Pancreatitis/Cholecystitis Flashcards
What position often makes the pain improve in pancreatitis?
Sitting forward
What mimics sepsis and is a complication of pancreatitis?
ARDS/SERS
Acute respiratory distress syndrome
-> whole body oedema
Causes of Ileus
Intrabdominal problems
Post op
Electrolyte disturbances
What is ileus
where the gi tract doesnt function, ,pressure builds up as no absorption -> vomitting
How can lipase action cause hypocalcemia?
Lipase action on mesenteric fat causes release of free fatty acids which bind to calcium in blood -> insoluble calcium salts which decrease serum calcium levels
Why does hypercalcemia cause pancreatitis?
It activates enzymes oin the pancreas
What does th eGlasgow imry score suggest? What level is high risk?
24 hours risk of moving to ITU
3 + = high risk
In pancreatitis
Whta does ransons score predict in pancreatitis?
Mortality
Apatoni2 score when used
In ITU - multisystem scoring, accurate for pancreatitis
What is pancreatitis?
Acute inflammation of the pancreas causing release if exocrine enzymes that cause autodigestion of the organ - local tissues and distant organs.
Pathophysiology of pancreatitis?
Trigger eg alcohol -> marked elevation intracellular calcium -> activation of exocrine pancreatic enzymes -> acinar cell injury + necrosis, + migration inflammatory cells + sometimes systemic inflammatory response -> single or multi organ failure
Causes of pancreatitis
IGETSMASHED
Iatrogenic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune, ascaris infection
Scorpion venom
Hypertriglyceridemia, Hyperchylomicronawmia, hyhpercalcemia, hypothermia
ERCP
Drugs eg azathioprine, bendroflumethiazide, furosemide, mesalazine, steorids, sodium valproate
What is the glasgow imrie criteria?
PANCREAS @48 hour admission
PaO2 <8kpa
Age >55 years
Neutrophilia = WCC >15 x10’9/L
Calcium < 2.0mmol/L
Renal (serum urea) >16 mmol/L
Enzymes LDH >600IU/L
Albumin <32g/L
Sugar - glucose >10mmol/L
Cholecystitis on exam
=pain in the upper right quadrant that radiates tp back
-palpable mass
-Boas and Murphys sign
-Fever, HR
First line investigations cholecystitis
CT or MRI of the abdomen
abdominal ultrasound
FBC
CRP
Investigations to consider cholecystitis
magnetic resonance cholangiopancreatography (MRCP)
endoscopic ultrasound (EUS)
Boas’s sign
presence of an area of hyperaesthesia at the site of radiation of the pain to the back, typically, below the scapula.
Potential outcomes for acute cholecysitis
Self resolving - 1-7 dyas
25-30% people develop complications or require surgery
Acute cholecysitis complications
Necrosis of gallbladder wall
Perforation of the gallbladder
Biliary peritonitis
Pericholecystic abscess
Fistula - between gallbladder and duodenum
Jaundice - inflammation of adjoining biliary ducts - Mirizzis syndrome
-Sepsis
Symptoms of cholecystitis
fever, anorexia, nausea, vomiting, back or shoulder pain, right upper quadrant mass, and a positive Murphy’s sign.
What sign is positive on exam in cholecsyitis?
Murphys sign
-Pain and stop inspiration when press on RUQ
Why admit to hospital with cholecysitits?
Confirmation of the diagnosis, including abdominal ultrasound and blood tests (such as a white blood cell count, C-reactive protein, and serum amylase).
Monitoring (for example blood pressure, pulse, and urinary output).
Treatment (may include intravenous fluids, antibiotics, and analgesia).
Surgical assessment for cholecystectomy.
Oedematous cholecystitis is?
occurs after 2–4 days of obstruction. The gallbladder tissue is intact histologically, with oedema in the subserosal layer.
When does necrotising cholecystitis occur?
occurs after 3–5 days of obstruction and is characterized by oedematous changes in the gallbladder, with areas of haemorrhage and necrosis. Necrosis does not involve the full thickness of the gall bladder wall.
What is suppurative cholecystitis?
occurs after 7–10 days of obstruction and is characterized by thickened gallbladder wall with white cell infiltration, intra-wall abscesses, and necrosis. May result in perforation of the gallbladder and a pericholecystic abscess formation.
