3.9 Chronic Pancreatitis & Biliary Tract Disease

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

3.9 Chronic Pancreatitis & Biliary Tract Disease

Key Takeaways Explain This Topic AI

Biliary tract disease is its own blueprint subsection listing cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, primary sclerosing cholangitis and sphincter of Oddi dysfunction.

A low fecal elastase level establishes exocrine pancreatic insufficiency, which is treated with pancreatic enzyme replacement taken with meals plus fat-soluble vitamin supplementation.

Ascending cholangitis is suggested by Charcot triad of fever, jaundice and right upper quadrant pain and requires antibiotics plus urgent biliary drainage.

Primary biliary cholangitis presents with pruritus, fatigue and cholestatic enzymes with a positive antimitochondrial antibody, and ursodeoxycholic acid is first-line therapy.

Primary sclerosing cholangitis shows multifocal strictures on magnetic resonance cholangiopancreatography, is strongly associated with ulcerative colitis, and has no proven medical therapy that alters survival.

Last updated: August 2026

• 1. Chronic Pancreatitis
• Pathophysiology & Etiology

Chronic Pancreatitis is an irreversible fibro-inflammatory disease leading to destruction of exocrine parenchyma, ductal fibrosis, and loss of endocrine islets.

TIGAR-O Classification: T oxic-metabolic (Alcohol 70–80%, Tobacco smoking is an independent, dose-dependent accelerator), I diopathic, G enetic ( PRSS1 hereditary pancreatitis causes a 40–50% lifetime risk of pancreatic adenocarcinoma; SPINK1 , CFTR ), A utoimmune, R ecurrent/severe acute pancreatitis, O bstructive.

Clinical Presentation & Late Classic Triad

Pancreatic Calcifications: Visible on abdominal CT or plain radiographs.

Steatorrhea: Voluminous, greasy, foul-smelling stools due to exocrine pancreatic insufficiency (occurs when > 90 % >90\% > 90% of exocrine function is lost).

Pancreatogenic Diabetes (Type 3c Diabetes): Characterized by destruction of both insulin-producing β \beta β -cells and glucagon-producing α \alpha α -cells, producing labile "brittle" diabetes with high risk for severe hypoglycemia.

Diagnostic Evaluation & Management

Diagnostic Modality of Choice for Exocrine Function: Fecal Elastase-1 ( < 200 μ g/g <200\;\mu\text{g/g} < 200 μ g/g indicates exocrine insufficiency; < 100 μ g/g <100\;\mu\text{g/g} < 100 μ g/g indicates severe insufficiency). Fecal elastase-1 remains accurate while the patient is taking oral pancreatic enzymes.

Imaging: CT demonstrates parenchymal atrophy, ductal dilatation, and coarse intraductal calcifications. Secretin-stimulated MRCP or EUS (Rosemont criteria) detects early subtle changes.

Medical Therapy:

Pancreatic Enzyme Replacement Therapy (PERT): Enteric-coated pancrelipase (e.g., Creon, Zenpep; high lipase doses ≥ 40 , 000 − 50 , 000 USP units \ge 40,000-50,000\text{ USP units} ≥ 40 , 000 − 50 , 000 USP units per meal and half-dose with snacks) taken with the first bite of food . Add a PPI or H2RA to prevent duodenal acid inactivation if non-enteric coated.

Pain Management: Non-opioid analgesics, pregabalin/gabapentin, celiac plexus nerve block for refractory pain.

Lifestyle: Absolute cessation of alcohol and tobacco smoking (critical to arrest progression and decrease cancer risk).

Fat-Soluble Vitamin Supplementation: Replete vitamins A, D, E, and K.

• 2. Biliary Tract Disorders
• Comparative Spectrum of Gallstone Diseases

Biliary Condition Pathophysiology Clinical Presentation & Physical Exam Diagnostic Findings Evidence-Based Management Protocol

Symptomatic Cholelithiasis (Biliary Colic) Transient cystic duct obstruction by a gallstone during gallbladder contraction. Episodic, severe, steady RUQ pain lasting < 4 − 6 hours < 4-6\text{ hours} < 4 − 6 hours , radiating to right shoulder/scapula. Normal vital signs; benign exam. RUQ Ultrasound: Gallstones with acoustic shadowing; normal wall thickness ( < 4 mm <4\text{ mm} < 4 mm ); no pericholecystic fluid. Labs normal. Outpatient Elective Laparoscopic Cholecystectomy ; NSAIDs (Ketorolac/Ibuprofen) for acute colic.

