General surgery (3) (Common conditions) Flashcards
pancreatitis
Inflammation of the pancreas. Can be acute or chronic
acute pancreatitis vs chronic pancreatitis presentation
- Acute – presents with a rapid onset of inflammation and symptoms. Function returns to normal after
- Chronic pancreatitis- involves longer term inflammation and symptoms with a. progressive and permanent deterioration in pancreatic function
main causes of acute pancreatitis
-
Gallstones
- Gallstone stuck in ampulla of vater, blocking flow of bile and pancreatic juice into the duodenum
- Reflux of bile in pancreatic duct and prevention of pancreatic juice enzymes being secreted results in inflammation in the pancreas
-
Alcohol
- Directly toxic to pancreatic cells, resulting in inflammation
- Post-ERCP
longer list of causes of pancreatitis
I GET SMASHED is a popular mnemonic for remembering a long list of causes of pancreatitis:
- I – Idiopathic
- G – Gallstones
- E – Ethanol (alcohol consumption)
- T – Trauma
- S – Steroids
- M – Mumps
- A – Autoimmune
- S – Scorpion sting (the one everyone remembers)
- H – Hyperlipidaemia
- E – ERCP
- D – Drugs (furosemide, thiazide diuretics and azathioprine)
risk factors of acute pancreatitis
- Gallstone pancreatitis- women and older patients
- Alcohol induce- more common in men and younger patients
presentation of acute pancreatitis
- Severe epigastric pain
- Radiating through to the back
- Associated vomiting
- Abdominal tenderness
- Systemically unwell (e.g., low-grade fever and tachycardia)
investigations for acute pancreatitis
- Initial investigations for any acute abdomen
- FBC (for white cell count)
- U&E (for urea)
- LFT (for transaminases and albumin
- Calcium
- ABG (for PaO2 and blood glucose)
- Specific
- AMYLASE (raised x3 (may not rise in chronic))
- CRP
- US- gallstones
- CT abdomen abdomen- complications of pancreatitis
scoring system for severity of pancreatitis
glasgow score
glasgow score
- 0 or 1 – mild pancreatitis
- 2 – moderate pancreatitis
- 3 or more – severe pancreatitis
The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer):
- P – Pa02 < 8 KPa
- A – Age > 55
- N – Neutrophils (WBC > 15)
- C – Calcium < 2
- R – uRea >16
- E – Enzymes (LDH > 600 or AST/ALT >200)
- A – Albumin < 32
- S – Sugar (Glucose >10)
management of acute pancreatitis
Mod to severe cases should be considered for management on ICU= pt may deteriorate rapidly
- Initial resuscitation (ABCDE approach)
- IV fluids
- Nil by mouth
- Analgesia
- Careful monitoring
- Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
- Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
- Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
key complications fo acute pancreatitis
- Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis
- Necrotic area
- Abscess formation
- Acute peripancreatic fluid collections
- Chronic pancreatitis
pancreatic necoriss
Ongoing inflammation eventually leads to ischaemic infarction of the pancreatic tissue, hence such progression should be suspected in patients with evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis.
Any suspected pancreatic necrosis should be confirmed by CT imaging and treatment will often warrant pancreatic necrosectomy (open or endoscopic)*.
Pancreatic necrosis is prone to infection and should be suspected if there is a clinical deterioration in the patient associated with raised infection markers (or from positive blood culture or changes of low density within the pancreas on CT). Definitive diagnosis of infected pancreatic necrosis can be confirmed by a fine needle aspiration of the necrosis.
*General consensus for intervention in cases of confirmed pancreatic necrosis is to be delayed until walled-off necrosis has developed, typically 3-5 weeks after the onset of symptoms
pancreatic pseudocyst
A pancreatic pseudocyst is a collection of fluid containing pancreatic enzymes, blood, and necrotic tissue; they can occur anywhere within or adjacent to the pancreas, however are usually seen in the lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesions..
They are typically formed weeks after the initial acute pancreatitis episode. They lack an epithelial lining, therefore termed pseudocyst, and instead have a vascular and fibrotic wall surrounding the collection.
Pseudocysts may be found incidentally on imaging or can present with symptoms of mass effect, such as biliary obstruction or gastric outlet obstruction. They are prone to haemorrhage or rupture, and can become infected.