How is chronic cholecystitis defined?
occurs after repeated episodes of mild attacks and is characterized by mucosal atrophy and fibrosis of the gallbladder wall. Acute-on-chronic cholecystitis refers to an acute infection that has occurred in chronic cholecystitis.
How does acute cholecystitis become complicated?
As the gallbladder becomes more distended and inflamed, blood flow and lymphatic drainage are compromised, leading to mucosal ischemia.Secondary bacterial infection of the bile may occur.
Continued inflammation, ischemia, and/or infection can result in necrosis and gallbladder perforation.
Gallstone risk factors
gallstones include increasing age, female gender, obesity, and a low fibre diet.
Which type of cholecysitits is mortality highest in?
Acalculous - 10-50%
Which type of patient does acalculous cholecystitis often occur in?
Critically ill people
Combindation of factors -> bile stasis (gallbladder hypomotility/dysmotility) or thickening (dehydration)
Conditions ass with biliary stasis or thickening
Sepsis.
Extensive trauma.
Burns.
Major surgery.
Prolonged fasting or starvation.
Prolonged total parenteral nutrition use.
Risk factors for acalculous cholecystitis?
Diabetes, end stage renal disease, congestive HF/CAD, peripheral vascular disease
Drugs - cyclosporin, ceftriaxone
Infection eg EBV
HIV+ - cholangiopathy with microsporidia species
Nature of the pain in cholecystitis
A constant pain present for several hours is consistent with acute cholecystitis. The duration of pain can be shorter if the gallstone returns into the gallbladder lumen or passes into the duodenum.
The pain is severe, steady, and may radiate to the back.
Referred pain from the gallbladder may be felt in the right shoulder or interscapular region.
Symptoms to ask for in history for cholecystitis
Fever/chills
nausea
Vomitting
Anorexia
If have episode of biliary pain, how likely have another in 12 months?
50%
When is Murphys sign unreliable?
Older people or critically ill people
What is Mirizzis syndrome?
Gallstone impacted in gallbladder neck
How is acute analgesia managed conservatively?
Bed rest
Electrolyte compensation
Fasting
Analgesia with NSAIDs + opiates
Anti-emetics
IV fluids
Antibiotics - broad spectrum
Surgical management cholecystitis
Cholecystectomy - laproscopic - early has better outcomes - within 72 hours of admission
When do an emergency cholecystectomy
Fever
Marked leukocytsosi
Diffuse abdominal tenderness -> necrosis, empyema or rupture and surgery within 12 to 23 hours is indicated
Patients with diabetes
Elderly + immunocompromised patients
Grading of cholecystitis + when do Lap Cholecystectomy with each grade
Grades I - III
Urgent Lap C if patient has good status in Grade II + III + blood culture or bile culutre
Within 7 days if Grade I
Grade III also do urgent biliary drainage
What does Ransons score predict?
Mortality in pancreatitis
Features of ransons score
On admission - WCC
WBC > 16K
Age > 55
Glucose >200 mg/dL (>10 mmol/L)
AST > 250
LDH > 350
AFTER 48 hours
Hct drop >10% from admission
BUN increase >5 mg/dL (>1.79 mmol/L) from admission
Ca <8 mg/dL (<2 mmol/L) within 48 hours
Arterial pO2 <60 mmHg within 48 hours
Base deficit (24 - HCO3) >4 mg/dL within 48 hours
Fluid needs > 6L within 48 hours
What glasgow IMrie score suggests severe pancreatiits/
= or over 3
What new score is used in pancreatitis?
BISAP score
What are the criteria for Glasgow imrie score?
PaO₂ <59.3 mmHg (7.9 kPa)
Age >55 years
WBC >15 x 10³/µL (10⁹/L)
Calcium <8 mg/dL (2 mmol/L)
BUN >44.8 mg/dL (serum urea >16 mmol/L)
LDH >600 IU/L
Albumin <3.2 g/dL (32 g/L)
Glucose >180 mg/dL (10 mmol/L)
What use abdo X rays to investigate
Obstructed
Perforation
Toxic megacolon
Foreign body
Abdo x ray approach
- A - air
- B - bowel
- 3/6/9 rule
- C - calcification
- D - dense objects eg bones
- E - external - everything else
What is pneumobilia?