Acute Cholecystitis Persistent, sustained cystic duct stone impaction causing mucosal inflammation and secondary bacterial infection. Constant severe RUQ pain lasting > 6 hours > 6\text{ hours} > 6 hours , fever, nausea, vomiting, Positive Murphy Sign (inspiratory arrest on RUQ palpation). RUQ Ultrasound: Gallstones, gallbladder wall thickening > 4 mm > 4\text{ mm} > 4 mm , pericholecystic fluid, sonographic Murphy sign.; HIDA Scan: Gold standard if US equivocal (non-visualization of gallbladder at 4h). Leukocytosis. NPO, IV fluids, IV broad-spectrum antibiotics (e.g., Ceftriaxone + Metronidazole), and Early Laparoscopic Cholecystectomy within 24–72 hours . (Percutaneous cholecystostomy tube for high-risk surgical patients).

Choledocholithiasis Migration of gallstones into the Common Bile Duct (CBD) , obstructing biliary flow. Biliary pain + Jaundice (dark urine, acholic stools), pruritus. No fever or sepsis. Elevated Cholestatic Enzymes: Alkaline Phosphatase, GGT, Total & Direct Bilirubin. Dilated CBD on US ( > 6 mm >6\text{ mm} > 6 mm ). High Risk: Direct Therapeutic ERCP with sphincterotomy & stone extraction, followed by cholecystectomy.; Intermediate Risk: MRCP or EUS to confirm stone prior to ERCP.

Acute Ascending Cholangitis Bacterial infection of an obstructed biliary tree under high intraluminal pressure; rapid bacteremia. Charcot's Triad: ; 1. RUQ Pain; 2. Jaundice; 3. Fever / Chills; Reynolds' Pentad: ; + 4. Hypotension (Shock); + 5. Altered Mental Status Leukocytosis, marked hyperbilirubinemia, elevated Alk Phos/transaminases, dilated biliary tree on US/CT. Blood cultures positive ( E. coli , Klebsiella ). Medical Emergency: ICU admission, IV fluid resuscitation, IV Broad-Spectrum Antibiotics (e.g., Piperacillin-tazobactam), and Emergency Biliary Decompression via ERCP within 24 hours (emergent within hours if septic shock).

Autoimmune & Cholestatic Liver Diseases: PBC vs. PSC Primary Biliary Cholangitis (PBC) ➔ Middle-aged Women | Intrahepatic Interlobular Ducts | AMA Positive | UDCA Therapy

Primary Sclerosing Cholangitis (PSC) ➔ Young/Middle-aged Men | Intra- & Extrahepatic Ducts | Ulcerative Colitis (70-80%) | Beaded Ducts | High Cholangiocarcinoma Risk

Disease Feature Primary Biliary Cholangitis (PBC) Primary Sclerosing Cholangitis (PSC)

Epidemiology Females (90%) , typical age 40 to 60 years . Males (70%) , typical age 30 to 50 years .

Pathophysiology Autoimmune granulomatous destruction of intrahepatic interlobular bile ducts (florid duct lesions). Progressive obliterative fibrosis and stricturing of intrahepatic AND extrahepatic bile ducts .

Clinical Hallmarks Severe pruritus (often worse at night), debilitating fatigue, xanthelasma/xanthomas , hyperpigmentation. Progressive fatigue, pruritus, fluctuating jaundice, recurrent episodes of acute ascending bacterial cholangitis.

Associated Diseases Sjögren syndrome, Hashimoto thyroiditis, Scleroderma (CREST syndrome). Inflammatory Bowel Disease (70–80% have Ulcerative Colitis) .

Serology & Antibodies Anti-Mitochondrial Antibodies (AMA positive > 95 % >95\% > 95% ) ; elevated serum IgM. p-ANCA positive (~80%) ; AMA negative.

Diagnostic Modality Elevated Alk Phos + Positive AMA titer ( ≥ 1 : 40 \ge 1:40 ≥ 1 : 40 ) is diagnostic without liver biopsy . MRCP (Magnetic Resonance Cholangiopancreatography): Diagnostic gold standard showing multifocal segmental strictures and dilatations producing a "beaded" appearance of bile ducts.

Malignancy Risks Osteoporosis/osteopenia, HCC in cirrhotic stage. High risk of Cholangiocarcinoma (10–15% lifetime risk) and Colorectal Carcinoma (due to coexisting UC).

Surveillance Protocol DEXA scan q2–3y, HCC ultrasound q6m if cirrhotic. • Annual MRCP + Serum CA 19-9 for Cholangiocarcinoma.; • Annual Colonoscopy with surveillance biopsies starting at PSC diagnosis for CRC.

First-Line Medical Therapy Ursodeoxycholic Acid (UDCA, 13–15 mg/kg/day) slows histologic progression and prolongs transplant-free survival. Second-line: Obeticholic acid or Bezafibrate. No effective medical therapy proven to alter disease progression (UDCA does not improve survival). Endoscopic balloon dilation of dominant strictures; Liver transplantation for end-stage disease.