CPC 8 acute abdo Flashcards
What stimulates the acute phase response?
Cytokines IL-1, IL-6 and TNF
What does the acute phase response increase (blood results)
CRP and fibrinogen, increased ESR, fever, increased leukocytes and negative nitrogen balance.
What does a CRP of 100-200 suggest
Marked inflammation, bacterial infection
What does a CRP of more than 200 suggest?
Severe bacterial infection or extensive trauma.
What is pyelonephritis?
Suppurative inflammation of the kidney, with neutrophils within the tuules and interstitioum, although glomeruli are only involved in severe disease. Generally there are yellow-white cortical abscesses and surrounding hyperaemia.
What are some complications of pyelonephritis
Pyonephritis
Peri-nephric abscess
Papillary necrosis,
Causes of papillary necrosis - acronym
POST CARDS
Causes of papillary necrosis, POST CARDS
Pyelonephritis Obstruction of the urogenital tract Sickle cell disease Tuberculosis Chronic liver disease Analgesia/alcohol abuse Rejection of renal transplant Diabetes mellitus Systemic vasculitis.
First line investigations for suspected pyelonephritis
MSU and blood cultures.
Treatment for uncomplicated pyelonephritis
Ciprofloxacin for 7 days.
How do you treat an infection which is resistant to several antibiotics i.e. has extended spectrum beta lactamase?
With meropenem.
What are the components of human bile?
bile salts (primary and secondary), phospholipids, cholesterol, protein, bilirubin and electrolytes.
Discuss the pathogenesis of gall stones
Cholesterol supersaturation in bile (with mucin hypersecretion
gall bladder hypomotility
and increased intetinal conversion to deoxycholate also involved.)
Crystal nucleation
Stone growth
What are the types of gall stones?
Cholesterol and pigment. Cholesterol is most common in western populations, while pigment stones are predominantly in others.
What populations are susceptible to cholesterol stones?
Western populations. Forty, fat, female, fertile, also those who have just had rapid weight loss and or have inborn errors of bile acid metabolism.
What populations are risk factors for pigment stones?
Chronic hemolytic syndromes, biliary infection, ileal disease (crohn’s, resection or bypass), cystic fibrosis with pancreatic insufficiency.
Where does gallstone pain radiate?
Epigastric pain radiating to the back (in waves if in CBD), vomiting. If gall stone ileus, also pain and distension. If in bile duct, jaundice.
What investigation do you do for a suspected bile duct stone?
EUS is best, but MRCP if this is not available. US not really good for duct stones.
Complications of gallstones?
Biliary sepsis
Gall bladder empyema
Gall stone ileus
Acute cholecystitis.
What organisms cause biliary sepsis (mostly)
E. coli and bacteroides fragilis.
What immune cells are mostly involved in gall bladder empyema?
Neutrophils.
What is the treatment for biliary sepsis which is mild and community acquired?
Co-amoxiclav
What is the treatment for biliary sepsis which is mild and community acquired with penicillin allergy?
ciprofloxacin and metronidazole
What is the treatment for biliary sepsis which is hospital acquired MRSA positive?
Vancomycin (for MRSA) and Piperacillin-Tazobactam (for anaerobes)
What is the treatment for biliary sepsis which is hospital acquired MRSA positive in penicillin allergic patient?
vancomycin, ciprofloxacin and metronidazole.
What causes acute cholecystitis?
Diabetes mellitus, gallstones, sepsis, immunosuppression and trauma.
What is the appearance of a gallbladder with cholecystitis?
Fibrinous exudate on external surface
Subserosal haemorrhage
Gallbladder wall is thickened, oedematous and hyperaemic
Neutrophilic inflammation
What is the most common cause of chronic cholecystitis?
Gallstones (90%)
General chronic cholecystitis info
Supersaturation of bile leads to chronic inflammation and stone formation.
⅓ have E. coli or enterococcus in bile.
Appearance of gallbladder in chronic cholecystitis
Thickened wall, variable chronic inflammation, sub-epithelial and sub-serosal fibrosis, outpouchings of epithelium through the wall.
Imaging of choice for right iliac fossa pain, fever and diarrhoea
CT the best, but US has less radiation.
Differential diagnoses for right iliac fossa pain, fever and diarrhoea
Appendicitis Carcinoid tumour Endometriosis Enterobius vermicularis Idiopathic inflammatory bowel disease. Ectopic pregnancy
Pathophysiology of appendicitis
Obstruction of lumen → stasis and loss of venous outflow → bacterial proliferation, inflam.response and ischaemia → neutrophilic inflammation and necrosis.
Appearance of appendix in appendicitis
Hyperaemic dilated vessels and/or fibrinious exudate on surface and/or perforation.
Neutrophilic infiltrate at least as far as muscularis propria. Serosal involvement suggests peritonitis.
Complications of appendicitis
Perforation and peritonitis Appendix mass Pyelophlebitis Portal vein thrombosis Liver abscess Bacteraemia
Basic info on carcinoid tumours
Well differentiated neuro-endocrine tumour.
40% jejunum/ileum,
Carcinoid syndrome symptoms
Flushing
Diarrhoea
Secondary restrictive cardiomyopathy.
What would be your imaging method of choice in the 74 year old with central abdominal pain radiating to the back and down into the legs?
CT
What would be your imaging of choice for suspected acute diverticulitis?
