Full of bile Flashcards
What might be causing upper abdominal pain?
Hepatitis Hepatic congestion Pancreatitis Biliary pain Sub diaphragmatic abscess Function pain Splenic abscess or infarct Cardiac (Myocarditis, ischaemia) Pneumonia
What aspects should you consider when assessing abdominal pain?
Onset - suddenly or more gradual
Progression - increased, decreased, stayed the same, changed in character, absent then present again
Migration - has the pain moved from original location
Character - clarify exactly the kind of pain e.g. cramping
Intensity - how the patient reacts to pain
Localisation - indicate the site of pain while standing and in the prone position to be certain of true location
What might sudden, rapid or gradual onset of pain suggest?
Sudden onset of pain - perforation of the GI tract from a gastric or duodenal ulcer, a colonic diverticulum or a foreign body, ectopic pregnancy, ruptured aortic aneurysm or embolism of an abdo vessel.
Rapid onset of pain - begins within a few seconds and steadily increases over minutes. Could suggest pancreatitis, intestinal obstruction, diverticulitis and appendicitis.
Gradual onset of pain - becomes more severe over a number of hours or even days. Could suggest neoplasms, chronic inflammatory processes or large bowel obstructions.
How do visceral and somatic pain differ in their presentation?
Visceral pain resulting from the stretching of smooth muscle is often localised in the three midline zone of the abdomen so the epigastric, umbilical and supra pubic regions. This type of pain is poorly localised and covers many body segments. It can also be a dull or cramping like pain. Nausea, vomiting, pallor and sweating are commonly associated with visceral pain.
Somatic pain is well localised and often intensified by deep inspiration or pressure on the abdominal wall.
What is abdominal pain?
Abdominal pain refers to discomfort in the space between the chest and the pelvis. Most cases of abdo pain are mild and have a variety of common causes, such as indigestion or muscle strain.
How to assess abdominal pain by examination?
Palpate the area by applying pressure with your fingers, feeling for rigidity, guarding, masses or spasms.
Assess the location by using the 4 quadrants or 9 divisions.
Assess for asymmetry, scars, fullness of the abdomen and any pulsations (AAA).
Consider their general appearance: acute/chronic? look healthy? look malnourished? how are their positioning themselves?
Assess any associated conditions: nausea, vomiting, difficulty urinating or passing stools.
Assess recent events: travelling, menstrual cycle, pregnancy, UTIs
Assess past medical history: look for abdo surgery, cholecystitis, diverticulitis, IBD, Crohn’s, Appendicitis, Diabetes, pregnancy
Assess bowel sounds: silent (paralytic/surgical bowel), hyperactive peristalsis (diarrhoea), murmur (aortic aneurysms, artery stenosis)
How to distinguish between GI and CVS causes of abdominal pain?
GI causes tend to be associated with pain accompanied by diarrhoea, bloating, cramping, constipation. These signs are unlikely to be seen with respiratory/CVS causes.
It is possible for certain cardiac conditions to cause pain in the abdomen, especially in diabetic patients and women.
Important to take accurate history and also assess other symptoms when considering the cause.
What does the gallbladder do?
Bile is made in the liver and then travels down the main bile duct to be stored in the gallbladder as reservoir. During eating, the gallbladder contracts and the stored bile empties in the duodenum via ampulla of Vater. Bile contains various substance including bile pigments, cholesterol and lecithin.
What causes gallstones to form?
An imbalance in the chemical composition of bile which leads to the formation of crystals.
OR if the patient’s gallbladder doesn’t function correctly. Therefore, it can’t empty completely or often enough meaning the bile becomes abnormally concentration and contributes to the formation of the gallstones.
What are the two major chemical imbalances which cause gallstones to form?
- High cholesterol levels that cannot be dissolved. Normally, bile contains enough chemicals to dissolve cholesterol excreted by your liver but if the liver excretes more cholesterol that the bile can dissolve there is an excess. This is common and produces gallstone that are yellow in colour.
- High bilirubin levels, which is a waste product of RBC breakdown. Certain conditions cause the liver to produce too much bilirubin. These include liver cirrhosis, biliary tract infections and certain blood disorders. It’s less common but produces gallstones that are brown/black in colour.
What are the risk factors for gallstones?
Female (particularly patients that have had children, are taking the combined oral contraceptive pill or are undergoing high dose oestrogen therapy) Overweight or obese 40 years or older Have a condition that affects the flow of bile (Cirrhosis) Have Crohn’s disease or IBS Previous family history Recent fast weight loss Are taking Ceftriaxone
What are the symptoms of gallstones?
Most cases are asymptomatic
Biliary colic: sudden, severe abdo pain which can last from anywhere between one or five hours. The pain can be felt in the umbilical region or in the right hypochondriac region and may be felt as referred pain the shoulder.
It can occur in episodes, with weeks or months passing in between each one.
