Pancreatic/Biliary Disease Flashcards by Melissa Denker

What are the ?? main types of pancreatic/biliary disease?

Gallstones

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What are the risk factors for developing gallstones? (4)

4 Fs:

Female
Fat
Forty (years old)
Fair

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What is the main symptom of gallstones?

Describe it. (5)

Biliary colic:

Acute onset
Severe
Location: RUQ/epigastrium
Steady character
Duration: 4-6 hours

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How are gallstones diagnosed?

Describe the features of gallstones on this particular procedure.

Ultrasound

Features:

Mobile
Echogenic
Shadowing

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List 4 indications for a cholecystectomy for gallstones.

Recurrent biliary colic
Cholecystitis
Pancreatitis
Cholangitis

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List 4 complications of gallstones.

Acute cholecystitis
Chronic cholecystitis
Acute pancreatitis
Ascending cholangitis/biliary sepsis

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List 4 risk factors for acute cholecystitis.

4Fs
Rapid weight loss
Pregnancy
Hormonal drugs

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Describe the clinical features of acute cholecystitis.

What are the symptoms? (5)

What are the signs? (2)

SYMPTOMS:
Pain in RUQ/epigastrium
Radiation to right shoulder
Fever
Nausea
Jaundice

SIGNS:
Positive Murphy’s sign
Deranged LFTs

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What is Murphy’s sign, and how is it elicited?

What does it indicate?

Examiner’s fingers pressed on the gallbladder. Patient asked to breathe in

Positive: pain
Negative: no pain

Positive result indicates cholecystitis

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What changes in LFTs might be caused by acute cholecystitis? (4)

Elevated ALP/AST
Elevated ASP
Mild hyperbilirubinaemia
Mild hyperamylasaemia

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Describe the features seen on ultrasound in acute cholecystitis. (4)

Gallbladder wall thickening (3+mm)
Gallstones
Gallbladder enlargement
Positive sonographic Murphy’s sign

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List 4 complications of acute cholecystitis.

Gallbladder empyema
Perforation
Gangrene
Gallstone ileus

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How would you treat acute cholecystitis? (2)

Resolves within 4 days

Antibiotics
Analgesia

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List 3 causes of cholangitis/biliary sepsis.

Gallstones
Biliary manipulation
Hepatobiliary malignancy

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Describe the symptoms of cholangitis/biliary sepsis. (8)

HINT: there are 1 groups of symptoms.

Charcot’s triad:

Fever
Jaundice
RUQ pain

Reynold’s pentad:

Fever
Jaundice
RUQ pain
Mental confusion
Septic shock

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Describe the signs on investigation found in cholangitis/biliary sepsis. (2)

Obstructive LFTs (raised ALP, bilirubin)

Positive blood cultures, especially:

Klebsiella
E. coli
Enterococcus

How would you treat cholangitis/biliary sepsis? (3)

Broad spectrum antibiotics

ERCP (endoscopic retrograde cholangio-pancreatography)

PTC (percutaneous transhepatic cholangiography)

List 11 causes of acute pancreatitis.

HINT: acronym: “I GET SMASHED”

Idiopathic
Gallstones
Ethanol
Trauma

Steroids
Mumps/malignancy
Autoimmune
Scorpion sting
Hypercalcaemia/lipidaemia
ERCP/EUS
Drugs (esp. azathioprine)

What are the 2 types of acute pancreatitis?

Interstitial oedematous acute pancreatitis

Necrotising acute pancreatitis

How do you classify the severity of acute pancreatitis? (3)

Mild:

No organ failure
No complications

Moderate:

Organ failure lasting <48 hours
Local complications

Severe:
-Persistent organ failure

Describe the symptoms of acute pancreatitis. (4)

What are the symptoms of severe pancreatitis? (3)

SYMPTOMS:
Acute, severe upper abdo pain
Radiation to back
Partially relieved by sitting/bending forwards
Jaundice

SEVERE PANCREATITIS:
Multi-organ failure
Pleural effusion
Ascites

Describe the signs found on examination of acute pancreatitis. (2)

Cullen’s sign - bruising around umbilicus

Grey Turner sign - bruising on the flanks

How would you diagnose acute pancreatitis? (3)

Elevated serum amylase
Elevated serum lipase
CT scan

How would you manage acute pancreatitis? (3)

Supportive treatment
Treat underlying cause
Drainage of persistent fluid collections

List 6 causes of chronic pancreatitis. HINT: remember: "TIGARO"

``` Toxic/metabolic (esp. alcohol) Idiopathic Genetic Autoimmune RAP/SAP associated (post-necrotic, vascular or post-irradiation) Obstruction ```

List 3 types of mutation which can cause chronic pancreatitis. Which other condition is associated with one of these?

PRSS1 CFTR (cystic fibrosis) SPINK1

Describe the symptoms of chronic pancreatitis. (6) Which sign might you see? What causes it?

``` Pain (radiates to back; relieved sitting forwards/with hot water bottle) Malnutrition Bloating Steatorrhoea Weight loss Brittle diabetes ``` Erythema ab igne - mottled grey skin lesions caused by constant use of hot water bottles

Which 5 imaging methods would you use to diagnose chronic pancreatitis? Which feature is seen on all of them? Give 2 further investigations.

IMAGING: Ultrasound CT scan MRCP (magnetic resonance cholangiopancreatography) ERCP (endoscopic retrograde cholangiopancreatography) Abdominal x-ray (AXR) Feature: pancreatic calcification FURTHER TESTS: Labelled carbon breath test Wedge biopsy

Which criteria are used to measure severity of chronic pancreatitis?

Rosemont criteria

How would you treat chronic pancreatitis? (6)

1. Potent analgesia 2. Duct drainage 3. Fix exocrine/endocrine needs 4. Smoking cessation 5. Alcohol cessation 6. Surgery

List 2 complications of chronic pancreatitis.

Diabetes | Pancreatic cancer

List 10 causes of pancreatic exocrine insufficiency. HINT: there are 2 main categories of causes.

``` PANCREATIC DISEASE: Acute pancreatitis Diabetes mellitus Pancreatectomy Duct obstruction, e.g. -Cystic fibrosis -Chronic pancreatitis -Pancreatic cancer ``` ``` DUODENAL DISEASE: Gastrectomy Coeliac disease IBD Zollinger-Ellison syndrome ```

How do you diagnose pancreatic exocrine insufficiency? (2)

Faecal elastase | Response to PERT

How do you treat pancreatic exocrine insufficiency? (3)

Creon If ineffective: - Add PPI - Increase enzyme dose

List 4 complications of acute pancreatitis.

Fat necrosis Acute haemorrhagic pancreatitis Pancreatitic abscess Pancreatic pseudocyst

List the 4 types of cancer affecting the pancreas and biliary tree.

Pancreatic carcinoma Pancreatic endocrine tumour Cholangiocarcinoma Carcinoma of gallbladder

What are the 2 types of cholangiocarcinoma?

Intrahepatic | Extrahepatic

Which 3 locations are the commonest sites for gallstones to get stuck?

Gallbladder fundus Sphincter of Oddi Pancreatic duct