gallstone-related pancreatitis varies slightly (Table below).
RANSON CRITERIA FOR GALLSTONE-RELATED PANCREATITIS:
Another system that can be used for predicting the severity of pancreatitis is the Glasgow and Modified Glasgow criteria. These have been validated for gallstone and alcoholic associated pancreatitis (Table below).
GLASGOW CRITERIA FOR PREDICTING THE SEVERITY OF PANCREATITIS:
The Modified Glasgow criteria can be remembered by the following pneumonic.
PANCREAS
If ≥ three of these are present within 48 hours of onset then the patient most likely has severe pancreatitis.
References:
A 58-year-old male presents with pruritis and dark urine. On examination there is a mild yellow discolouration of his sclera.
Which ONE of the following statements is most CORRECT?
Answer: D: Jaundice may be detected clinically when the serum bilirubin levels are >40mmol/L. It is seen in tissues with a high albumin concentration such as the skin and sclera.
Bacteria acting on bilirubin in the gastrointestinal tract produce urobilinogen. It is water soluble and is excreted in the urine. A non-obstructed biliary system is required for its presence in the urine as the bilirubin has to reach the gastrointestinal tract.
Testicular atrophy and caput medusa are signs of chronic liver disease and not pancreatic cancer. Mirizzi syndrome manifests in a presentation of gallstones lodged in either the cystic duct or Hartmann’s pouch of the gallbladder causing obstructive jaundice. The mechanism is presumed to be from external compression of the common hepatic duct.
Which ONE of the statements regarding hernias is most CORRECT?
Answer: B: Umbilical hernias in children are congenital and rarely become incarcerated. They usually resolve spontaneously in children. In adults, however, it is an acquired defect where risk factors include obesity, pregnancy and ascites. They usually increase in size, are at higher risk of complications (e.g. incarceration) and frequently require operative repair.
Incisional hernias are recognised as a complication of abdominal surgery. Risk factors include extensive or complicated surgery, postoperative wound infection and obesity. They occur in 10–20% of laparotomies. The origin is usually wide and therefore complications are uncommon. Surgical repair may be required; however, the recurrence rates are high.
Direct inguinal hernias pass medial to the inferior epigastric artery, while indirect hernias pass lateral to the inferior epigastric artery. Direct inguinal hernias are due to a weakness in the transversalis fascia and the anterior abdominal wall through which they protrude. They do not pass through the inguinal canal and do not extend into the scrotum. They are less symptomatic and have fewer complications (incarceration or strangulation) than indirect inguinal hernias. They are more likely to recur following surgery than indirect inguinal hernias.
Indirect inguinal hernias are due to a patent processus vaginalis. They are more common in males secondary to the embryological decent of the testis and occur more frequently on the right side due to the later decent of the right testis. The hernia passes through the inguinal canal and into the scrotum as it enlarges. Complications are frequent particularly in females and infants. Around 5% of term and 30% of preterm infants will have an inguinal hernia. Surgery is recommended, if they are symptomatic or complications arise.
Regarding hernias, which ONE of the following statements is the most CORRECT?
Answer: D: Indications for attempting to reduce a hernia are the presence of a hernia and the absence of strangulation. Strangulated hernias, bowel obstruction secondary to the hernia, or hernia contents containing ovaries or testes are contraindications to hernia reduction in the ED. A surgical opinion should be sought in such instances. Repetitive attempts at reducing the hernia should be avoided as this will only lead to increased swelling. Analgesia and sedation may be required if an attempt at reduction is to be performed in the ED. For an inguinal hernia, placing the patient in a Trendelenburg position can help facilitate reduction.
Femoral hernias occur more commonly in women than men. They have a high incidence of strangulation and should therefore always be repaired electively when the diagnosis has been made.
Which ONE of the following patients is the MOST suitable for discharge from the ED?
Answer: A: Patient A has a urinary tract infection. She has mild symptoms and no signs of peritonism. She has no signs or symptoms of pyelonephritis. She will most likely be suitable for discharge on oral antibiotics. Patient B potentially has a large bowel obstruction and should not be discharged.
Bowel obstruction is the most common cause of abdominal pain in the elderly population. Patients with large bowel obstruction can present with abdominal distention, colicky abdominal pain and obstipation. Vomiting may or may not be present.
Patient C could have an abdominal aortic aneurysm (AAA) and requires urgent management.
Risk factors for abdominal aortic aneurysms include hypertension, atherosclerosis and a positive family history. AAA can present with sudden onset of abdominal, back or flank pain. Hypotension associated with a ruptured AAA can be transient. The most common misdiagnosis of AAA in the elderly is renal colic. It is estimated that this misdiagnosis occurs approximately 16–30% of the time. The mortality of AAA rupture is high 50–70%.
Patient D could have anything from gastroenteritis to acute myocardial infarction. He requires further investigation and management.
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