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Pancreatitis/Cholecystitis Flashcards

1
Q

What position often makes the pain improve in pancreatitis?

A

Sitting forward

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2
Q

What mimics sepsis and is a complication of pancreatitis?

A

ARDS/SERS
Acute respiratory distress syndrome
-> whole body oedema

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3
Q

Causes of Ileus

A

Intrabdominal problems
Post op
Electrolyte disturbances

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4
Q

What is ileus

A

where the gi tract doesnt function, ,pressure builds up as no absorption -> vomitting

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5
Q

How can lipase action cause hypocalcemia?

A

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

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6
Q

Why does hypercalcemia cause pancreatitis?

A

It activates enzymes oin the pancreas

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7
Q

What does th eGlasgow imry score suggest? What level is high risk?

A

24 hours risk of moving to ITU
3 + = high risk
In pancreatitis

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8
Q

Whta does ransons score predict in pancreatitis?

A

Mortality

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9
Q

Apatoni2 score when used

A

In ITU - multisystem scoring, accurate for pancreatitis

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10
Q

What is pancreatitis?

A

Acute inflammation of the pancreas causing release if exocrine enzymes that cause autodigestion of the organ - local tissues and distant organs.

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11
Q

Pathophysiology of pancreatitis?

A

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

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12
Q

Causes of pancreatitis

A

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

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13
Q

What is the glasgow imrie criteria?

A

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

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14
Q

Cholecystitis on exam

A

=pain in the upper right quadrant that radiates tp back
-palpable mass
-Boas and Murphys sign
-Fever, HR

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15
Q

First line investigations cholecystitis

A

CT or MRI of the abdomen
abdominal ultrasound
FBC
CRP

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16
Q

Investigations to consider cholecystitis

A

magnetic resonance cholangiopancreatography (MRCP)
endoscopic ultrasound (EUS)

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17
Q

Boas’s sign

A

presence of an area of hyperaesthesia at the site of radiation of the pain to the back, typically, below the scapula.

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18
Q

Potential outcomes for acute cholecysitis

A

Self resolving - 1-7 dyas
25-30% people develop complications or require surgery

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19
Q

Acute cholecysitis complications

A

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

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20
Q

Symptoms of cholecystitis

A

fever, anorexia, nausea, vomiting, back or shoulder pain, right upper quadrant mass, and a positive Murphy’s sign.

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21
Q

What sign is positive on exam in cholecsyitis?

A

Murphys sign
-Pain and stop inspiration when press on RUQ

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22
Q

Why admit to hospital with cholecysitits?

A

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.

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23
Q

Oedematous cholecystitis is?

A

occurs after 2–4 days of obstruction. The gallbladder tissue is intact histologically, with oedema in the subserosal layer.

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24
Q

When does necrotising cholecystitis occur?

A

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.

