EOR GI part 10- acute pancreatitis Flashcards
What are the big 4 RFs for cholelithiasis?
Female
Fat
Forty
Fertile (multiparity)
What are the types of gallstones?
Cholesterol (75%)
Pigment (25%)
What are the types of pigmented gallstones?
Black stones (contain calcium bilirubinate) Brown stones (associated with biliary tract infection)
What are the causes of black pigmented stones?
Cirrhosis
Hemolysis
What is the pathogenesis of cholesterol stones?
Secretion of bile supersaturated with cholesterol
Then, cholesterol precipitates out and forms solid crystals, then gallstones
S/sx of cholelithiasis
Biliary colic cholangitis Choledocholithiasis Gallstone Pancreatitis
What percentage of pts with gallstones are asympmtomatic?
80% of pts with cholelithiasis are asymptomatic
What is thought to cause biliary colic?
Gallbladder contraction against a stone temporarily at the gallbladder/cystic duct junction
A stone in the cystic duct
A stone passing through the cystic duct
What are the five major complications of gallstones?
Acute cholecystitis Choledocholithiasis Gallstone pancreatitis Gallstone ileus Cholangitis
How is cholelithiasis diagnosed?
Hx
PE
U/s
How often does u/s detect choledocholithiasis?
~33% of the time, not a very good study for it
How are symptomatic or complicated cases of cholilithiasis treated?
Cholecystectomy
What are the possible complications of a lap chole?
Common bile duct injury
Right hepatic duct/artery injury
Cystic duct leak
Biloma (collection of bile)
What are the indications for cholecystectomy in the asymptomatic pt?
Sickle-cell dz
Calcified gallbladder (porcelain gallbladder)
Pt is a child
What is the management of choledocholithiasis?
ERCP with papillotomy and basket/balloon retrieval of stones
Laparoscopic transcystic duct or trans common bile duct retrieval
Open common bile duct exploration
What medication may dissolve a cholesterol gallstone?
Chenodeoxycholic acid, ursodeoxycholic acid
But, if meds are stopped, gallstones often recur?
Whatis the major feared complication of ERCP?
Pancreatitis
Pathogenesis of acute cholecystitis
Obstruction of cystic duct leads to inflammation of the gallbladder
~95% of cases result from calculi
~5% from acalculous obstruction
RFs for acute cholecystitis
Gallstones
S/sx of acute cholecystitis
Unrelenting RUQ pain or tenderness Fever N/V Painful palpable gallbladder in 33% Pos Murphy's sign R subscapular pain (referred) Epigastric discomfort (referred)
What is Murphy’s sign?
Acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration
Complications of acute cholecystitis
Abscess Perforation Choledocholithiasis Cholecystenteric fistula formation Gallstone ileus
What lab results are associated with acute cholecystitis?
Increased WBC
May have:
Slight elevation in alkaline phosphatase, LFTs
Slight elevation in amylase, total bilirubin
What are the signs of acute cholecystitis on ultrasound?
Thickened gallbladder wall (>3 mm) Pericholecystic fluid Distended gallbladder Gallstones present/cystic duct stone Sonographic Murphy's sign
What is the difference between acute cholecystitis and biliary colic?
Biliary colic has temporary pain
Acute cholecystitis has pain that does not resolve, usually with elevated WBCs, fever, and signs of acute inflammation on u/s
Tx of acute cholecystitis
IVFs
Abx
Early chole
What is cholangitis?
Bacterial infection of the biliary tract from obstruction
Common causes of cholangitis
Choledocholithiasis Stricture (usually postop) Neoplasm (usually ampullary carcinoma) Extrinsic compression (pancreatic pseudocyst/pancreatitis) Instrumentation of the bile ducts Biliary stent
What is the MCC of cholangitis?
Gallstones in common bile duct (choledocholithiasis)
S/sx of cholangitis
Charcot’s triad:
Fever/chills
RUQ pain
Jaundice
What is Reynold’s pentad?
Charcot’s triad plus:
Mental status changes
Shock
Which organisms are commonly associated with cholangitis?
Gram-neg organisms (E. coli, Klebsiella, Pseudomonas, Enterobacter, Proteus, Serratia) are the most common
Diagnostic tests of choice for cholangitis
Ultrasound and contrast study (e.g. ERCP or IOC) after pt has “cooled off” with IV abx
What is suppurative cholangitis?
Severe infection with sepsis
Management of cholangitis
Nonsuppurative: IVF and abx, with definitive tx later
Suppurative: IVF, abx, and decompression can be obtained with ERCP with papillotomy, PTC with cath drainage, or laparotomy with T-tube placement
What are the MC etiologies of acute pancreatitis in the US?
EtOH abuse (50%)
Gallstones (30%)
Idiopathic (10%)
Sx of acute pancreatitis
Epigastric pain (frequently radiates to the back) Nausea and vomiting
Signs of acute pancreatitis
Epigastric tenderness Diffuse abdominal tenderness Decreased bowel sounds (adynamic ileus) Fever Dehydration/shock
What lab tests should be ordered for acute pancreatitis?
Amylase/lipase
What are the associated diagnostic findings for acute pancreatitis?
Lab- High amylase, high lipase, high WBC
AXR- sentinel loop, colon cutoff, possibly gallstones
U/s- phlegmon, cholelithiasis
CT- phlegmon, pancreatic necrosis
What is the MC sign of acute pancreatitis on AXR?
Sentinel loop(s)
Tx of acute pancreatitis
NPO IVF NGT if vomiting Postpyloric tube feeds H2 blocker/PPI Analgesia (not morphine) Correction of coags/electrolytes \+/- alcohol withdrawal prophylaxis "Tincture of time"
Possible complications of acute pancreatitis
Pseudocyst Abscess/infection Pancreatic necrosis Splenic/mesenteric/portal vessel rupture or thrombosis Pancreatic ascites/pancreatic pleural effusion Diabetes ARDS/sepsis/MOF Coagulopathy/DIC Encephalopathy Severe hypocalcemia
Prognosis of acute pancreatitis
Based on Ranson’s criteria
Are postpyloric tube feeds safe in acute pancreatitis?
Yes
What are Ranson’s criteria for acute pancreatitis at presentation?
Age >55 WBC >16,000 Glucose >200 AST >250 LDH >350
What are Ranson’s criteria for acute pancreatitis during the intial 48 hrs?
Base deficit >4 BUN increase >5 mg/dL Fluid sequestration >6 L Serum Ca <8 Hct decrease >10% PO2 (ABG) <60 mm Hg
What is the etiology of hypocalcemia with pancreatitis?
Fat saponification: fat necrosis binds to calcium
What complication is associated with splenic vein thrombosis?
Gastric varices (tx with splenectomy)
Can TPN with lipids be given to a pt with pancreatitis?
Yes, if the pt does not suffer from hyperlipidemia (triglycerides >300)
What is the least common cause of acute pancreatitis?
Scorpion bite