About 50% will spontaneously resolve, hence conservative management is usually the initial treatment of choice.
- Cysts which have been present for longer than 6 weeks are unlikely to resolve spontaneously.
- Treatment options include surgical debridement or endoscopic drainage (often into the stomach).
chronic pancreatitis
Chronic pancreatitis refers to chronic inflammation in the pancreas. It results in fibrosis and reduced function of the pancreatic tissue.
causes of chronic pancreatitis
- Alcohol is the most common cause.
presentation of chronic pancreatitis
- Similar symptoms to acute pancreatitis, but generally less intense and longer-lasting.
key complications of chronic pancreatitis
- Chronic epigastric pain
- Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract
- Loss of endocrine function, resulting in a lack of insulin, leading to diabetes
- Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile
- Formation of pseudocysts or abscesses
chronic pancreatitis associated with
diabetes due to loss of endocrine function
management of chronic pancreatitis
- Conservative
- Quit alcohol; and smoking
- Analgesia for pain
- Replacement of pancreatic enzymes (Creon)
- If loss of pancreatic enzyme e.g. lipase- malabsorption of fat causing steatorrhea and deficiency in fat soluble vitamins
- Subcut insulin regimes
- ERCP with stenting (strictures and obstruction)
- Surgery to treat:
- Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue)
- Obstruction of the biliary system and pancreatic duct
- Pseudocysts
- Abscesses
why replace pancreatic enzymes (creon) in chronic pancreatitis
- If loss of pancreatic enzyme e.g. lipase- malabsorption of fat causing steatorrhea and deficiency in fat soluble vitamins
colonostomy
Colostomy
Large intestine (colon) is brought onto the skin
- Stool type: more solid due to much of the water being reabsorbed in remaining large intestine
- Flatter compared to ileostomy, as solid content less irritating to surrounding skin
- Location: left iliac fossa
Ileostomy
Where end portion of small bowel (ileum) is brought onto the skin
- Stool type: more liquid stool
- Spout- since fluid is very irritating to surrounding skin
- Location: right iliac fossa
urostomy
Creating opening from the urinary system onto the skin e.g. after cystectomy (removal of bladder)
- Ureters of the kidneys are anastomosed to an ileal conduit (created by resection a portion of the ileum)
- End of the ileal conduit exits onto the skin and urine drained into bag
- Urine can irritate skin- bag needs to fit tightly
end colostomy/end ileostomy
- Created after removal of section of bowel
- Proximal portion brought onto the skin
- Faeces drain out the end colostomy into stoma bag
- The other open end of the remaining bowel (distal part) is sutured and left in the abdomen
- May be reversed at a later date → two ends sutured together creating an anastomosis
j pouch
- J pouch- ileo-anal anastomosis
- Ileum is folded back on itself and fashioned into a larger pouch that functions like a rectum – collects stools prior to person passing a motion
Loop colostomy/loop ileostomy
- Temporary stoma used to allow distal portion of the bowel and anastomosis to heal after surgery
- Allows faces to bypass the distal, healing portion of the bowel until healed and ready to restart normal function
- Reversed 6-8 weeks later
-
Surgery
- The bowel is partially opened and folded so that there are two openings on the skin side-by-side, attached in the middle.
- “Loop” refers to it being the two ends (proximal and distal) of a section of small bowel being brought out onto the skin. The proximal end (the productive side) is turned inside out to form a spout to protect the surrounding skin. This distal end is flatter. This allows you to distinguish between the proximal and distal portions of the bowel.
causes of haemorrhoids
Enlarged anal vascular cushion
- Not clear
- Constipation
- Straining
describing haemorrhoids
The location of pathology at the anus is described as a clock face, as though the patient was in the lithotomy position (on their back with their legs raised). 12 o’clock is towards the genitals and 6 o’clock is towards the back. The anal cushions are usually located at 3, 7 and 11 o’clock.
4 clinical grades of haemorrhoid
- 1st degree: no prolapse
- 2nd degree: prolapse when straining and return on relaxing
- 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
- 4th degree: prolapsed permanently
presentation of thrombosed haemorrhoids
Thrombosed haemorrhoids appear as purplish, very tender, swollen lumps around the anus.
