Abdominal pain and pancreatitis

Question 1

Summarise the functions of the pancreas

Answer 1

Endocrine
Islet cells of Langerhans
Exocrine
1.5 L of pancreatic juice, enzyme rich for digestion of fats, carbohydrates and proteins

Question 2

Ultimately, what do we want to know from the patient

Answer 2

What is the diagnosis?

How sick is he?

What is the underlying cause?

Question 3

Define acute pancreatitis

Answer 3

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.

Question 4

List some symptoms of acute pancreatitis

Answer 4

T 38.4
Pulse 120, BP 90/60
Sats 94% on room air
Peripherally shut down, capillary refill >4s

Abdomen tender in the epigastrium

Question 5

Describe peripheral shut down

Answer 5

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

Question 6

Outline a basic diagnostic approach for pancreatitis

Answer 6

History
Examination
Tests
SIMPLE - BP, pulse, urine dipsticks 
BLOOD TESTS
COMPLEX BLOOD TEST 
SIMPLE IMAGING
CROSS SECTIONAL IMAGING
INVASIVE TEST

Question 7

Describe the blood tests for acute pancreatitis

Answer 7

§ 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.

Question 8

Describe the different type of imaging techniques for acute pancreatitis

Answer 8

§ Simple imaging – X-rays, Ultrasound.
§ Cross-sectional imaging – CT scan, MRCP scans.
§ Invasive tests – ERCP.

Question 9

Describe the importance of albumin

Answer 9

If low- indicates a problem somewhere (most likely the liver)- the lower it is- the worse it is

Question 10

Describe the importance of WCC

Answer 10

WCC 17.4 (neut 15.1)

If high- indicates acute inflammation and infection

Question 11

What is ALT

Answer 11

Alanine aminotransferase- indicative of hepatocyte death and damage
ALK too

Question 12

What is ERCP

Answer 12

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.

Question 13

Which 3 scoring systems could you use to determine how sick he is

Answer 13

Ranson’s criteria
APACHE II
SIRS

Question 14

What are the criteria for SIRS

Answer 14

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

Question 15

What are the criteria for Ranson’s

Answer 15

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

Question 16

List the key risk factors for severity

Answer 16

Necrosis vs non necrosis
Organ failure
Age
Co morbidities
Alcohol

Question 17

List the main causes of pancreatitis

Answer 17

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)

Question 18

List the systemic complications of pancreatitis

Answer 18

Hypovolaemia
Hypoxia
Hypocalcaemia
Hyperglycaemia
DIC
Multiple organ failure

Question 19

List the localised complications of pancreatitis

Answer 19

Pancreatic necrosis
Fluid collections – mature into pseduocysts
Splenic vein thrombosis/pseudoaneurysm
Chronic Pancreatitis

Question 20

Describe the treatment for acute pancreatitis

Answer 20

Supportive
Fluids
Painkillers
Nutrition- if they are not unwell- parenteral feeding is better than I.V 
Organ Support
Management of complications

Question 21

Define chronic pancreatitis

Answer 21

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

Question 22

Describe the complications of chronic pancreatitis

Answer 22

Malabsorption
Loss of 90% exocrine function
Fat soluble vitamin malabsorption
(A, D, E, K)

Question 23

Outline the investigations for acute pancreatitis

Answer 23

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

Question 24

Outline the treatment for chronic pancreatitis

Answer 24

Stop alcohol and smoking
Small meals with low fat
PPI and pancreatic supplements- pancreatic enzymes
Analgesia

Question 25

What can be common in pancreatitis

Answer 25

§ 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).

Question 26

When interpreting abdominal pain what should you consider

Answer 26

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

Question 27

How should you approach abdominal pain

Answer 27

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

Question 28

Describe SOCRATES

Answer 28

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-

Question 29

Describe the characteristics of GI pain

Answer 29

Usually characterised by: 
§ Initially, poorly located. 
§ Onset over hours (can be quick). 
§ Usually more of a dull ache. 
§ May have associated GI symptoms.

Question 30

Describe the areas presenting with abdominal pain

Answer 30

§ Foregut – oesophagus, stomach, pancreas, liver, gallbladder and duodenum.
§ Midgut – duodenum to mid-transverse colon.
§ Hindgut – transverse colon to the anal canal.

Question 31

Where may pain for a heart attack be felt

Answer 31

In the epigastric region

Question 32

Describe colicky pain

Answer 32

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.

Question 33

Describe peritonitis (e.g appendicitis)

Answer 33

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.