Jaundice and Pancreatitis Flashcards
when is hyperbilirubinaemia and jaundice clinically detectable?
when serum bilirubin >50
describe bilirubin metabolism?
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
what conjugates bilirubin?
UGT (in the liver)
which type of jaundice causes the highest bilirubin?
post-hepatic > hepatic > pre-hepatic
causes of pre-hepatic jaundice?
haemolytic anaemia
haemolytic drugs
blood transfusion reaction
herocytosis/sickle cell
type of bilirubin in pre-hepatic jaundice?
unconjugated
causes of intrahepatic jaundice?
hepatitis malignancy cirrhosis fulminant hepatic infection anything that causes hepatocyte/biliary canaliculi damage
causes of post-hepatic jaundice?
gallstones (most common)
malignancy in pancreas/bile duct
bile duct stricture
type of bilirubin in intrahepatic?
mixed
type of bilirubin in post-hepatic?
conjugated
is the pancreas intra-peritoneal or retroperitoneal?
retro
functions of pancreas?
endocrine (produces hormones)
exocrine (produces enzymes
what is acute pancreatitis?
acute inflammatory process involving pancreas
usually painful and self limiting
can be an isolated event or recurring illness
how does pancreatitis affect function?
pancreatic function and morphology returns to normal after or in between attacks
causes of pancreatitis?
I GET SMASHED idiopathic gallstones ethanol trauma scorpion sting malignancy, mumps autoimmune steroids hypercalcaemia ERCP drugs
drugs which can cause pancreatitis?
AIDS therapy anti-inflammatories anti-microbials (metronidazole, tetracycline, nitrofurantoin) diuretics IBD drugs (sulfasalazine, mesalamine) immunosuppressives neuropsychiatrics (valproate)
what is pancreatic divisum?
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
there are 3 stages in the pathogenesis of pancreatitis, what happens in stage 1?
pancreatic injury
- pain
- oedema
- inflammation
- dehydration
what happens in stage 2?
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)
what happens in stage 3?
systemic complications (mainly due to fluid loss)
- hypotension/shock
- metabolic disturbance
- sepsis/organ failure
clinical presentation of pancreatitis?
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)
diagnosis of pancreatitis?
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)
pancreatitis severity scoring system?
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)
how is ranson and glasgow used?
uses age, WBC, urea, ALT/AST, PO2, glucose, albumin, calcium
1 = mild
2 = mod
3 = severe
systemic complications of pancreatitis?
shock AKI organ failure (liver) ARDS DIC
local complications?
fluid collections (pseudocysts, pseudoaneurysms)
necrosis
abscess
regional complications?
obstruction
early complications (<2 weeks)?
systemic ones
necrosis
late complications (>2 weeks)?
pseudocysts
pseudoaneurysm
treatment of mild pancreatitis?
fluid resuscitation = most important pancreatic rest (oral free fluid) supportive care (pain management etc) observations and urine output
when can you start eating solid foods again in pancreatitis?
3-7 days after
ensure bowel sounds are present and the patient is hungry and pain free
how is severe pancreatitis managed?
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
true or false, most pancreatitis is mild and will respond to conservative treatment (fluids and pain control)?
true
should still always look for the cause
normal urine and stools with jaundice?
pre-hepatic
dark urine and normal stools with jaundice?
intra-hepatic
dark urine and pale stools with jaundice?
post-hepatic jaundice
causes of unconjugated jaundice?
haemolysis
impaired hepatic uptake (drugs, heart failure)
impaired conjugation (eg gilberts syndrome)
causes of conjugated jaundice/
hepatocellular injury
cholestasis
hepatic vs cholestatic LFTs?
hepatic = AST and ALT cholestatic = ALP and GGT
what is charcots triad?
fever
RUQ pain
jaundice
classic features of biliary colic?
fat, female, 40s, fertile
colickly RUQ pain worse after heavy or fatty meals
diagnosis of billiary colic?
US
management of biliary colic?
laparoscopic cholecystectomy if found within 72 hrs
elective cholecystectomy if after 72 hrs
