3 - Pancreatitis And Cholecystitis Flashcards
Most cases of pancreatitis are:
Mild - involve only mild inflammation of the pancreas
Generally resolves with supportive care
Risk factors for pancreatitis
Smoking
DM
Obesity
Gallstones
Alcohol consumption
MCC’s of pancreatitis
Gallstones
EtOH
Idiopathic
Sxs of acute pancreatitis
Acute, severe, persistent abd pain
N/V
Anorexia
Decrease oral intake
Pain of pancreatitis
Epigastrium or occasionally in the left or right upper quadrants
May radiate to the back, chest, or flanks
What kind of pain is highly unlikely to be pancreatitis
Lower abdominal pain, dull or colicky pain
Cullen’s Sign
Belly button
Grey-Turner
Flanks
Formal dx of pancreatitis
- Looks like pancreatitis
- Lipase/amylase high
- Imaging
Need at least two of three criteria
Gold standard for lab (pancreatitis)?
None
Which is better - amylase or lipase?
Lipase better for dx’ing
Imaging for pancreatitis
CT Abdomen pelvis with IV contrast
However, if they meet criteria, you don’t HAVE to get imaging - just treat it - you’ve clinically diagnosed it
Characteristic findings on CT
Parenchymal inflammation
Parenchymal necrosis
Peripancreatic fluid collection
Pancreatic pseudocyst
(do not need to memorize)
Txt for pancreatitis
Supportive
Rehydration
2 to 4 L of fluid q 12 to 24 hrs
Txt the pain and nausea
No ABX
Local complications
Gastric outlet syndrome
Walled off necrosis
Splenic and portal vein thrombosis
Acute peripancreatic fluid collection
don’t need to memorize
MC’ly used scoring for pancreatitis
Ranson
SIRS (+) persistent for 48hrs good predictor of:
Acute pancreatitis
Features of criteria for predicting pancreatitis severity
> 55yrs Obese AMS Comorbidities BUN > 20 Crit > 44% Increase creat
Consider admission for:
- First time pancreatitis
- Biliary pancreatitis
- High pain med need
- Not able to drink / eat
- Persistent abnormal V/S
- And sign of organ insufficiency
When its biliary pancreatitis
And it don’t look good
Who you gonna call???
Surgeon, not medicine
Or the Ghostbusters, providers choice
Mortality worse for acute or chronic pancreatitis?
Acute
MC complication of gallstone disease?
Biliary colic
What is uncommon but life-threatening for the gallbladder?
Perforation
Emphysematous cholecystitis
Gas-producing organisms
Acute acalculous cholecystitis occurs in the absence of:
Gallstones
Much less common but more serious
Occurs in the setting of critical illness like septic shock, burns, major trauma, or surgery
Old age, DM, immunosuppression are risk factors
Biliary colic - pattern of pain
Coincides with meals, usually
Typically mild RUQ tenderness without peritoneal signs
MURPHY’S SIGN
What is rarely seen with acute cholecystitis?
Jaundice
Study of choice for acute cholecystitis
US
Charcot’s Triad
Fever
RUQ pain
Jaundice
CHOLANGITIS
Pentad? Add AMS and shock (seen in less than 10% of cholangitis patients)
Differential for gallbladder stuff (RUQ)
Could be appendix displaced superiorly
Could be chest stuff
Labs for cholecystitis
WBC’s
CRP
Get LFT’s
Why are plain films pointless?
Most stones don’t have enough calcium to show up
Thats why we use US (study of choice)
Sonographic Murphy’s sign
Find the gallbladder
Compress the gallbladder with the probe
(+) pain reproduced - identified gallbladder as source of inflammation
Good diagnostic tools for cholecystitis
Presence of stone on US
Sonographic Murphy’s sign
If we see a large CBD, plan for:
MRCP (probably a stone causing obstruction)
Can i r/o choledocholithiasis with US or CT?
Nope
Normal common bile duct diameter
You’re allowed 6mm up to age 60yrs (i.e. 6.1mm = enlarged)
You’re allowed another mm each decade after 60yrs
If gallbladder was removed, they’re allowed up to 10mm of enlargement
MEMORIZE THIS STUFF
Preferred initial imaging for acute cholecystitis
US
Slide 54
Good chart of what findings go with what tests
ED management for acute cholecystitis
Prophylactic ABX
NPO
mIVF
NSAIDs / opioids (try to avoid opioids if possible)
If it’s biliary colic and they’re stable:
You can discharge to follow-up with a general surgeon (with instructions to return to ED if shit gets worse)
Pt with acute cholecystitis or cholangitis
ADMIT! They’re really sick
Probably need
CCU
Emphysematous cholecystitis - study of choice>?
IV contrast CT (to see air form gas-producing bacteria)
Emphysematous cholecystitis prognosis
15% mortality - yikes
Acalculous cholecystitis most commonly occurs in what setting?
Patients with critical illness
Complications of acalculous cholecysititis
Gangrene
Perf
If it looks like cholecystitis but they don’t have a gallbladder, consider:
Retained stone
Billy has 32 candy bars, he eats 28 of them. What does Billy have now?
Diabetes
