3. Biliary disease and Pancreatitis

Question 1

If someone present with abdo pain what organs could it be to do with

a) above the diaphragm
b) below the diaphragm

Answer 1

above: pleuritic pain, inferior myocardial infarction
below: liver, gallbladder, pancreas, bowels, kidneys

Question 2

If someone presents with abdo pain what are the most common differentials to consider

Answer 2

acute pancreatitis
perforated ulcer
cholangitis/biliary colic
pyelonephritis/ renal colic (inflammation of the kidney)
acute mesenteric ischaema ie blood supply to the bowel (embolism or thrombosis)
pneumonia
myocardial infarction (inferior)

Question 3

If someone presents to A&E with abdo pain and their chest X ray was to show something under one of the hemi-diahpragms (looks white) what does it imply

Answer 3

that there is free gas

• implies a perforated viscus (internal organ)
• consider gastric/duodenal ulcer or perforated small/large intestine

Question 4

What kind of obstruction presents with painful jaundice and minimal dilation of the bile ducts

Answer 4

biliary obstruction due to gallstones

Question 5

what kind of disease will present with progressively worsening painless jaundice and marked dilation of the biliary tree

Answer 5

carcinoma of the head of the pancreas or ampulla of Vater

Question 6

What do all of the following lead to a suggestion of:

Jaundice (predominantly caused by conjugated bilirubin)
marginally abnormal liver function
increased alkaline phosphatase 
Severe pain 
fever
increased WBC

Answer 6

Gallstones (with or without biliary colic) with cholangitits

Question 7

When imaging the biliary tree with ultrasound what does a dilated duct show

Answer 7

long term obstruction to the flow of bile

Question 8

Which of the following can you view gallstones the best with;
ultrasound
CT
MRI

Answer 8

ultrasound

Question 9

What does acute cholangitis mean

Answer 9

thickening of the bile duct

Question 10

what does cholelithiasis mean

Answer 10

formation of gallstones

Question 11

What are the most common causes of pancreatitis

Answer 11

alcohol
gallstones
post-ERCP

Question 12

what are the functions of the pancreas

Answer 12

exocrine functions- produce enzymes to help with digestion

endocrine function- release hormones to regulate blood sugars

Question 13

what is the issue in pancreatitis

Answer 13

Inflammation of the pancreas
Pancreatic enzymes (amylase / lipase) attack the pancreatic tissue 'auto digestion'

Question 14

how is acute pancreatitis diagnosed

Answer 14

pancreatic enzymes (amylase/lipase) but mainly amylase in the blood 
CT scan which will show inflammation

Question 15

why might amylase not rise in an acute exacerbation of chronic pancreatitis

Answer 15

the pancreas has lost its ability to produce the enzyme

Question 16

Escalation of care in pancreatitis is achieved by using the Glasgow score where less than 2 is mild, 2 is moderate and more than 2 is severe.
PANCREAS is the mnemonic, what does it stand for

Answer 16

P – Pa02 < 60
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)

Question 17

what is the treatment for acute pancreatitis

Answer 17

Escalate care according to Glascow score
Careful monitoring
IV fluids
Analgesia
Endoscopic drainage of large pseudocysts
Antibiotics only if evidence of infected pancreatic necrosis
Surgery to remove infected pancreatic necrosis

Question 18

What genetic condition can cause chronic pancreatitis

Answer 18

cystic fibrosis

Question 19

what can chronic pancreatitis be caused by

Answer 19

cystic fibrosis
elevated triglycerides
smoking
drinking

Question 20

In chronic pancreatitis you get pancreatic instability, what symptoms does this present as

Answer 20

oily, foul smelling stools, weight loss and diabetes, intermittent abdo pain that gets worse when eating high fat foods

Question 21

there is no treatment for chronic pancreatitis but what is the management

Answer 21

o No alcohol
o Quit smoking
o Avoid high fat foods
o Pain management
o Medication (pancreatic enzyme replacement therapy)
o Multivitamin and mineral supplements due to not being able to absorb food as well

Question 22

what are all of the causes of pancreatitis, not just the clinically significant ones you see in practice
(GET SMASHED)

Answer 22

• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps (other viruses include Coxsackie B)
• Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
• Scorpion venom
• Hypertriglyceridaemia, Hyperchylomicronaemia (disorder of lipoprotein metabolism), Hypercalcaemia, Hypothermia
• ERCP (Endoscopic retrograde cholangiopancreatography)
• Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Question 23

How does the pain in biliary colic differ from the pain ini cholecystitis

Answer 23

Biliary colic:
- sudden right upper quadrant (RUQ) pain due to gallstone temporarily blocking the cystic duct. Pain typically lasts from one to a few hours
Cholecystitis
- Mid epigastric pain that’s continuous