Abdominal pain and pancreatitis Flashcards
Summarise the functions of the pancreas
Endocrine
Islet cells of Langerhans
Exocrine
1.5 L of pancreatic juice, enzyme rich for digestion of fats, carbohydrates and proteins
Ultimately, what do we want to know from the patient
What is the diagnosis?
How sick is he?
What is the underlying cause?
Define acute pancreatitis
An acute inflammatory process that leads to necrosis of the pancreatic parenchyma.
Signs and symptoms include severe abdominal pain, nausea, vomiting, diarrhoea, fever, and shock.
List some symptoms of acute pancreatitis
T 38.4
Pulse 120, BP 90/60
Sats 94% on room air
Peripherally shut down, capillary refill >4s
Abdomen tender in the epigastrium
Describe peripheral shut down
Keep blood in central areas- away from the skin and feet
delayed capillary refill (greater than 4 seconds)- shown by squeezing hand, and timing how long it takes to become a pinky colour again upon release
Outline a basic diagnostic approach for pancreatitis
History Examination Tests SIMPLE - BP, pulse, urine dipsticks BLOOD TESTS COMPLEX BLOOD TEST SIMPLE IMAGING CROSS SECTIONAL IMAGING INVASIVE TEST
Describe the blood tests for acute pancreatitis
§ Blood tests – Full blood count, urea/electrolytes (checks liver function too), inflammation markers, liver function tests, clotting, calcium, glucose.
· Hyperglycaemia, hypocalcaemia.
· CRP measures time since pancreatic attack.
· Elevated white count, bilirubin and liver enzymes.
§ Complex blood tests – Amylase, Lipase, Triglycerides.
· Elevated in pancreatitis.
Describe the different type of imaging techniques for acute pancreatitis
§ Simple imaging – X-rays, Ultrasound.
§ Cross-sectional imaging – CT scan, MRCP scans.
§ Invasive tests – ERCP.
Describe the importance of albumin
If low- indicates a problem somewhere (most likely the liver)- the lower it is- the worse it is
Describe the importance of WCC
WCC 17.4 (neut 15.1)
If high- indicates acute inflammation and infection
What is ALT
Alanine aminotransferase- indicative of hepatocyte death and damage
ALK too
What is ERCP
Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy (X-Ray) to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject a contrast medium into the ducts in the biliary tree and pancreas so they can be seen on radiographs.
Which 3 scoring systems could you use to determine how sick he is
Ranson’s criteria
APACHE II
SIRS
What are the criteria for SIRS
Two or more :
Temp above 38.3 or lower than 36
HR >90
Respiratory rate >20 or PaCO2 < 32 mmHg
WBC > 12000 cells/mL or <4000 cells/mL
What are the criteria for Ranson’s
The Ranson criteria form a clinical prediction rule for predicting the prognosis and mortality risk of acute pancreatitis.
Age > 55 WCC > 16000/ MM^3 Blood glucose > 11.1 mmol/L LDH > 350 U/L Aspartate aminotransferase > 250 U/L
After 48 hours: Hct fall by 10 Blood urea nitrogen increase by more than 1.8 mmol/L Serum calcium < 2mmol/L pO2 < 60 mmHg Base deficit >4 Fluid sequestration > 6000 mL
List the key risk factors for severity
Necrosis vs non necrosis Organ failure Age Co morbidities Alcohol
List the main causes of pancreatitis
Causes of Pancreatitis – GET SMASHED: Gallstones – MAIN CAUSE (aka cholelithiasis).
Ethanol – MAIN CAUSE
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom Hyperlipidaemia/Hypercalcaemia ERCP
Drugs (azathioprine, NSAID, furosemide, sulphonamides)
List the systemic complications of pancreatitis
Hypovolaemia Hypoxia Hypocalcaemia Hyperglycaemia DIC Multiple organ failure
List the localised complications of pancreatitis
Pancreatic necrosis
Fluid collections – mature into pseduocysts
Splenic vein thrombosis/pseudoaneurysm
Chronic Pancreatitis
Describe the treatment for acute pancreatitis
Supportive Fluids Painkillers Nutrition- if they are not unwell- parenteral feeding is better than I.V Organ Support Management of complications
Define chronic pancreatitis
Chronic pancreatitis is a progressive fibroinflammatory process of the pancreas that results in permanent structural damage, which leads to impairment of exocrine and endocrine function
Describe the complications of chronic pancreatitis
Malabsorption
Loss of 90% exocrine function
Fat soluble vitamin malabsorption
(A, D, E, K)
Outline the investigations for acute pancreatitis
Plain x-ray: many calcifications within the pancreas
CT Scan: shows duct issues- dilation of pancreatic duct e.g
Faecal elastase: elastase secreted by pancreas - so marker for all enzymes; if low in stool sample then indicates chronic pancreatitis
Outline the treatment for chronic pancreatitis
Stop alcohol and smoking
Small meals with low fat
PPI and pancreatic supplements- pancreatic enzymes
Analgesia
What can be common in pancreatitis
§ Presents with a very variable set of symptoms such as jaundice, RUQ pain, low blood pressure etc.
§ Normally pain is localised to the epigastrium and radiates towards the back.
§ Nausea and vomiting is common.
§ May have evidence of jaundice (Pancreas swelling blocks pancreatic and common ducts and blocks removal of bilirubin pigment).
When interpreting abdominal pain what should you consider
Subjectivity - what is considered pain by one person may be considered as discomfort or painless to another. Similarly, the location of the pain may not be described correctly or perceived typically
Interpretability - pain and the sensation of pain is complex. Sometimes, just because the pain is perceived in one place doesn’t mean that it originates from there
How should you approach abdominal pain
History - talk to your patient, find out what is wrong and how long it has been a problem. Find out about their personal and family history by asking the right questions. Remember, its unlikely your patient is as highly trained in medicine as you!
Examination - undertake an examination of your patient, using visual (look at them), auditory (ausculation), smell (perhaps a pungent external infection?) and tactile (is their skin cold, clammy, rough?) inputs
Investigations - to confirm or exclude diagnoses, you may need laboratory and/or imaging investigations to generate a clearer picture
Describe SOCRATES
Site Where is the pain? Onset How sit it come on? Character What does the pain feel like? Radiation Where does the pain move to/extend to? Associated symptoms Any other symptoms? Timing How quickly did the pain come on/go? Exacerbating/relieving factors What makes the pain better/worse? Severity How much does the pin hurt on a scale of 1-
Describe the characteristics of GI pain
Usually characterised by: § Initially, poorly located. § Onset over hours (can be quick). § Usually more of a dull ache. § May have associated GI symptoms.
Describe the areas presenting with abdominal pain
§ Foregut – oesophagus, stomach, pancreas, liver, gallbladder and duodenum.
§ Midgut – duodenum to mid-transverse colon.
§ Hindgut – transverse colon to the anal canal.
Where may pain for a heart attack be felt
In the epigastric region
Describe colicky pain
Pain that comes and goes due to contractions of a hollow tube in an attempt to relieve obstructions.
§ Examples of hollow tubes include: ureter, urethra, colon, bile ducts, pancreatic ducts. An example where this pain would be apparent is in kidney stones.
Describe peritonitis (e.g appendicitis)
Sharp pain that is very severe.
§ Localised initially but becomes more generalised.
§ Pain is much worse on movement.
§ Patients with peritonitis display tendencies to:
o Guard – involuntary contractions of abdominal muscles to protect the area.
o Rebound tenderness – the application of pressure gives no pain but release and rebound gives pain.
