Mr XY a 72 year old gentle man underwent failed ERCP for choledocolithiasis in the distal CBD.  Later in the evening he began to feel unwell and the nurse noted tachypnoea when doing the patients observations.  On medical review he was complaining of severe epigastric pain associated nausea and diaphoresis.  Of note his past medical history includes angina, hypertension, AF, COPD and penicillin allergy.  On examination he was found to be alert and uncomfortably aroused with tenderness over the epigastrium.  Bowel sounds were present and the abdomen was soft.  Other than AF the remaining examination was unremarkable although the patient was slightly icteric.

Question 1a (Clinical Features)

Based on the initial clinical features what differential diagnosis would be most likely

a)      Acute MI given the man’s history of IHD and the risk of atypical clinical features or silent MI in surgical patients.

b)      Acute pancreatitis following ERCP as this is a well know complication of this procedure

c)      Acute small bowel obstruction secondary to gallstone ileus as the patient likely has passed the stone via a cystenteric fistula to the small bowel

d)     Perforation of his duodenum following passage of a side viewing scope for the ERCP

e)      Atypical biliary colic as the procedure has failed, a stone is still present in the distal CBD and jaundice is persisting

Question 1b (Investigation)

What investigation would be most informative in this situation?

a)      Chest x-ray

b)      Serum amylase

c)      Urinary amylase

d)     CT abdomen

e)      Serum lipase

Question 2 (Clinically Applied Basic Science)

If CT abdomen was performed where is the pancreas located and what are its anatomical relations?

Question 3 (Prognostication)

What scoring systems are used to predict the severity of pancreatitis?

Question 4 a & b (Aetiology)

(a) Multiple true false: Other than gallstones and alcohol, using a surgical sieve approach, which of the aetiological groups below can cause acute pancreatitis?

(b) Other than idiopathic, name an example from each true answer from the true false list.

Question 5a (Complications)

On review the next day the patient has marked reduced air entry bibasally, is very tachypnoeic and hypoxic on room air.  Name three local complications of acute pancreatitis and what is the most likely cause of this patient’s current clinical condition?

Question 5b (Complications)

Later in the evening of day 2 the patient becomes more unwell with pyrexia, tachypnoea, tachycardia and hypotension.  How is this condition defined and how are the three main related conditions defined?

Question 5c (Complications)

Following immediate assessment and resuscitation what two investigations would be required?

Question 6a (Clinical Pharmacology)

Severe pancreatitis develops with persisting organ dysfunction and the patient is subsequently admitted to ICU for further support.  Following a fourteen day admission he is returned to the ward.  Currently, his main problem is malnutrition, poor rate control of AF and supratherapeutic INR.  The patient is on the following medicines; Warfarin, Beta blocker, short and long acting Beta agonist.  Comment on the potential cautions in using these medicines in a malnourished patient with AF and severe acute illness.

Question 6b (Clinical Pharmacology)

Following rationalisation of medications and discontinuation of bisoprolol, the patient is later started on digoxin for rate control of atrial fibrillation with a rapid ventricular response.  A few days later a report of a 24 hour ambulatory ECG was handed to you by the staff nurse and an episode of VT was highlighted.  What drug and electrolyte interaction may be relevant?

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