- Air in biliary system = pneumobilia
What condition occurs when UTI with bacteria which produce air → bladder perforation
- Emphysematous cystitis/pyelonephritis
- Emphysematous cholecysitis
What does loin to groin pain signal?
Kindey stones
Surgical sieve
VITAMIN Cmay come in handy.
V- Vascular– Stroke, MI – Can uncommonly present with this.
I – Infection(Primary CNS infection orsecondary to sepsis);
T – Trauma– Surgery, traumatic brain injuries (including subdural and extracranial hemorrhage)
A – Autoimmune– Vasculitis
M – Metabolic–Hypoglycemia, hyperglycemia, uremia, hepatic encephalopathy, electrolyte abnormalities (e.g. hypercalcemia, hyponatremia), constipation, urinary retention
I – Iatrogenic– Medications, illicit drugs
N – Neoplasia– CNS Tumours
C – Congenital Abnormalities
What is renal stenosis
Construction of efferent blood vessels/ one or both renal arteries causing reduced blood flow to the kidneys, decreased perfusion and a build up of waste products and fluids
What is renal stenosis caused by?
- Atherosclerosis
- Fivromuscular dysplasia (in younger ppl)
Treatment and what Complications for renal stenosis
- Angioplasty
- Lifestyle
- Diuretics
comp
- CKD
- Kidney failure
What is rigglers sign?
SIgnals bowel perforation
Bowel wall appears as white line - dark air either side
What is rigglers sign?
SIgnals bowel perforation
Bowel wall appears as white line - dark air either side
What are the criteria for Glasgow imrie score?
PaO₂ <59.3 mmHg (7.9 kPa
Age >55 years
WBC >15 x 10³/µL (10⁹/L)
Calcium <8 mg/dL (2 mmol/L)
BUN >44.8 mg/dL (serum urea >16 mmol/L)
LDH >600 IU/L
Albumin <3.2 g/dL (32 g/L)
Glucose >180 mg/dL (10 mmol/L)
3,6,9rule
- 3cm for small cowel
- 6cm for colon
- 9cm for caecum
How can you score severity of pancreatitis?
Ransons score
APACHE II
Glasgow Imrie criteria
CRP emasurement
BISAP score
How much higher does serum amylase need to be to be considered diagnostic?
3 x baselline
Which is more sensitive and specific, amylase or lipase?
Lipase
What does raised serum aminotransferase and/or bilirubin suggest?
Gallstones
Why do you measure calcium in acute pancreatitis?
Hypocalcemia is relatively common in acute pancreatitis - may help prognosis
Symptoms of pancreatitis
Acute severe upper abdo pain radiating to back
N+V
Anorecia
Pyrexia
Signs of pancreatitis
Fever, hypotension, tachycardia,pnoe
Epigastric tenderness, guaring on exam
Decreased bowel sounds
Jaundice
Grey Turners sign
Cullens sign
What is Cullens sign
Bruises periumbilical circle suggestive of pancreatitis
What is Grey Turners sign
Bruises around flank
What are cullens and greys signs indicative of
Retroperitoneal haemorrhage
LATE presentation of acute pancreatitis
Imaging investigations ofr pancreatitis
AXR erect
CXR
CT pancreas - contrast enhanved
US abdomen - first line
MRI pancreas
Which investigation is used prior to pancreatic surgery?
CT pancreas with contrast
-Pancreatic swelling, fluid collections and density changes
What can be seen on a US abdomen of the pancreas in pancreatitis?
Swollen pancreas, dilated CBD, free peritoneal fluid
Gallstones
sWhat is seen in severe pancreatitis on CXR?
Hemidiaphragm elevation, infiltrates, ARDS, pleural effusions
What is chronic pancreatitis defined as?
Chronic irreversible inflammation of the pancreas +/or fibrosis
Severe abdo pain and progressive endocrine and exocrine insufficiency
Pathophysiology of chronic pancreattitis
Pancreatic enzyme activation (trauma, CF, unknown) -> tissue injury and necrosis -? fibrogenesis in respnse, releasing growth factors, cytokines, chemokines - ECM depositions
Oxidative stress?