If it causes obstruction or moves to another organ: high temp, more persistent pain, tachycardia, jaundice, itchy skin, diarrhoea, chills/shivering, confusion or loss of appetite.
How to diagnose gallstones?
May be difficult if the patient is asymptomatic
Murphy’s Sign Test (Place hand on the upper right area of the patient’s stomach and ask them to breathe in. If this is painful - inflamed gallbladder)
Blood Tests (Useful for checking for infection or abnormal liver function)
Ultrasound scan (Used to confirm the presence of gallstones. It can’t tell you for certain if any have passed into the bile duct)
Cholangiography (A dye injected into the bloodstream or the bile ducts or using an endoscope. After the dye has been introduced, X ray images will be taken to identify if there are any abnormalities in the bile or pancreatic systems)
CT Scan (Look for any complications of gallstones such as acute pancreatitis).
What are the potential complications of gallstones?
Acute cholecystitis - infection of gallbladder with pain lasting longer than 5 hours. It can lead to gallbladder abscess or peritonitis
Jaundice - this is caused by a blocked bile duct. Leads to yellowing of the skin and eyes, dark brown urine, pale stools and itching.
Acute cholangitis - an infection of the bile duct. It can lead to pain, high temp, jaundice, chills, confusion and itchy skin.
Acute pancreatitis - an infection of the pancreas. Leads to a sudden dull ache with sickness, diarrhoea, loss of appetite, high temp and jaundice.
Cancer of the gallbladder - rare but there is an increased risk. Symptoms include abdominal pain, high temp and jaundice.
Gallstones Ileus - a rare bowel obstruction via a fistula. There is a risk of rupture. It causes pain, sickness, abdominal swelling and constipation.
How would you treat gallstones?
Asymptomatic = Active Monitoring
Mild and infrequent episodes of biliary colic = Prescribed painkillers and healthy eating advice.
Severe and frequent episodes of biliary colic = Gallbladder removal through laparoscopic cholecystectomy or an open cholecystectomy. It’s also possible to use an endoscopic retrograde cholangio – pancreatography.
Ursodeoxycholic acid tablets are rarely used because they take a long time to work and the gallstones can reoccur.
How does acute pancreatitis present?
Condition where the pancreas becomes inflamed over a short period of time, with symptoms such as sudden pain felt in the epigastric region, nausea with or without vomiting, diarrhoea as well as a high temp. Patients can also present with hypotension, which in severe cases can cause shock.
Patients tend to feel better within a week and have no further problems.
What is chronic pancreatitis?
Condition where the pancreas has become permanently damaged from inflammation and therefore stops working properly. Patients have usually had multiple previous acute pancreatitis attacks.
Repeated episodes of burning or shooting severe pain the abdomen, usually in the centre and moving towards the left-hand side into the back.
Can have a constant dull ache between episodes.
Tends to affect patients (men more than women) in their 30s/40s who are heavy drinkers.
What are the causes of pancreatitis?
Gallstones and excessive alcohol intake are the most common causes of pancreatitis.
Others examples include drugs, hyperglycaemia, pancreas divisium and viral infection.
Many cases are also idiopathic.
What’s the link between alcohol and pancreatitis?
The more a patient drinks, the more likely they are to have recurrent acute episodes eventually leading to permanent scarring.
One theory is that the enzymes from the alcohol interact with the pancreatic cells to prevent them from functioning correctly. It is also exacerbated by smoking, as the contents of cigarette smoke increases the effects of the alcohol on the pancreas.
What is the pathogenesis behind pancreatitis?
Occurs due to injury to the pancreas leading to the release and activation of digestive enzymes which cause necrosis of the pancreatic tissue. Exudation of the plasma into the retroperitoneal spaces around the pancreas can lead to decreased intravascular volume as well as cardiovascular instability. It can also cause obstruction of the intestines due to paralysis of the intestinal muscle from extensive inflammation occurring near the bowel.
With chronic pancreatitis, this recurrent chronic inflammation leads to the replacement of the functional pancreatic tissue with fibrous scar tissue.
How would you treat acute pancreatitis?
Initial treatment: Resuscitation with IV fluids, supplemental oxygen, pain relief, antibiotics for treatment of any associated infections, early nutritional support.
Initial investigations: Lipase or amylase levels (raised), Imaging techniques (CT scans, MRI, ultrasonography).
Pancreatitis caused by gallstones: Endoscopic retrograde cholangiopancreatography and/or Cholecystectomy
How would you treat chronic pancreatitis?
Investigations: blood tests (liver function tests may be abnormal if there is coexistent liver disease or compression of the intra pancreatic bile duct), abdominal ultrasonography in order to exclude other conditions such as gallstones, identify signs of chronic pancreatitis such as pancreatic calcification.
Treated by a specialist but also given lifestyle advice, adequate pain relief, screening for diabetes/osteoporosis.
