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Stage 2: Inflammation > Acute Abdominal Inflammatory Conditions - General, Gallstones and Pancreatitis > Flashcards

Acute Abdominal Inflammatory Conditions - General, Gallstones and Pancreatitis Flashcards

1
Q

What are 4 common upper abdominal inflammatory conditions?

A

1) Gall stone disease
2) Pancreatitis
3) Peptic ulcer disease
4) GORD oesophagitis

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2
Q

What are 5 common lower abdominal inflammatory conditions?

A

1) Appendicitis
2) Diverticular disease
3) IBD
4) C. difficile colitis
5) Radiation proctitis

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3
Q

What are the most common abdominal presenting complaints?

A

Pain, nausea, diarrhoea, vomiting

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4
Q

What are the differentials of right iliac fossa pain in women of a reproductive age?

A
  • Appendicitis
  • Ovarian cyst/torsion
  • Ectopic pregnancy (unilateral)
  • PID (bilateral)
  • Nephrolithiasis
  • Pyelonephritis
  • Infectious colitis
  • IBD
  • Inguinal hernia
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5
Q

What type of stone is more likely to be radio-opaque than a gall stone?

A

Renal stone

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6
Q

What are the 3 key things to find out about abdominal pain?

A

1) Nature (continuous, colicky, radiation - not mutually exclusive)
2) Onset
3) Location (organ involved)

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7
Q

What does colicky pain generally indicate?

A

Obstruction to hollow viscus (blocking a tube)

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8
Q

What does continuous pain generally indicate?

A

Inflammation of an organ, may increase in severity

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9
Q

What is colicky pain?

A

Squeezing pain, comes and goes

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10
Q

What does sudden pain suggest?

A

Perforation

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11
Q

What does gradual pain suggest?

A

Inflammation

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12
Q

What are the 5 phrases to remember the typical patient with gall stones?

A

Fat, fair, female, fertile, forty

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13
Q

What is cholelithiasis?

A

Gall stones

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14
Q

Are gallstones mostly asymptomatic and what do you do?

A

Yes - don’t operate

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15
Q

What are other risk factors for gall stones?

A
  • FH
  • Sudden weight loss e.g. bariatric surgery
  • Haemolytics
  • Diabetes (metabolic syndrome)
  • Oral contraceptives
  • HRT
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16
Q

Describe biliary colic

A
  • When the stone intermittently obstructs the cystic duct the gall bladder contracts causing pain
  • When the stone falls back from the cystic duct the gall bladder relaxes and pain subsides
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17
Q

What are the clinical features of gallstone pain?

A
  • Pain localised to RUQ
  • Sudden onset (<1h after fatty meal)
  • Frequently radiates to right scapula/shoulder
  • Typically constant, not colicky
  • Lasts 1-4 hours
  • Relieved by analgesia and rest
  • Moderate to excruciating
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18
Q

Describe the clinical features of gallstones

A
  • Pain is associated with sweating (diaphoresis), nausea, vomiting
  • Patients typically do not look ‘unwell’
  • No pyrexia or tachycardia
  • No peritoneal pain (purely visceral pain)
  • Patients often have several attacks before seeking medical attention
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19
Q

What should pyrexia and/or pain persisting beyond 5 hours with gallstones raise suspicion of?

A

Acute cholecystitis

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20
Q

What causes acute cholecystitis?

A
  • Cystic duct is blocked by a gallstone
  • This causes an obstruction to secretion of bile from the gall bladder
  • Bile becomes concentrated
  • This leads to chemical inflammation and then bacterial inflammation by organisms released by liver into bile stream
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21
Q

How do you carry out testing for Murphy’s sign and what happens?

A
  • Hand at costal margin in RUQ
  • Deep inspiration causes diaphragm to move down
  • Pain occurs when the inflamed gallbladder contacts palpating hand
  • Manoeuvre in LUQ should not elicit pain
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22
Q

What are complications of acute cholecystitis?

A
  • Empyema of the gall bladder (suparative cholecystitis)
  • Gangrene of the gall bladder (in severe disease that interferes with the blood supply)
  • Perforation of the gall bladder
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23
Q

What is Boas sign?

A

An area of high sensitivity in the back, below the right scapula, indicating acute cholecystitis

24
Q

What are complications of gallstone disease?

A
  • Biliary colic
  • Acute cholecystitis
  • Obstructive jaundice
  • Ascending cholangitis
  • Pancreatitis
  • Gallstone ileus
25
Q

Describe what happens in obstructive jaundice and ascending cholangitis

A
  • Obstruction of common bile duct by a stone with infection/pus proximal to the blockage
  • Usually gram-negative bacilli e.g. E.coli
  • Danger is progression to ascending cholangitis
  • 50-70% of patients present with Charcot’s triad
26
Q

What is Charcot’s triad?

A

Jaundice, fever and RUQ pain

27
Q

What are the early complications of a laparoscopic cholecystectomy?

A
  • Bleeding
  • Bile leak
  • Damage to common bile duct
28
Q

What are the late complications of a laparoscopic cholecystectomy?

A
  • Retained stones

- Bile duct stricture

29
Q

Why do surgeons stay close to the gall bladder during a laparoscopic cholecystectomy?

A

To avoid damaging structures in Calot’s triangle

30
Q

What are the causes of pancreatitis?

A
  • Idiopathic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps, TB, CMV, coxsackie B
  • Autoimmune (Sjögren’s, autoimmune thyroiditis, sclerosing cholangitis)
  • Scorpion venom
  • Hyperlipidaemia, hypercalcaemia, hypothermia
  • ERCP and emboli
  • Drugs
  • Pregnancy and neoplasia
31
Q

What drugs can cause pancreatitis?