Pathophysiology of alcohol on the pancreas
Proteins precipitate in ductular structure -> dilatation and fibrosis, direct effects of alcohol toxic on pancreas
Common complications of pancreatitis
Malabsorption
DM
Chronic pain
Osteoporosis
Pseudocyst formation
Pancreatic calcification
Common complications of pancreatitis
Malabsorption
DM
Chronic pain
Osteoporosis
Pseudocyst formation
Pancreatic calcification
Why can jaundice be a feature of pancreatitis?
Complciation of biliary obstruction
If a patient presents with vommittting and anorexia and are not passing faeces with pancreatitis what is the concern?
Duodenal or gastric outlet obstruction
Bowel obstruction due to metastases from pancreatic cnacer
How can pancreatitis affect the venal supply to the lvier?
Splenic or portal VTE
Conservative management of pancreatitis
Stop alcohol and smoking
Dietician support
Risk factors pancreatitis
Male
Age
Smoking
Obestiy
What need for a diagnosis of pancreatitis
Abdominal pain plus a history suggestive of acute pancreatitis
Serum amylase/lipase of over three times the upper limit of normal
Imaging findings characteristic of acute pancreatitis
Differentials for sudden onset severe epigastric pain
Leaking abdominal aortic aneurysm
Aortic dissection
Myocardial infarction
Perforated gastric/duodenal ulcer
Oesophageal rupture
Atlanta criteria for classification of pancreatitis
Mild: no organ dysfunction/complications, resolves 1 week
Moderate: some evidence organ failure improves 48 hours
Severe: persistent organ dysfunction > 48 hours, with local or systemic complications
Bedside investigations for pancreatitis
ECG
Urinalysis n
Pain relief of chronic pancreatitis
Simple analgesia - aparacetemol and NSAIDs
Opiates - tramadol
Coeliac plexus block - ensocopy
ERCP = dilate strictures of ducts
Managing pancreatic insufficiency
Replacing pancreatic enzymes - malabsorption and reduce pain
Fat soluble vitamins - A, D, E, K
DM - insulin, blood sugar monitoring
Why do you need to monitor blood sugar in a=chronic pancreatitis?
Damage to beta cells in severe disease can cause diabetes
Surgical options pancreatitis
Cholecystectoy - gallstones
Sphincterextomy
Percutaneous or surgical drainage
Partial pancreatic resection
Extracorpereal shockwave lithrotripsy -
Total pancreatotomy
What is Extracorpereal shockwave lithrotripsy used ofr
Gallstone blocking the pancreatic duct
What drugs can cause pancreatitis?
Thiazide like diuretics, azathioprine, tetracyclines, valproic acid and DDP-4 inhibitors
What is azathioprine?
a DMARD immunosuppressant used in RA, organ transplant, IBD and vasculitis’s
What are tetracyclines?
Class of antibiotic
Doxycycline, tetracycline
inhibit protein synthesis in the microbial RNA
Congenital causes of pancreatitis
Pancreas divisum, annular pancreas
Autoimmune disorders that can cause pancreatitis
Sjrogen syndrome, IBD, primary biliary cirrhosis
Imaging for chronic pancreatitis
AXR
Abdo US
Abdo CT - 1st LINE
MRCP/ERCP
Endoscopic US
Features of chronic pancreatitis
As acute plus
Malabsorption with weight loss, diarrhoea, steatorrhea and protein deficiecny
DM
Nutrition in severe pacreatitis
Nil by mouth - NBM until pain improves
Nasojejunal feeding
or total parenteral nutrition
Management of gallstone pancreatitis
ERCP
Cholecystectomy
Alcohol induced pancreatitis management
CIWA score for alcohol withdrawal
Benzodiazpines to treat withdrawal agitation and seizures
Thiamine, folate and vit B12 replacement
Early complications pancreatitis
Necortising
Infected pancreatic necrosis
Pancreatic abscess
ARDS = boilateral infiltrates on CXR
ARDS on CXR
Widespread bilateral pulmonary infiltrates
Late complciations of pancreatitis
Pancreatic pseudocysts
Portal vein/splenic thrombosis
Chronic pancreatittis
Pancreatic insufficiency
Score used for SERS
QSOFA
What is diclophenac used in?
Renal colic - antispasmodic
What score on glasgow imrie means patient should move to ITU?
3
What score predicts mortality in pancreatitis?
Ransons
What scores predict ITU in pancreatitis? which is better and why
Glasgow imrie
Apatoni2score - done in ITU, multisystem consideration
