HPB Flashcards
Most common causes of acute pancreatitis
I GET SMASHED
I - idiopathic
G - gallstones
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion poison
H - hypercalcaemia/hypertriglyceridemia
E - ERCP
D - drugs
Acute pancreatitis pathophysiology
Intrapancreatic activation of pancreatic enzymes → increased proteolytic and lipolytic enzyme activity → destruction of pancreatic parenchyma → attraction of inflammatory cells → release of inflammatory cytokines → acute pancreatitis
The three main sequelae of acute pancreatitis are:
Distributive shock
Pancreatic necrosis
Hypocalcaemia
Symptoms associated with acute pancreatitis
Constant, severe epigastric pain radiating towards the back.
Nausea +/- vomiting.
Fever.
Examination findings associated with acute pancreatitis
Signs of shock: tachycardia, hypotension, oliguria/anuria.
Abdominal: tenderness, distension.
Skin: Cullen sign, Grey Turner sign, Fox sign
Cullen sign
Periumbilical ecchymosis and discolouration. Associated with acute pancreatitis.
Grey Turner sign
Flank ecchymosis with discolouration. Associated with acute pancreatitis.
Fox sign
Bruising over the inguinal ligament. Associated with acute pancreatitis.
Diagnosis of acute pancreatitis is made if the patient has at least 2 of the following features:
- Characteristic abdominal pain
- Biochemical evidence of pancreatitis (serum amylase or lipase elevated more than 3 times the ULN)
- Radiographic evidence of pancreatitis on imaging
Mild acute pancreatitis is characterised by
no local or systemic complications.
Moderate acute pancreatitis is characterised by
local or systemic complications or organ failure that resolves within 48hrs.
Severe acute pancreatitis is characterised by
organ failure that persists for more than 48hrs.
Initial management of acute pancreatitis (regardless of severity) includes
Fluid administration
Analgesia
Gallstones most commonly consist of:
Cholesterol
Cholelithiasis definition
The presence of gallstones in the gallbladder
6 Fs of gallstones
Fat
Female
Fertile
Forty
Fair skinned
Family history
20/20/20 rule of gallstones
20% of the population have gallstones
20% of those people will be symptomatic
20% of those will have complications
Increased levels of oestrogen predispose to gallstone development by:
Increased secretion of bile rich in cholesterol (lithogenic bile)
Increased progesterone predisposes to gallstones by:
Smooth muscle relaxation, decreased gallbladder contraction and subsequent cholestasis
Pregnancy predisposes patients to the development of gallstones due to:
Dramatically increased oestrogen levels
Medications that increase oestrogen levels include:
OCPs, HRT
Medications that alter cholesterol metabolism and increase risk of gallstones include:
Fibrates
Transabdominal ultrasound findings for cholelithiasis include
Gallstones visualised within the gallbladder with posterior acoustic shadowing
Biliary colic definition
Constant, dull right upper quadrant pain lasting less than 6hrs caused by gallstones intermittently obstructing the neck of the gallbladder (cystic duct)
Biliary colic especially occurs:
post-prandially
Mechanism by which eating induces biliary colic onset:
CCK release following a fatty meal —> gallbladder contraction —> attempts to force stone into the cystic duct
Points of pain radiation in biliary colic
Epigastrium, right shoulder tip or back
In choledocolithiasis, LFTs often show:
Elevated ALP and bilirubin
Lifestyle changes to reduce the occurrence of biliary colic include:
Low fat diet and weight loss
Choledocolithiasis definition
Presence of gallstones in the common bile duct.
Pain associated with choledocolithiasis is usually __________ compared with uncomplicated biliary colic
more severe/prolonged, and lasting >6hrs
Signs of extrahepatic cholestasis
Jaundice, pale stools, dark urine, pruritus.
Cholestasis usually appears as a __________ picture on LFTs
Obstructive
Obstructive LFT picture:
Increased ALP and GGT with conjugated hyperbilirubinaemia.
Ultrasound findings associated with choledocolithiasis
Dilated CBD (>6mm). Presence of gallstones in the gallbladder with associated posterior acoustic shadowing.
Acute/ascending cholangitis definition
Bacterial infection of the biliary tract, typically secondary to biliary obstruction and stasis.
Acute cholangitis occurs in __% of patients with cholelithiasis
9%
Acute cholangitis pathophysiology
Biliary obstruction —> bile stasis with increased intraductal pressure —> bacterial translocation into the bile ducts —> bacterial infection ascends the biliary tract —> acute cholangitis
The most common cause of ascending cholangitis is:
Choledocolithiasis
Other causes of acute cholangitis include:
Biliary strictures, malignant obstruction (cholangiocarcinoma, pancreatic cancer), contamination of bile with intestinal contents due to manipulation of the biliary tract.
Charcot’s triad is associated with:
Ascending cholangitis
Charcot’s triad
Right upper quadrant abdominal pain, fever and jaundice
Reynold’s pentad is associated with:
Acute cholangitis
Reynold’s pentad
RUQ abdominal pain, fever, jaundice, hypotension, mental status changes
Bloods of a patient with acute cholangitis will likely show the following derangements:
Elevated CRP, leukocytosis with left shift, signs of cholestasis on LFTs (elevated GGT, ALP, ALT, hyperbilirubinaemia), possible positive blood cultures in the case of concurrent sepsis
Imaging findings for patients with ascending cholangitis include:
Dilated CBD, pneumobilia, bile duct sclerosis
Common causes of pneumobilia include
IBD and infection
Elevated ALP and GGT are associated with:
An obstructive picture.
5 Fs of gallstones
Female
Fertile
Fat
Fair
Forty
ALP and AST are _________ markers
Intrahepatic
Glasgow-Imrie Criteria
Used for severity grading of acute pancreatitis. 3 or more of the listed features in the first 48hrs indicates severe acute pancreatitis and patient may require transfer to HDU/ICU.
Mnemonic: PANCREAS
Pa02 <8KPa
Age >55
Neutrophils >15
Calcium <2mmolL
Renal function (urea>16mmolL)
Enzymes (LDH>600IU/L, AST>2000IU/L)
Albumin <32g/L
Sugar >10mmolL
