Acute Abdominal Inflammatory Conditions - General, Gallstones and Pancreatitis Flashcards
What are 4 common upper abdominal inflammatory conditions?
1) Gall stone disease
2) Pancreatitis
3) Peptic ulcer disease
4) GORD oesophagitis
What are 5 common lower abdominal inflammatory conditions?
1) Appendicitis
2) Diverticular disease
3) IBD
4) C. difficile colitis
5) Radiation proctitis
What are the most common abdominal presenting complaints?
Pain, nausea, diarrhoea, vomiting
What are the differentials of right iliac fossa pain in women of a reproductive age?
- Appendicitis
- Ovarian cyst/torsion
- Ectopic pregnancy (unilateral)
- PID (bilateral)
- Nephrolithiasis
- Pyelonephritis
- Infectious colitis
- IBD
- Inguinal hernia
What type of stone is more likely to be radio-opaque than a gall stone?
Renal stone
What are the 3 key things to find out about abdominal pain?
1) Nature (continuous, colicky, radiation - not mutually exclusive)
2) Onset
3) Location (organ involved)
What does colicky pain generally indicate?
Obstruction to hollow viscus (blocking a tube)
What does continuous pain generally indicate?
Inflammation of an organ, may increase in severity
What is colicky pain?
Squeezing pain, comes and goes
What does sudden pain suggest?
Perforation
What does gradual pain suggest?
Inflammation
What are the 5 phrases to remember the typical patient with gall stones?
Fat, fair, female, fertile, forty
What is cholelithiasis?
Gall stones
Are gallstones mostly asymptomatic and what do you do?
Yes - don’t operate
What are other risk factors for gall stones?
- FH
- Sudden weight loss e.g. bariatric surgery
- Haemolytics
- Diabetes (metabolic syndrome)
- Oral contraceptives
- HRT
Describe biliary colic
- 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
What are the clinical features of gallstone pain?
- 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
Describe the clinical features of gallstones
- 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
What should pyrexia and/or pain persisting beyond 5 hours with gallstones raise suspicion of?
Acute cholecystitis
What causes acute cholecystitis?
- 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
How do you carry out testing for Murphy’s sign and what happens?
- 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
What are complications of acute cholecystitis?
- 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
What is Boas sign?
An area of high sensitivity in the back, below the right scapula, indicating acute cholecystitis
What are complications of gallstone disease?
- Biliary colic
- Acute cholecystitis
- Obstructive jaundice
- Ascending cholangitis
- Pancreatitis
- Gallstone ileus
Describe what happens in obstructive jaundice and ascending cholangitis
- 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
What is Charcot’s triad?
Jaundice, fever and RUQ pain
What are the early complications of a laparoscopic cholecystectomy?
- Bleeding
- Bile leak
- Damage to common bile duct
What are the late complications of a laparoscopic cholecystectomy?
- Retained stones
- Bile duct stricture
Why do surgeons stay close to the gall bladder during a laparoscopic cholecystectomy?
To avoid damaging structures in Calot’s triangle
What are the causes of pancreatitis?
- 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
What drugs can cause pancreatitis?
- Azathioprine
- 6-MP
- Oestrogen
- Tamoxifen
- Metronidazole
- NSAIDs
- Simvastatin
- Sulfonamides
- Thiazides
- Tetracycline
What happens in pancreatitis?
- 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
How do you diagnose pancreatitis?
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
What is the first test you do for pancreatitis?
Urine dip stick
What investigations do you do for pancreatitis?
- Serum amylase/lipase
- LFTs, U&Es, WCC, glucose, calcium
- ABG - oxygenation and acid-base status
- Imaging
What imaging do you do for pancreatitis and why?
- AXR
- Erect CXR to exclude perforation
- CT to assess severity
- Ultrasound/MRCP if gallstones suspected
What does no psoas shadow on a AXR indicate?
Retroperitoneal fluid
What are local complications of pancreatitis?
- 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)
What are systemic complications of pancreatitis?
Exacerbation of co-morbidities
What is a good measurement of how inflamed the pancreas is?
CRP
What is an acute peripancreatic fluid collection?
Adjacent to the pancreas with no definable wall encapsulating the collection (in 4 weeks can progress to a pancreatic pseudocyst)
What is a pancreatic pseudocyst?
- Fluid is encapsulated by a well-defined wall
- Usually extrapancreatic
- Usually occurs > 4 weeks after onset of AP
What is an acute necrotic collection as a complication of pancreatitis?
- Variable amounts of both fluid and necrosis
- No definable wall
- Intrapancreatic and/or extrapancreatic
- In 4 weeks can progress to walled-off necrosis
What is walled-off necrosis as a complication of pancreatitis?
- Mature, encapsulated collection of pancreatic and/or peripancreatic necrosis
- Maturation usually requires 4 weeks
What does collection of fluid outside the pancreas usually occur?
In the lesser sac
Describe infected necrosis as a complication of pancreatitis
- 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
What are the 4 stages of severity of acute pancreatitis?
- Mild
- Moderately severe
- Severe
- Presence/absence of local and systemic complications, persistent organ failure (>48h)
Describe mild acute pancreatitis
- No organ failure
- No local or systemic complications
- No imaging required
- Discharged within 1 week
- 75% of cases
Describe moderately severe acute pancreatitis
- Transient organ failure (resolves within 48h)
- Local or systemic complications
- Discharged at 2nd/3rd week
- Mortality < 8%
Describe severe acute pancreatitis
- Persistent organ failure (>48h)
- > 1 local/systemic complication
- Develops during early phase - mortality = 36-50%
- Infected necrosis further increases mortality
- Managed in HDU/ICU
Why does calcium decrease in severe acute pancreatitis?
Calcium binds with the inflammatory mass (needed for normal heart function)
Why does dehydration occur in severe acute pancreatitis?
Because it is like a chemical burn on the inside
What clinical scoring system is used to predict severity of pancreatitis and how is it used?
Glasgow prognostic score (within 48h) - ≥ 3 criteria = severe acute pancreatitis
What is the medical management of acute pancreatitis?
- 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
What is the surgical/endoscopic management of acute pancreatitis?
- 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
How is infected necrosis (common cause of late death in AP) treated?
- Needs radiological-guided, endoscopic or laparoscopic drainage
- Retroperitoneal approach or if there is walled-off collection behind the stomach - transgastric endoscopic necrosectomy
Why is MRCP (can be used to look at biliary tree) only used therapeutically?
Because it is very invasive