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25
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.
26
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.
27
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.
28
Gallstone risk factors
gallstones include increasing age, female gender, obesity, and a low fibre diet.
29
Which type of cholecysitits is mortality highest in?
Acalculous - 10-50%
30
Which type of patient does acalculous cholecystitis often occur in?
Critically ill people Combindation of factors -> bile stasis (gallbladder hypomotility/dysmotility) or thickening (dehydration)
31
Conditions ass with biliary stasis or thickening
Sepsis. Extensive trauma. Burns. Major surgery. Prolonged fasting or starvation. Prolonged total parenteral nutrition use.
32
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
33
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.
34
Symptoms to ask for in history for cholecystitis
Fever/chills nausea Vomitting Anorexia
35
If have episode of biliary pain, how likely have another in 12 months?
50%
36
When is Murphys sign unreliable?
Older people or critically ill people
37
What is Mirizzis syndrome?
Gallstone impacted in gallbladder neck
38
How is acute analgesia managed conservatively?
Bed rest Electrolyte compensation Fasting Analgesia with NSAIDs + opiates Anti-emetics IV fluids Antibiotics - broad spectrum
39
Surgical management cholecystitis
Cholecystectomy - laproscopic - early has better outcomes - within 72 hours of admission
40
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
41
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
42
What does Ransons score predict?
Mortality in pancreatitis
43
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
44
What glasgow IMrie score suggests severe pancreatiits/
= or over 3
45
What new score is used in pancreatitis?
BISAP score
46
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)
47
What use abdo X rays to investigate
Obstructed Perforation Toxic megacolon Foreign body
48
Abdo x ray approach
- A - air - B - bowel - 3/6/9 rule - C - calcification - D - dense objects eg bones - E - external - everything else
49
What is pneumobilia?
- Air in biliary system = pneumobilia
50
What condition occurs when UTI with bacteria which produce air → bladder perforation
- Emphysematous cystitis/pyelonephritis - Emphysematous cholecysitis
51
What does loin to groin pain signal?
Kindey stones
52
Surgical sieve
**VITAMIN C** may come in handy**.** **V- Vascular** – Stroke, MI – Can uncommonly present with this. **I – Infection** (Primary CNS infection or secondary 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**
53
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
54
What is renal stenosis caused by?
- Atherosclerosis - Fivromuscular dysplasia (in younger ppl)
55
Treatment and what Complications for renal stenosis
- Angioplasty - Lifestyle - Diuretics comp - CKD - Kidney failure
56
What is rigglers sign?
SIgnals bowel perforation Bowel wall appears as white line - dark air either side
57
What is rigglers sign?
SIgnals bowel perforation Bowel wall appears as white line - dark air either side
58
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)
58
3,6,9rule
- 3cm for small cowel - 6cm for colon - 9cm for caecum
59
How can you score severity of pancreatitis?
Ransons score APACHE II Glasgow Imrie criteria CRP emasurement BISAP score
60
How much higher does serum amylase need to be to be considered diagnostic?
3 x baselline
61
Which is more sensitive and specific, amylase or lipase?
Lipase
62
What does raised serum aminotransferase and/or bilirubin suggest?
Gallstones
63
Why do you measure calcium in acute pancreatitis?
Hypocalcemia is relatively common in acute pancreatitis - may help prognosis
64
Symptoms of pancreatitis
Acute severe upper abdo pain radiating to back N+V Anorecia Pyrexia
65
Signs of pancreatitis
Fever, hypotension, tachycardia,pnoe Epigastric tenderness, guaring on exam Decreased bowel sounds Jaundice Grey Turners sign Cullens sign
66
What is Cullens sign
Bruises periumbilical circle suggestive of pancreatitis
67
What is Grey Turners sign
Bruises around flank
68
What are cullens and greys signs indicative of
Retroperitoneal haemorrhage LATE presentation of acute pancreatitis
69
Imaging investigations ofr pancreatitis
AXR erect CXR CT pancreas - contrast enhanved US abdomen - first line MRI pancreas
70
Which investigation is used prior to pancreatic surgery?
CT pancreas with contrast -Pancreatic swelling, fluid collections and density changes
71
What can be seen on a US abdomen of the pancreas in pancreatitis?
Swollen pancreas, dilated CBD, free peritoneal fluid Gallstones
72
sWhat is seen in severe pancreatitis on CXR?
Hemidiaphragm elevation, infiltrates, ARDS, pleural effusions
73
What is chronic pancreatitis defined as?
Chronic irreversible inflammation of the pancreas +/or fibrosis Severe abdo pain and progressive endocrine and exocrine insufficiency
74
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?
75
Pathophysiology of alcohol on the pancreas
Proteins precipitate in ductular structure -> dilatation and fibrosis, direct effects of alcohol toxic on pancreas
76
Common complications of pancreatitis
Malabsorption DM Chronic pain Osteoporosis Pseudocyst formation Pancreatic calcification
77
Common complications of pancreatitis
Malabsorption DM Chronic pain Osteoporosis Pseudocyst formation Pancreatic calcification
78
Why can jaundice be a feature of pancreatitis?
Complciation of biliary obstruction
79
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
80
How can pancreatitis affect the venal supply to the lvier?
Splenic or portal VTE
81
Conservative management of pancreatitis
Stop alcohol and smoking Dietician support
82
Risk factors pancreatitis
Male Age Smoking Obestiy
83
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
84
Differentials for sudden onset severe epigastric pain
Leaking abdominal aortic aneurysm Aortic dissection Myocardial infarction Perforated gastric/duodenal ulcer Oesophageal rupture
85
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
86
Bedside investigations for pancreatitis
ECG Urinalysis n
87
Pain relief of chronic pancreatitis
Simple analgesia - aparacetemol and NSAIDs Opiates - tramadol Coeliac plexus block - ensocopy ERCP = dilate strictures of ducts
88
Managing pancreatic insufficiency
Replacing pancreatic enzymes - malabsorption and reduce pain Fat soluble vitamins - A, D, E, K DM - insulin, blood sugar monitoring
89
Why do you need to monitor blood sugar in a=chronic pancreatitis?
Damage to beta cells in severe disease can cause diabetes
90
Surgical options pancreatitis
Cholecystectoy - gallstones Sphincterextomy Percutaneous or surgical drainage Partial pancreatic resection Extracorpereal shockwave lithrotripsy - Total pancreatotomy
91
What is Extracorpereal shockwave lithrotripsy used ofr
Gallstone blocking the pancreatic duct
92
What drugs can cause pancreatitis?
Thiazide like diuretics, azathioprine, tetracyclines, valproic acid and DDP-4 inhibitors
93
What is azathioprine?
a DMARD immunosuppressant used in RA, organ transplant, IBD and vasculitis's
94
What are tetracyclines?
Class of antibiotic Doxycycline, tetracycline inhibit protein synthesis in the microbial RNA
95
Congenital causes of pancreatitis
Pancreas divisum, annular pancreas
96
Autoimmune disorders that can cause pancreatitis
Sjrogen syndrome, IBD, primary biliary cirrhosis
97
Imaging for chronic pancreatitis
AXR Abdo US Abdo CT - 1st LINE MRCP/ERCP Endoscopic US
98
Features of chronic pancreatitis
As acute plus Malabsorption with weight loss, diarrhoea, steatorrhea and protein deficiecny DM
99
Nutrition in severe pacreatitis
Nil by mouth - NBM until pain improves Nasojejunal feeding or total parenteral nutrition
100
Management of gallstone pancreatitis
ERCP Cholecystectomy
101
Alcohol induced pancreatitis management
CIWA score for alcohol withdrawal Benzodiazpines to treat withdrawal agitation and seizures Thiamine, folate and vit B12 replacement
102
Early complications pancreatitis
Necortising Infected pancreatic necrosis Pancreatic abscess ARDS = boilateral infiltrates on CXR
103
ARDS on CXR
Widespread bilateral pulmonary infiltrates
104
Late complciations of pancreatitis
Pancreatic pseudocysts Portal vein/splenic thrombosis Chronic pancreatittis Pancreatic insufficiency
105
Score used for SERS
QSOFA
106
What is diclophenac used in?
Renal colic - antispasmodic
107
What score on glasgow imrie means patient should move to ITU?
3
108
What score predicts mortality in pancreatitis?
Ransons
109
What scores predict ITU in pancreatitis? which is better and why
Glasgow imrie Apatoni2score - done in ITU, multisystem consideration

GI, liver, kidney (50 decks)

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