Block 32 Week 8 Flashcards
acute pancreatitis?
- acute inflammation of the pancreas
- uncontr release of activated pancreatic enzymes -> autodigestion
most common cause of acute panc?
1) Gallstones
2) alcohol
I GET SMASHED
gallstones -> panc?
- most common cause
- almost half of cases
- can obstruct the ampulla -> biliary reflux
alcohol -> acute panceatitis?
- increased production of digestive enzymes
- alcohol commonly causes chronic panc but also causes acute
ERCP?
-> acute panc
endocrine function of pancreas?
- islets of langerhans
- insulin and glucagon
exocrine function of panc?
- pancreatic ductal cells
- produce pancreatic juice
- trypsin imp in pancreatitus
pain in acute panc?
- sudden onset epigastric pain
- vomiting
- worse on movement
- radiation to back
why may patients have reduced urinary output in panc?
- vomiting and third spacing of fluid - fluid exits the vascular space into tissues due to inflammation
- can result in a significant fluid deficit and as such patients may have dry mucous membranes and reduced urinary output
Sx of acute panc?
- Abdominal pain (may radiate to the back)
- Nausea
- Vomiting
- Anorexia
- Diarrhoea
Signs of acute panc?
- Abdominal tenderness
- Abdominal distention
- Tachycardia
- Tachypnea
- Pyrexia
Acute panc - 2 signs?
Cullens sign and grey turners
Cullens sign =
peri-umbilical bruising
grey turner sign?
flank bruising
diagnostic test of acute panc?
amylase 3x the reference range
how long does amylase stay elevated?
- 3 days
- patients who present late may have a missed peak
amylase in acute on chronic panc?
even in severe pancreatitis the amylase may be normal, particularly in those with acute-on-chronic disease. In these cases, a CT abdomen and pelvis is generally needed to confirm the diagnosis and exclude alternative causes.
mild elevation of amylase?
- parotitis
- bowel obstruction
- intestinal inflammation
- trauma
- malignancy
- ruptured ectopic pregnancy
Lipase vs amylase?
- lipase is more specific for panc
- has a longer half life so levels remain elevated for longer
lipase levels suggesting acute panc?
3x above reference range
bedside Ix for acute panc?
- Observations
- ECG
- Blood sugar
- Pregnancy test
Bloods for panc?
- amylase/ lipase
- U&Es
- LFTs - assessing for cholangitis
- LDH
- glucose
- lipids
US in acute panc?
used to demonstrate gallstones or a dilated common bile duct. The pancreas may be visualised.
CT in acute panc?
used to confirm diagnosis when uncertainty remains and to exclude complications of disease.
MRCP in acute panc?
most commonly indicated in suspected gallstone pancreatitis to help evaluate for CBD stones.
scoring for acute panc?
glasgow
glasgow score indicating severe panc?
> 3
Tx of acute panc?
- supportive
- IV fluids
- Analgesia
- Nutritional support
nutrition in acute panc?
in mild cases low fat diet reintro
Severe panc - feeding?
- enteral feeding is preferred to total parenteral nutrition (TPN).
- It is thought enteral feeding helps maintain the mucosa and prevents translocation of bacteria. Nasojejunal feeding is commonly used.
when should ab be used?
- NOT for acute panc
- should be used for suspected cholangitis
ERCP?
- Gallstone panc
- stone extraction
pancreatic necrosis?
- continued inflammation -> local thrombosis, haemorrhage and necorsis in the panc
- high infection risk
- major cause of mortality
Ix for pancreatic necrosis?
- CT guided fine needle aspiration and culture
panc pseudocyst?
- present 4+ weeks after an episode
- psudo means epithelial lining around the cyst rather than granulation tissue
vascular complications of acute panc?
- pseudoaneurysm
- venous thrombosis
pseudoaneurysm?
- rare but life threatning haemorrhages
- often seen in splenic and hepatic arteries
- normally occur in association w pancreatic pseudocysts
venous thrombosis?
