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Surgery Rotation > EOR GI part 10- acute pancreatitis > Flashcards

EOR GI part 10- acute pancreatitis Flashcards

1
Q

What are the big 4 RFs for cholelithiasis?

A

Female
Fat
Forty
Fertile (multiparity)

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2
Q

What are the types of gallstones?

A

Cholesterol (75%)

Pigment (25%)

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3
Q

What are the types of pigmented gallstones?

A 
Black stones (contain calcium bilirubinate)
Brown stones (associated with biliary tract infection)
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4
Q

What are the causes of black pigmented stones?

A

Cirrhosis

Hemolysis

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5
Q

What is the pathogenesis of cholesterol stones?

A

Secretion of bile supersaturated with cholesterol

Then, cholesterol precipitates out and forms solid crystals, then gallstones

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6
Q

S/sx of cholelithiasis

A 
Biliary colic
cholangitis
Choledocholithiasis
Gallstone
Pancreatitis
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7
Q

What percentage of pts with gallstones are asympmtomatic?

A

80% of pts with cholelithiasis are asymptomatic

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8
Q

What is thought to cause biliary colic?

A

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

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9
Q

What are the five major complications of gallstones?

A 
Acute cholecystitis
Choledocholithiasis
Gallstone pancreatitis
Gallstone ileus
Cholangitis
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10
Q

How is cholelithiasis diagnosed?

A

Hx
PE
U/s

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11
Q

How often does u/s detect choledocholithiasis?

A

~33% of the time, not a very good study for it

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12
Q

How are symptomatic or complicated cases of cholilithiasis treated?

A

Cholecystectomy

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13
Q

What are the possible complications of a lap chole?

A

Common bile duct injury
Right hepatic duct/artery injury
Cystic duct leak
Biloma (collection of bile)

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14
Q

What are the indications for cholecystectomy in the asymptomatic pt?

A

Sickle-cell dz
Calcified gallbladder (porcelain gallbladder)
Pt is a child

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15
Q

What is the management of choledocholithiasis?

A

ERCP with papillotomy and basket/balloon retrieval of stones
Laparoscopic transcystic duct or trans common bile duct retrieval
Open common bile duct exploration

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16
Q

What medication may dissolve a cholesterol gallstone?

A

Chenodeoxycholic acid, ursodeoxycholic acid

But, if meds are stopped, gallstones often recur?

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17
Q

Whatis the major feared complication of ERCP?

A

Pancreatitis

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18
Q

Pathogenesis of acute cholecystitis

A

Obstruction of cystic duct leads to inflammation of the gallbladder
~95% of cases result from calculi
~5% from acalculous obstruction

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19
Q

RFs for acute cholecystitis

A

Gallstones

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20
Q

S/sx of acute cholecystitis

A 
Unrelenting RUQ pain or tenderness
Fever
N/V
Painful palpable gallbladder in 33%
Pos Murphy's sign
R subscapular pain (referred)
Epigastric discomfort (referred)
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21
Q

What is Murphy’s sign?

A

Acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration

22
Q

Complications of acute cholecystitis

A 
Abscess
Perforation
Choledocholithiasis
Cholecystenteric fistula formation
Gallstone ileus
23
Q

What lab results are associated with acute cholecystitis?

A

Increased WBC
May have:
Slight elevation in alkaline phosphatase, LFTs
Slight elevation in amylase, total bilirubin

24
Q

What are the signs of acute cholecystitis on ultrasound?

A 
Thickened gallbladder wall (>3 mm)
Pericholecystic fluid
Distended gallbladder
Gallstones present/cystic duct stone
Sonographic Murphy's sign
25
Q

What is the difference between acute cholecystitis and biliary colic?

A

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

26
Q

Tx of acute cholecystitis

A

IVFs
Abx
Early chole

27
Q

What is cholangitis?

A

Bacterial infection of the biliary tract from obstruction

28
Q

Common causes of cholangitis

A 
Choledocholithiasis
Stricture (usually postop)
Neoplasm (usually ampullary carcinoma)
Extrinsic compression (pancreatic pseudocyst/pancreatitis)
Instrumentation of the bile ducts
Biliary stent
29
Q

What is the MCC of cholangitis?

A

Gallstones in common bile duct (choledocholithiasis)

30
Q

S/sx of cholangitis

A

Charcot’s triad:
Fever/chills
RUQ pain
Jaundice

31
Q

What is Reynold’s pentad?

A

Charcot’s triad plus:
Mental status changes
Shock

32
Q

Which organisms are commonly associated with cholangitis?

A

Gram-neg organisms (E. coli, Klebsiella, Pseudomonas, Enterobacter, Proteus, Serratia) are the most common

33
Q

Diagnostic tests of choice for cholangitis

A

Ultrasound and contrast study (e.g. ERCP or IOC) after pt has “cooled off” with IV abx

34
Q

What is suppurative cholangitis?

A

Severe infection with sepsis

35
Q

Management of cholangitis

A

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

36
Q

What are the MC etiologies of acute pancreatitis in the US?

A

EtOH abuse (50%)
Gallstones (30%)
Idiopathic (10%)

37
Q

Sx of acute pancreatitis

A 
Epigastric pain (frequently radiates to the back)
Nausea and vomiting
38
Q

Signs of acute pancreatitis

A 
Epigastric tenderness
Diffuse abdominal tenderness
Decreased bowel sounds (adynamic ileus)
Fever
Dehydration/shock
39
Q

What lab tests should be ordered for acute pancreatitis?

A

Amylase/lipase

40
Q

What are the associated diagnostic findings for acute pancreatitis?

A

Lab- High amylase, high lipase, high WBC
AXR- sentinel loop, colon cutoff, possibly gallstones
U/s- phlegmon, cholelithiasis
CT- phlegmon, pancreatic necrosis

41
Q

What is the MC sign of acute pancreatitis on AXR?

A

Sentinel loop(s)

42
Q

Tx of acute pancreatitis

A 
NPO
IVF
NGT if vomiting
Postpyloric tube feeds
H2 blocker/PPI
Analgesia (not morphine)
Correction of coags/electrolytes
\+/- alcohol withdrawal prophylaxis
"Tincture of time"
43
Q

Possible complications of acute pancreatitis

A 
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
44
Q

Prognosis of acute pancreatitis

A

Based on Ranson’s criteria

45
Q

Are postpyloric tube feeds safe in acute pancreatitis?

A

Yes

46
Q

What are Ranson’s criteria for acute pancreatitis at presentation?

A 
Age >55
WBC >16,000
Glucose >200
AST >250
LDH >350
47
Q

What are Ranson’s criteria for acute pancreatitis during the intial 48 hrs?

A 
Base deficit >4
BUN increase >5 mg/dL
Fluid sequestration >6 L
Serum Ca <8
Hct decrease >10%
PO2 (ABG) <60 mm Hg
48
Q

What is the etiology of hypocalcemia with pancreatitis?

A

Fat saponification: fat necrosis binds to calcium

49
Q

What complication is associated with splenic vein thrombosis?

A

Gastric varices (tx with splenectomy)

50
Q

Can TPN with lipids be given to a pt with pancreatitis?

A

Yes, if the pt does not suffer from hyperlipidemia (triglycerides >300)

51
Q

What is the least common cause of acute pancreatitis?

A

Scorpion bite

Surgery Rotation (19 decks)

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