Pancreatitis + Peritonitis Flashcards
S+S pancreatitis
Epigastric/ LUQ pain N+V Steatorrhoea Jaundice Tachycardia Cullen's sign = periumbilical bruising
Causes of pancreatitis
Obstruction of bicarbonate secretion which activates pancreatic enzymes - leads to necrosis GET SMASHED Gallstones Ethanol (alcohol) Trauma Steroids Mumps Autoimmune diseases eg SLE Scorpion venom Hypercalcaemia ERCP Drugs: azithioprine, NSAIDs
Investigations for pancreatitis
Secretin stimulation test
Raised lipase + amylase (diagnostic if 3x upper limit)
Bloods - AST + bilirubin raised, ALT raised if gallstones cause
ABG = metabolic acidosis.
Low Ca
AXR = perf, gas loops + calcification (sentinel loop sign)
CT with contrast if >48hrs
USS - for gallstones
ERCP for gallstones Tx
What scoring system is used to assess severity + prognosis of pancreatitis?
Glasgow + Ranson
Tx for pancreatitis
O2, fluids (Hartmanns) Pain relief = NSAIDs/ morphine (PCA) Abx (imipenem) Nutritional support - soft diet, low fat + residue, after 24hrs. Enteral nutrition for severe cases ERCP to remove gallstones
Complications of pancreatitis
Pancreatic necrosis due to ischaemia - suspected if S+S last >7 days.
Acute necrotic collection or walled off necrosis (4 weeks)
Pancreatic pseudocyst (4 weeks)
Infected necrosis
Hypocalcaemia
Hyperglycaemia
Hypovolemic shock (due to 3rd space leakage)
Pathology of pancreatitis
Pancreatic enzymes leak out of acinar cells to interstitial space + then to circulation
Causes acute elevation in pancreatic enzymes
When can the diagnosis of pancreatitis be made?
2 of the following:
Acute onset severe epigastric pain
Elevation in lipase or amylase x3
Characteristic findings on imaging
Why is lipase better than amylase for diagnosing?
Lipase is more sensitive, elevations occur earlier + last longer
What are the two types of acute pancreatitis?
Edematous interstitial + necrotising
How is pancreatitis graded (mild, mod + severe)?
Mild = absence of organ failure + complications Moderate = no/ transient organ failure and/or local complications Severe = persistent organ failure
Presentation of SBP
Pts with cirrhosis who develop S+S: Fever Abdo pain/ tenderness Altered mental status Hypotension
Investigation for SBP
Paracentesis with analysis of fluid for: Aerobic + anaerobic culture PCR for DNA Cell count + differential Gram stain Albumin Protein Glucose Lactate Amylase Bilirubin CEA Alk phos
Bloods- FBC, serum creatinine
When is a diagnosis of SBP made?
When neutrophils in ascitic fluid are high + culture is positive
What is the difference in management between SBP + secondary peritonitis?
SBP - abx
Secondary = abx + surgery
What is the relevance of the MELD score to SBP?
Higher the MELD score, more advanced the cirrhosis, higher risk of SBP
Difference in presentation between SBP + peritonitis
SBP = no rigid abdo (ascites is between visceral + parietal surfaces)
S+S of SBP
Fever, abdo pain/ tenderness, altered mental state
Diarrhea, paralytic ileus, hypotension, hypothermia
Peripheral leukocytosis, metabolic acidosis, azotemia
Why is fever particularly significant in SBP?
Cirrhosis pts are usually hypothermic so temperature of 37.8 is significant
What is the Reitan trail test?
diagnostic aid to detect subtle changes in mental state in pts with cirrhosis
Which bacteria commonly cause SBP?
E coli + Klebsiella
Staph + strep less common
What medication should be stopped in SBP?
Nonselective BB (propranolol + labetalol)
Management of SBP before culture results
Cefotaxime (broad spectrum 3rd gen cephalosporin) or ciprofloxacin for 5 days
What is the severe complication of SBP + how is it prevented?
Renal failure - occurs in 30-40%
Prevent with IV infusion of albumin
