Jaundice and Pancreatitis

Question 1

when is hyperbilirubinaemia and jaundice clinically detectable?

Answer 1

when serum bilirubin >50

Question 2

describe bilirubin metabolism?

Answer 2

heme > biliverdin > unconjugated bilirubin > conjugated bilirubin > bile > urobilinogen > stercobilin
urobilinogen in intestine either goes back to liver or excreted via kidney
stercobilin excreted in faeces

Question 3

what conjugates bilirubin?

Answer 3

UGT (in the liver)

Question 4

which type of jaundice causes the highest bilirubin?

Answer 4

post-hepatic > hepatic > pre-hepatic

Question 5

causes of pre-hepatic jaundice?

Answer 5

haemolytic anaemia
haemolytic drugs
blood transfusion reaction
herocytosis/sickle cell

Question 6

type of bilirubin in pre-hepatic jaundice?

Answer 6

unconjugated

Question 7

causes of intrahepatic jaundice?

Answer 7

hepatitis
malignancy
cirrhosis
fulminant hepatic infection
anything that causes hepatocyte/biliary canaliculi damage

Question 8

causes of post-hepatic jaundice?

Answer 8

gallstones (most common)
malignancy in pancreas/bile duct
bile duct stricture

Question 9

type of bilirubin in intrahepatic?

Answer 9

mixed

Question 10

type of bilirubin in post-hepatic?

Answer 10

conjugated

Question 11

is the pancreas intra-peritoneal or retroperitoneal?

Answer 11

retro

Question 12

functions of pancreas?

Answer 12

endocrine (produces hormones)

exocrine (produces enzymes

Question 13

what is acute pancreatitis?

Answer 13

acute inflammatory process involving pancreas
usually painful and self limiting
can be an isolated event or recurring illness

Question 14

how does pancreatitis affect function?

Answer 14

pancreatic function and morphology returns to normal after or in between attacks

Question 15

causes of pancreatitis?

Answer 15

I GET SMASHED
idiopathic
gallstones
ethanol
trauma
scorpion sting
malignancy, mumps
autoimmune
steroids
hypercalcaemia 
ERCP
drugs

Question 16

drugs which can cause pancreatitis?

Answer 16

AIDS therapy
anti-inflammatories 
anti-microbials (metronidazole, tetracycline, nitrofurantoin)
diuretics
IBD drugs (sulfasalazine, mesalamine)
immunosuppressives 
neuropsychiatrics (valproate)

Question 17

what is pancreatic divisum?

Answer 17

congenital anomaly in the anatomy of the pancreas where the two pancreatic ducts dont become one and remain as 2 distinct dorsal and ventral ducts
ducts are constitutionally small causing increased chance of blockage > enzymes can go back up duct and autodigest the pancreas causing pancreatitis

Question 18

there are 3 stages in the pathogenesis of pancreatitis, what happens in stage 1?

Answer 18

pancreatic injury

• pain
• oedema
• inflammation
• dehydration

Question 19

what happens in stage 2?

Answer 19

local effects

• retroperitoneal oedema (fluid escapes and goes into retroperitoneal space, patient becomes dehydrated)
• ileus (bowel close to the pancreas looses function and stops moving)

Question 20

what happens in stage 3?

Answer 20

systemic complications (mainly due to fluid loss)

• hypotension/shock
• metabolic disturbance
• sepsis/organ failure

Question 21

clinical presentation of pancreatitis?

Answer 21

abdominal pain (epigastric, radiating to back, worse in supine position)
nausea and vomiting
fever (not due to infection, just inflammatory response so dont need antibiotics)

Question 22

diagnosis of pancreatitis?

Answer 22

clinical signs (cullen and grey turner sign due to inflammation eroding into nearby blood vessels)
lab tests (elevated serum amylase >3x normal, do urinary amylase if serum normal but high suspicion) 
radiology (everyone gets an US, some get CT too)

Question 23

pancreatitis severity scoring system?

Answer 23

APACHE (only useful in first 24 hrs)
Ranson and Glasgow criteria (24-48 hrs, not used much these days)
CT severity index (much better diagnostic and predictive tool)

Question 24

how is ranson and glasgow used?

Answer 24

uses age, WBC, urea, ALT/AST, PO2, glucose, albumin, calcium
1 = mild
2 = mod
3 = severe

Question 25

systemic complications of pancreatitis?

Answer 25

``` shock AKI organ failure (liver) ARDS DIC ```

Question 26

local complications?

Answer 26

fluid collections (pseudocysts, pseudoaneurysms) necrosis abscess

Question 27

regional complications?

Answer 27

obstruction

Question 28

early complications (<2 weeks)?

Answer 28

systemic ones | necrosis

Question 29

late complications (>2 weeks)?

Answer 29

pseudocysts | pseudoaneurysm

Question 30

treatment of mild pancreatitis?

Answer 30

``` fluid resuscitation = most important pancreatic rest (oral free fluid) supportive care (pain management etc) observations and urine output ```

Question 31

when can you start eating solid foods again in pancreatitis?

Answer 31

3-7 days after | ensure bowel sounds are present and the patient is hungry and pain free

Question 32

how is severe pancreatitis managed?

Answer 32

``` pancreatic rest and supportive care fluid recuscitation pulmonary and renal monitoring pain control correct electrolyte derangements rule out necrosis (contrast CT) prophylactic antibiotics if necrosis present surgical drainage if infected TPN or enteric nutritional support ```

Question 33

true or false, most pancreatitis is mild and will respond to conservative treatment (fluids and pain control)?

Answer 33

true | should still always look for the cause

Question 34

normal urine and stools with jaundice?

Answer 34

pre-hepatic

Question 35

dark urine and normal stools with jaundice?

Answer 35

intra-hepatic

Question 36

dark urine and pale stools with jaundice?

Answer 36

post-hepatic jaundice

Question 37

causes of unconjugated jaundice?

Answer 37

haemolysis impaired hepatic uptake (drugs, heart failure) impaired conjugation (eg gilberts syndrome)

Question 38

causes of conjugated jaundice/

Answer 38

hepatocellular injury | cholestasis

Question 39

hepatic vs cholestatic LFTs?

Answer 39

``` hepatic = AST and ALT cholestatic = ALP and GGT ```

Question 40

what is charcots triad?

Answer 40

fever RUQ pain jaundice

Question 41

classic features of biliary colic?

Answer 41

fat, female, 40s, fertile | colickly RUQ pain worse after heavy or fatty meals

Question 42

diagnosis of billiary colic?

Answer 42

US

Question 43

management of biliary colic?

Answer 43

laparoscopic cholecystectomy if found within 72 hrs | elective cholecystectomy if after 72 hrs