DSA 6: RUQ and Epigastric Pain Flashcards
what are the 4 main concerns on DDx for RUQ and epigastric pain?
- gallbladder disease
- hepatitis
- pancreatitis
- PUD
positive sign: deep inspiration or cough during palpation of RUX produces increased pain or inspiratory arrest
Murphy’s sign
what are the two major types of gallstones?
- cholesterol (80%)
- calcium bilirubinate (<20%)
what is the best diagnostic tool for cholelithiasis?
- *RUQ ultrasound/hepatobiliary US**
- NOTE: stones seen as “acoustic shadow””
what are the risk factors of gallstones?
- family hx
- female
- fair
- fate
- fertile
- forty
what are the protective factors for gallstones?
- low carb diet
- physical activity
- cardiorespiratory fitness
- consumption of caffeine (in women)
- ligh intake of Mg and polyunsaturated/monosat fat (in men)
- ASA, NSAIDs
calculous gallstones (>90% of cases) impacted in **cystic duct*
- can be acalculous stones
- large fatty meal -> acute attack
- bilirubinemia
- sometime jaundice is present, suggesting choledocolithiasis (bile duct obstruction)
acute cholecystitis
- dx: RUQ abd US
what is a severe complication of acute cholecystitis to keep in mind?
- *emphysematous cholecystitis** (air lining the gallbladder)
- secondary infection with a gas-forming organism
- requires urgent cholecystectomy!
what is the procedure of choice for dx and therapy for choledocolithiasis?
ERCP with sphincterotomy and stone extraction (can be done in same operation)
what is Charcot’s triad?
- RUQ pain
- fever/chills
- jaundice
what is the Reynold pentad? when does it present?
Charcot triad + altered mental status and hypotension
- ascending cholangiitis (infection of biliary tract as result of obstruction, leads to invasion of bacteria from duodenum)
- is very similar to choledocholithiasis, but will have positive blood cultures for E. Coli, Klebsiella, or Enterococcus
what are the top 2 causes of pancreatitis?
- alcoholism
2. gallstones
RUQ pain (similar to biliary colic), nausea, but normal ultrasound of gallbladder (no stones, sludge, microlithiasis, wall thickening or dilation)
biliary dyskinesia
- consider Rome III dx criteria for functional gallbladder
HIDA scan (radionucleotide scan - nuclear medicine Technetium Tc99m) what are normal and abnormal findings?
- normal: gallbladder visualized within 1 hour of injection, tracer also seen in small bowel
- abnormal: GB NOT seen -> stone in cystic duct of cholecystitis
cholecystokinin stimulated hepatobiliary iminodiacetic scan (CCK-HIDA)
- what is considered abnormal and warrants cholecystectomy?
an ejection fraction of less than 35-38% (should be much high with presence of CCK)
what is a porcelain gallbladder?
chronic inflammation shows an incidental calcified lesion
- most likely seen on plain X-ray
what is courvoisier’s gallbladder?
enlarged, palpable non-tender gallbladder with jaundice
- associated with cancer of the head of the pancreas
heavy alcohol use
- biliary tract: gallstones <5mm
- epigastric abdominal pain: constant, **boring”” pain straight through to the back
- edema/anasarca (d/t THIRD spacing)
- positive Cullen or Grey Turner sign
- LIPASE 3X above normal
- CT changes consistent with pancreatitis
acute pancreatitis
plain radiograph shows:
- calcified gallstones
- sentinel loop
- colon cutoff sign (gas filled segment of transverse colon abruptly ending at the area of pancreatic inflammation)
acute pancreatitis
when should a rapid bolus IV contract-enhanced CT be avoided in acute pancreatitis?
if pt has kidney issues! (serum Creatinine >1.5 mg/dL)
3 or more of the following predict a severe course complicated by pancreatic necrosis with sensitivity of 60-80%
- over 55 y/o
- WBC > 16x10^3
- blood glucose >200
- serum lactate DH >350
- aspartate aminotransferase (250)
Ranson criteria
what is the most important treatment of acute pancreatitis?
- *IV FUILDS**
- acute pancreatitis is very dehydrating (d/t third spacing)
- **1/3 of total 72 hour volume administered within 24 hours of presentation
what are the complications of acute pancreatitis?
- fluid collection (pleural effusion)
- infection (needs to be removed)
- pseudocysts
- ARDS
what does a sentinel loop of bowel often signal?
the presence of an adjacent irritative/inflammatory process -> acute pancreatitis
colon cut-off sign, Cvostek and Trousseas signs (for hypocalcemia) seen in what?
acute pancreatitis
bilateral diffuse fluffy infiltrates
- normal cardiac size
- complication of acute pancreatitis
ARDS
what is the most frequent cause of clinically apparent chronic pancreatitis?
alcoholism
first event initiates an inflammatory process that results in injury and later fibrosis
SAPE (sentinel acute pancreatitis event)
- *PAIN** is cardinal symptom
- steatorrhea
- hx of alcohol abuse
- elevated lipase
- decreased fecal ELASTASE (<100mcg)
chronic pancreatitis
what is the TIGAR-O mnemonic?
- used for chronic pancreatitis
- toxic-metabolic (alcoholic)
- idiopathic
- genetic
- autoimmune (IgG4 hypergammaglobulinemia)
- recurrent
- obstructive
what is the treatment for acute pancreatitis?
supportive
- pain control, but avoid opioids if possible
- low fat diet, NO ALCOHOL
what are complications of chronic pancreatitis?
- brittle diabetes mellitus (over 80% develop DM within 25 years after onset of chronic pancreatitis)
- pancreatic cancer (main cause of death)
what is the main pancreatic function test McGowan wants us to know?
- *fecal elastase**
- will be low in pancreatic insufficiency (<100mcg/gram stool)
pt presents with PAINLESS JAUNDICE
- or they have mild-epigastric pain that radiates to the back, hurts the most at night laying down, relieved with bending forward
- elevated CA 19-9 (>100 is highly specific for pancreatic malignancy!)
- Trousseau sign of malignancy (different than test for hypocalcemia, this one is recurrent vessel inflammation that occurs sporadically over body)
pancreatic cancer
coffee ground emesis, hematemesis, melena, or hematochezia
- EDG with biopsy (to exclude malignancy)
- detection of H. pylori via fecal antigen test
PUD
burning gnawing epigastric pain
- 60 min-3 hours after meal
- nocturnal
- relieved by food
duodenal ulcer (up to 95% caused by H. pylori!) - gastric acid HYPERsecretion
can be asymptomatic
- burning pain worse with food -> food aversion
- nausea/anorexia
- need to perform endoscopy with biopsy to rule out malignancy
gastric ulcer
- chronic NSAID use is risk factor
- H. pylori in up to 75%
- gastric acid secretory rates usually normal or reduced
pneumoperitoneum (below diaphragm) and pneumomediastinum (above diaphragm) are two types of what?
perforated viscus
- can happen in PUD, or with any hollow organ