A
  • Azathioprine
  • 6-MP
  • Oestrogen
  • Tamoxifen
  • Metronidazole
  • NSAIDs
  • Simvastatin
  • Sulfonamides
  • Thiazides
  • Tetracycline
32
Q

What happens in pancreatitis?

A
  • May extend to local and distant extrapancreatic tissues
  • Activation of pro-enzymes into active enzymes within the acinar calls - autodigestion of pancreas (necrosis)
  • Microcirculatory injury - activation of the complement system - proinflammatory mediators
  • Systemic shock - organ failure
33
Q

How do you diagnose pancreatitis?

A

2 of the following:

  • Epigastric pain and vomiting
  • Serum amylase or lipase > 3 x upper limit of normal
  • Contrast enhanced CT only if patient is not improving
34
Q

What is the first test you do for pancreatitis?

A

Urine dip stick

35
Q

What investigations do you do for pancreatitis?

A
  • Serum amylase/lipase
  • LFTs, U&Es, WCC, glucose, calcium
  • ABG - oxygenation and acid-base status
  • Imaging
36
Q

What imaging do you do for pancreatitis and why?

A
  • AXR
  • Erect CXR to exclude perforation
  • CT to assess severity
  • Ultrasound/MRCP if gallstones suspected
37
Q

What does no psoas shadow on a AXR indicate?

A

Retroperitoneal fluid

38
Q

What are local complications of pancreatitis?

A
  • Acute peripancreatic fluid collection
  • Pancreatic pseudocyst
  • Acute necrotic collection
  • Walled-off necrosis
  • Recurrence of abdominal pain
  • Secondary rise in amylase/lipase
  • Increasing organ dysfunction
  • Sepsis (fever, leucocytosis)
39
Q

What are systemic complications of pancreatitis?

A

Exacerbation of co-morbidities

40
Q

What is a good measurement of how inflamed the pancreas is?

A

CRP

41
Q

What is an acute peripancreatic fluid collection?

A

Adjacent to the pancreas with no definable wall encapsulating the collection (in 4 weeks can progress to a pancreatic pseudocyst)

42
Q

What is a pancreatic pseudocyst?

A
  • Fluid is encapsulated by a well-defined wall
  • Usually extrapancreatic
  • Usually occurs > 4 weeks after onset of AP
43
Q

What is an acute necrotic collection as a complication of pancreatitis?

A
  • Variable amounts of both fluid and necrosis
  • No definable wall
  • Intrapancreatic and/or extrapancreatic
  • In 4 weeks can progress to walled-off necrosis
44
Q

What is walled-off necrosis as a complication of pancreatitis?

A
  • Mature, encapsulated collection of pancreatic and/or peripancreatic necrosis
  • Maturation usually requires 4 weeks
45
Q

What does collection of fluid outside the pancreas usually occur?

A

In the lesser sac

46
Q

Describe infected necrosis as a complication of pancreatitis

A
  • Associated with 40% mortality
  • ⅓ patients with pancreatic necrosis will develop infected necrosis
  • Usually seen after 10 day s
  • Majority due to gut-derived microorganisms
  • Suspect in anyone who deteriorates (clinical signs of sepsis) or fails to improve after 7-10 days of hospitalisation
47
Q

What are the 4 stages of severity of acute pancreatitis?

A
  • Mild
  • Moderately severe
  • Severe
  • Presence/absence of local and systemic complications, persistent organ failure (>48h)
48
Q

Describe mild acute pancreatitis

A
  • No organ failure
  • No local or systemic complications
  • No imaging required
  • Discharged within 1 week
  • 75% of cases
49
Q

Describe moderately severe acute pancreatitis

A
  • Transient organ failure (resolves within 48h)
  • Local or systemic complications
  • Discharged at 2nd/3rd week
  • Mortality < 8%
50
Q

Describe severe acute pancreatitis

A
  • Persistent organ failure (>48h)
  • > 1 local/systemic complication
  • Develops during early phase - mortality = 36-50%
  • Infected necrosis further increases mortality
  • Managed in HDU/ICU
51
Q

Why does calcium decrease in severe acute pancreatitis?

A

Calcium binds with the inflammatory mass (needed for normal heart function)

52
Q

Why does dehydration occur in severe acute pancreatitis?

A

Because it is like a chemical burn on the inside

53
Q

What clinical scoring system is used to predict severity of pancreatitis and how is it used?

A

Glasgow prognostic score (within 48h) - ≥ 3 criteria = severe acute pancreatitis

54
Q

What is the medical management of acute pancreatitis?

A
  • Oxygen
  • IV fluids
  • Analgesia
  • NBM and NGT used if there is protracted vomiting
  • Fluid balance charts and urinary catheter
  • Antibiotics for infected necrosis
  • Oral diet when pain improves and appetite returns (day 3)
  • In severe cases and nausea, enteral feeding and naso-jejunal tube preferred over TPN
55
Q

What is the surgical/endoscopic management of acute pancreatitis?

A
  • ERCP within 72h of symptoms in suspected or proven gallstone aetiology
  • In severe attacks urgent endoscopic sphincterotomy reduces mortality
  • In mild attacks elective laparoscopic cholecystectomy within 2 weeks
56
Q

How is infected necrosis (common cause of late death in AP) treated?

A
  • Needs radiological-guided, endoscopic or laparoscopic drainage
  • Retroperitoneal approach or if there is walled-off collection behind the stomach - transgastric endoscopic necrosectomy
57
Q

Why is MRCP (can be used to look at biliary tree) only used therapeutically?

A

Because it is very invasive

Stage 2: Inflammation (39 decks)

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