- venous thrombosis may affect the portal, splenic and superior mesenteric veins
- requires AC
Severe acute pancreatitis can lead to ->
- Acute respiratory distress syndrome
- Renal failure
- Shock - disrtibutive
mortality in acute panc?
- 1% in mild panc
- sterile pancreatic necrosis: 10%
- infected panc necrosis: 25% mortality
Chronic pancreatitis refers to
chronic, irreversible, inflammation and/or fibrosis of the pancreas.
leading cause of chronic panc?
alcohol
endocrine dysfunction in chronic panc?
Endocrine dysfunction: damage to the islet cells result in lack of insulin and development of diabetes mellitus
exocrine dysfunction in chronic panc?
Exocrine dysfunction: damage to the acinar cells results in lack of pancreatic enzymes and malabsorption
Classification of the causes of panc?
TIGAR-O
Tigar-O?
T (toxic/metabolic): alcohol, smoking, high triglycerides, hypercalcaemia, chronic kidney disease
tIgar-O?
- idiopathic
- may be late onset, early onset or tropical
tiGar-O?
- genetics
- mutation in PRSS1
autoimmune panc?
- type 1
- type 2
Type 1 autoimmune panc?
- IgG4 disease
Type 2 autoimmune panc?
limited to the pancreas and associated with inflammatory bowel disease
tigaR-O?
- recurrent and severe acute panc
- patients with a severe episode of necrotising pancreatitis or those with acute recurrent pancreatitis can progress to chronic pancreatitis due to tissue destruction
tigar-O?
- chronic obstruction of the main pancreatic duct can lead to tissue damage and chronic pancreatitis upstream.
- Typical causes of obstruction include strictures, stones, cysts, and tumours
autosomal dominant hereditary panc?
- PRSS1 mutation
- encodes cationic trypsinogen
autosomal recessive hereditary panc?
- mutation in CTFR gene
- spink 1 gene
most common feature of chronic panc?
abd pain
pain in chronic pain?
- epigastric discomfort
- worse post-prandially and on lying down
pain in chronic panc may be assoc w ?
- nausea
- vomiting
- anorexia
CP - exocrine insufficiency?
- destruction of acinar cells -> loss of digestive enzymes -> malabs
- inability to digest fatty foods due to lack of lipase
features of panc exocrine insufficiency?
- Weight loss
- Bloating
- Flatulence
- Abdominal pain/discomfort
- Loose stools
- Steatorrhea
- > 90% of the pancreatic exocrine function needs to be lost before patients develop steatorrhea - consq of long standing panc damage
loss of endocrine cells in CP?
- Type 3c DM
- Polyuria, polydispsia, weight loss
assessment of chronic panc?
- CT or MRI with MRCP
features of chronic panc on CT?
- CT is excellent at looking for calcification changes within the pancreas.
- Features of chronic pancreatitis include atrophy, calcification, and ductal changes (e.g. dilatation, strictures).
Fecal elastase?
- indirect marker of panc function
- used to assess for panc exocrine insufficiency
- low levels suggest PEI
Bloods in CP?
- FBC, U&Es, LFTs
- lipid profile
- bone profile
- mag
- hbalc
general management of chronic panc?
- nutritional assessment
- alcohol cessation
- smoking cessation
- vitamin replacement e.g. vitamin D
Pain relief in chronic panc?
- basic first: paracetamol and NSAIDs
- then weak opiods: tramadol, codeine
PEI management?
- pancreatic enzyme replacement therapy
- abs can be improved using a PPI
Endoscopic management for chronic panc when:
- Pancreatic pseudocysts
- Pancreatic stones
- Main pancreatic duct strictures
- Other complications (e.g. biliary strictures,
duodenal obstruction)
complications of chronic panc?
- PEI
- DM
- osteoporosis
- panc cancer
- duodenal and biliary obst
Hb ab interpretation?
