Severe Upper Abdominal Pain Flashcards
28 year old female presented with 24 hours of intermittent epigastric pain with N+V
Non-smoker/non-drinker
PHx of similar, but milder, episode 2 months earlier (1 week post-partum)
O/E: HR 122, BP 80/60, temp 37.0, RR 22, O2 96%, moderate RUQ and epigastric tenderness, not clinically anaemic nor jaundiced
Working diagnosis?
Pancreatitis
Bleeding peptic ulcer
Perforated peptic ulcer
Cholecystitis, ascending cholangitis
28 year old female presented with 24 hours of intermittent epigastric pain with N+V
Initial Ix? Think about why each would be ordered
Blood glucose FBE UEC LFT Lipase Erect CXR/AXR ECG
If abnormal LFTs in setting of pancreatitis, what further Ix would you order? What findings would you expect?
Biliary U/S to confirm presence of gallstones
Presence of gallstones, gall bladder wall thickening, ascites
Proposed mechanism of gallstone pancreatitis
Obstruction and inflammation ultimately leads to intra-pancreatic zymogen activation and auto-digestion of acinar cells
Proposed mechanism of EtOH-induced pancreatitis
EtOH is a direct toxin to the acinar cell, resulting in inflammation and membrane destruction
What is the overall mortality rate of acute pancreatitis?
7-9%
What is the normal natural Hx of acute pancreatitis?
Most attacks are mild with recovery within a week
What is the mortality rate with severe necrotising pancreatitis?
25-30%
Ranson scoring system
On admission: age >55 years, BGL >11 mmol/L, LDH >300 IU/L, ALT >250 U/L, WCC >16x10^9g/L
At 48 hours: Hct fall >10%, urea rise >0.8 mmol/L, Ca2+ 4 meq/L, fluid sequestration >6L
≥3 factors = predicted severe pancreatitis
Fluid resuscitation in setting of acute pancreatitis
Balanced salt solution (NS or Hartmanns; 10-20 mL/kg), repeat if needed
Maintenance rate start at 30 mL/kg/24 hours
CSL
Compound sodium lactate (Hartmanns)
Example MET call criteria for adults
Deterioration in conscious state (progressively drowsy/unrousable)
SBP 140 (or >120 in first 4 hours post-op)
RR 30
Difficulty breathing
Multiple convulsions
Ischaemic chest pain
Nurse worried about patient’s condition
Where should cases of severe pancreatitis be admitted? How should should severe gallstone pancreatitis be definitively managed (controversial)?
To HDU/ICU
Consider early ERCP/ES (controversial but 4 RCTs show survival advantage in severe gallstone pancreatitis)
3 early complications of acute pancreatitis
Systemic Inflammatory Response Syndrome/to Shock (SIRS): hypoxia and renal failure/impairment
Hypovolaemic shock
Pancreas necrosis and sepsis
What is the difference between sepsis and SIRS?
Sepsis: clinical syndrome complicating severe infection, characterised by signs of inflammation (vasodilation, leukocyte accumulation, increased microvascular permeability) occuring in tissues remote from infection
SIRS: identical clinical syndrome that complicates a non-infectious insult
Examples of conditions which may precipitate SIRS
Acute pancreatitis
Pulmonary contusion
Others?
How do SIRS and sepsis cause mortality?
Lead to Multiple Organ Dysfunction Syndrome (MODS)
How can sepsis be differentiated from SIRS?
Cultures
CRP
WCC + blood film
What is the range of impacts an infection can have on ea patient?
Initial inflammatory response
Sepsis (with evidence of infective cause)
Septic shock (sepsis plus shock requiring resuscitation; fluids and vasoconstrictors)
What is ARDS?
Adult Respiratory Distress Syndrome: generic response of the lungs to insult/injury/inflammation
What 2 distinctions can be made in ARDS depending on the underlying mechanism?
Differentiate acute hydrostatic pulmonary oedema (associated with elevated LAP) from pulmonary oedema associated with low LAP as a result of increased capillary permeability
Causes of ARDS
Severe pancreatitis
??
How is ARDS managed?
Treat underlying cause
Protective ventilation to avoid further damage to lungs
Provide supportive intensive care (nutrition, DVT prophylaxis, mobilisation, pressure care, cautious fluid balance, etc)
If a patient with severe pancreatitis, what Ix should be considered and what complications are you looking for?
Contrast CT looking for:
Necrotising pancreatitis (vascular enhancement)
Infected pancreatic necrosis (often see gas)
Pancreatic fluid collections (usually seen day 2-3)
Pseudocyst formation can follow all of these complications
Bilateral pleural effusions and pancreatic ascites may be present
What specific signs are you looking for in each??
What is a pseudocyst?
Persistent fluid collection after 4 weeks
How do patients with a pseudocyst present?
Pain
Gastric outlet obstruction
How are pseudocysts managed?
Only treated if symptomatic or enlarging (>6cm)
May be treated endoscopically, radiologically or surgically… how??
When would you consider IV Abx in patients admitted with pancreatitis? Which Abx therapy is used?
Only indicated in patient with associated cholangitis or necrotising pancreatitis with suspicion of infection/abscess IV meropenem (broad spectrum, good tissue penetration) and early involvement of ID team
When is NJT indicated over NGT?
In setting of gastric stasis
Other indications??
Usually try NGT initially and monitor response
Describe the “step up” approach in management of pancreatic necrosis
IV Abx
Percutaneou drainage of peripancreatic space/collections
Up-size the drain
Consider percutaneous necrosectomy (retroperitoneal or intraperitoneal approach)
If all fail: consider open necrosectomy
N.B. Don’t want to do this early (may cause extra damage, risk precipitating another SIRS), wait at least 3 weeks
Management of acute pancreatitis
Conservative/supportive (analgesia, IV fluids, ?O2)
Interventions for complications
Long term: identify and treat cause
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