CT, unless young patient in which case expert US can be ok.
Causes of acute pancreatitis acronym
I GET SMASHED
Causes of acute pancreatitis I GET SMASHED
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia. ERCP and emboli Drugs (azathioprine)
Biochemistry of acute pancreatitis.
Increased serum amylase levels within first 24 hr
Rising serum lipases
10% have glycosuria
Hypocalcaemia secondary to deposition of calcium salts.
Histology of pancreatitis
Microvascular leak and oedema Fat necrosis Acute inflammation Destruction of parenchyma Destruction of blood vessels and interstitial haemorrhage.
Complications of acute pancreatitis
ARDS
Renal failure
Pseudocyst formation
Sterile abscess.
Hereditary pancreatitis - what genes cause it?
Gain of function in trypsinogen gene (PRSS1)
CFTR mutation
Loss of function of SPINK1, a trypsin inhibitor
What are the complications of hereditary pancreatitis
Pancreatitic carcinoma - 40% lifetime risk.
Chronic pancreatitis - general
Prolonged inflammation with irreversible injury and fibrosis
Exocrine injury occurs first, endocrine later.
Causes of chronic pancreatitis
alcohol, long-standing obstruction, autoimmune pancreatitis, hereditary pancreatitis.
What is diverticular disease?
Multiple outpouchings through the muscularis mucosae at taeniae coli where the vasa recta penetrate.
What is the pathology of diverticular disease
Inflammation, perforation, abscess formation, fistula.
What are the risk factors for colorectal carcinoma?
Diet high in refined carbs
NSAIDS are protective
FAP or HNPCC
How does the position affect the shape of a colorectal carcinoma?
Exophytic in proximal, annular if distal
Colorectal carcinoma prognosis depends on…
Prognosis depends on depth of invasion (vascular?) lymph node mets, differentiation and whether or not it is mucinous.
Histology of colorectal carcinoma
Dysplastic glands
Stromal changes
Pathophysiology of ischaemic colitis.
Acute compromise vs chronic hypoperfusion
Mucosal infarction may follow either
Transmural infaction typically follows acute vascular obstruction.
Causes of acute obstructive ischaemic colitis.
Severe atherosclerosis at the origin of the mesenteric vessels Abdominal aortic aneurysm Oral contraceptive pill use Embolisation of cardiac vegetations. Hypercoagulable states
Causes of intestinal hypoperfusion.
Cardiac failure
Shock
Dehydration
Vasocconstrictive drugs.
Macro appearance of ischaemic colitis
Congested and dusky
Bloodstained contents
Perforation
Serositis with fibrin.
Histopathology of ischaemic colitis.
Mucosa haemorrhagic and ulcerated Atrophy and sloughing of surface epithelium Crypts regenerative Neutrophils after reperfusion Fibrosis if chronic.
Ectopic pregnancy general
2% of confirmed pregnancies
Risk factors: appendicitis, endometriosis, previous surgery, IUCD.
Likely causes of peritonism with epigastric pain with nausea.
Peptic ulceration
Acute pancreatitis
Acute cholecystitis
(be aware appendicitis, lower lobe pneumonia, MI)
If someone has peritonism and pain, with cool peripheries, what does this mean?
He may have a degree of hypovolaemia - give him fluids.
Treatment for acute pancreatitis.
80%-90% resolve with conservative treatment - IV fluids, nil by mouth, possible Abx.
What is Wilson’s disease?
Autosomal recessive condition characterized by toxic accumulation of copper in the liver and brain. Neurological problems may manifest as dementia, tremor or dyskinesias.
Onset between 10-25 years
Features of Wilson’s disease
liver: hepatitis, cirrhosis
neurological: basal ganglia degeneration, speech and behavioural problems are often the first manifestations. Also: asterixis, chorea, dementia
Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails
Diagnosis of Wilson’s disease
reduced serum caeruloplasmin
increased 24hr urinary copper excretion
Treatment of Wilson’s disease
penicillamine (chelates copper) has been the traditional first-line treatment
trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future
tetrathiomolybdate is a newer agent that is currently under investigation
Next question
Probable cause of painless enlarged gallbladder with mild jaundice on background of alcoholism
Pancreatic cancer
Likely cause of diarrhoea 1-6 hr after exposure
Staphylococcus aureus, Bacillus cereus
Likely cause of diarrhoea 12-48 h after exposure
Salmonella, Escherichia coli
Likely cause of diarrhoea 48-72 h after exposure
Shigella, Campylobacter
Likely cause of diarrhoea more than 7 days after exposure.
Giardiasis, Amoebiasis
What is Budd-Chiari syndrome?
Budd–Chiari syndrome is a condition caused by occlusion of the hepatic veins that drain the liver.
What is primary sclerosing cholangitis?
a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts
What is primary sclerosing cholangitis associated with?
ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC
Crohn’s (much less common association than UC)
HIV
How to manage post-operative ileus
Nil by mouth and NG tube for stomach decompression
Charcot’s triad for ascending cholangitis
Right upper quadrant pain, fever and jaundice
Medication for renal colic
Diclofenac for pain relief
Alpha-adrenergic blockers to help stone pass.
What medication can help prevent calcium renal stones?
Thiazide diuretics, which increase Ca++ reabsorption.
Common features of viral hepatitis
nausea and vomiting, anorexia
myalgia
lethargy
right upper quadrant (RUQ) pain