HBsAg = ongoing infection, either acute or chronic if present > 6 months
anti-HBc = caught, i.e. negative if immunized
Transmission of hep A?
- faecal-oral
hep A disease coruse?
- self limiting
- doesn’t cause chronic disease
features of hep A?
- flu-like prodrome
- abdominal pain: typically right upper quadrant
- tender hepatomegaly
- jaundice
- deranged liver function tests
immunisation for hep?
- A
- B
hep B is a
double standed DNA hepadanvirus
how is hep B spread?
- exposure to infected blood or body fluids
- mother to child
incubation period for hep B?
6-20 weeks
features of hep B?
- fever
- jaundice
- elevated LFTs
features of chronic hep B on LM?
ground glass hepatocytes
complications of hep B
- HCC
- glomerulonephritis
- fulm liver failure
hep E spread?
- faecal oral
- Can be transmitted by seafood
incubation period of hep E?
3-8 WEEKS
Where is hep E common?
- central and south asia
- mexico
- north and west africa
hep E is especially problematic in?
- pregnancy - causes sig mortality
hep E does not cause ?
does not cause chronic disease or an increased risk of hepatocellular cancer
hep C affects?
- IV drug users
- patients who receive a blood transfusion
incubation period of hep C?
6-9 weeks
transmission of HepC?
- Needle stick injury
- mother to child
- sexual intercourse
what is not contra-indicated in hep C?
breastfeeding
there is no vaccine for ?
hep C
Comps of chronic hep C?
- Sjogren’s syndrome
- cirrhosis
- HCC
- glomerulonephritis
hep D?
- single stranded RNA virus
- transmitted parenterally (blood and body fluids)
how does hep D cause infection?
- requires hep B surface antigen to repllicate
how is hep D transmitted?
transmitted in a similar fashion to hepatitis B (exchange of bodily fluids) and patients may be infected with hepatitis B and hepatitis D at the same time.
Co-infection vs superinfection?
Co-infection: Hepatitis B and Hepatitis D infection at the same time.
Superinfection: A hepatitis B surface antigen positive patient subsequently develops a hepatitis D infection.
superinfection of hep B and D is assoc w a higher risk of?
Superinfection is associated with high risk of fulminant hepatitis, chronic hepatitis status and cirrhosis.
Ascending cholangitis is?
- infection of the biliary ducts
- caused by obstruction
how does ascending cholangitis present?
Charcots triad: fever, jaundice, RUQ pain
Reynol’d pentad?
- Ascending cholangitis
- fever, jaundice, RUQ pain, septic shock and mental confusion
common causes of asc cholamgitis?
choledocholithiasis (gallstones) and strictures of the biliary tree.
Reynold’s pentad indicated?
inc risk of septic shock -> medical emergency
LFTs with Ascending cholangitis?
hyperbilirubinaemia and elevated serum alkaline phosphatase
imaging for Ascending cholangitis?
- ERCP: when history of biliary disease
- transabd US: CBD dilatation
Mx of ascending cholangitis?
- pieracillin/ tazobactam
- IV fluids
- analgesia
- sepsis 5
definitive management of ascendinh cholngitis?
- biliary decompression
- ERCP or surgery
biliary colic pain?
- RUQ pain
- intermittent
- usually begins abruptly and subsides gradually
- attacks often occur after eating
Biliary colic - mneumonic?
- female
- forties
- fat
- fair
Acute cholesystitis pain?
- similar to biliary colic but more severe and persistent
- pain may radiate to back or right shoulder
acute cholesytitis sign?
- pyrexial
- murphy’s sign positive: arrest of inspiration on palpation of the RUQ
Gallstone ileus?
- SBO
- secondary to impacted gallstone
features of gallstone ileus?
Abdominal pain, distension and vomiting
Features of cholangiocarcinoma?
- persistent biliary colic symptoms
- anorexia
- jaundice
- weight loss