Severe Upper Abdominal Pain

Question 1

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?

Answer 1

Pancreatitis
Bleeding peptic ulcer
Perforated peptic ulcer
Cholecystitis, ascending cholangitis

Question 2

28 year old female presented with 24 hours of intermittent epigastric pain with N+V
Initial Ix? Think about why each would be ordered

Answer 2

Blood glucose
FBE
UEC
LFT
Lipase
Erect CXR/AXR
ECG

Question 3

If abnormal LFTs in setting of pancreatitis, what further Ix would you order? What findings would you expect?

Answer 3

Biliary U/S to confirm presence of gallstones

Presence of gallstones, gall bladder wall thickening, ascites

Question 4

Proposed mechanism of gallstone pancreatitis

Answer 4

Obstruction and inflammation ultimately leads to intra-pancreatic zymogen activation and auto-digestion of acinar cells

Question 5

Proposed mechanism of EtOH-induced pancreatitis

Answer 5

EtOH is a direct toxin to the acinar cell, resulting in inflammation and membrane destruction

Question 6

What is the overall mortality rate of acute pancreatitis?

Answer 6

7-9%

Question 7

What is the normal natural Hx of acute pancreatitis?

Answer 7

Most attacks are mild with recovery within a week

Question 8

What is the mortality rate with severe necrotising pancreatitis?

Answer 8

25-30%

Question 9

Ranson scoring system

Answer 9

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

Question 10

Fluid resuscitation in setting of acute pancreatitis

Answer 10

Balanced salt solution (NS or Hartmanns; 10-20 mL/kg), repeat if needed
Maintenance rate start at 30 mL/kg/24 hours

Question 11

CSL

Answer 11

Compound sodium lactate (Hartmanns)

Question 12

Example MET call criteria for adults

Answer 12

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

Question 13

Where should cases of severe pancreatitis be admitted? How should should severe gallstone pancreatitis be definitively managed (controversial)?

Answer 13

To HDU/ICU

Consider early ERCP/ES (controversial but 4 RCTs show survival advantage in severe gallstone pancreatitis)

Question 14

3 early complications of acute pancreatitis

Answer 14

Systemic Inflammatory Response Syndrome/to Shock (SIRS): hypoxia and renal failure/impairment
Hypovolaemic shock
Pancreas necrosis and sepsis

Question 15

What is the difference between sepsis and SIRS?

Answer 15

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

Question 16

Examples of conditions which may precipitate SIRS

Answer 16

Acute pancreatitis
Pulmonary contusion
Others?

Question 17

How do SIRS and sepsis cause mortality?

Answer 17

Lead to Multiple Organ Dysfunction Syndrome (MODS)

Question 18

How can sepsis be differentiated from SIRS?

Answer 18

Cultures
CRP
WCC + blood film

Question 19

What is the range of impacts an infection can have on ea patient?

Answer 19

Initial inflammatory response
Sepsis (with evidence of infective cause)
Septic shock (sepsis plus shock requiring resuscitation; fluids and vasoconstrictors)

Question 20

What is ARDS?

Answer 20

Adult Respiratory Distress Syndrome: generic response of the lungs to insult/injury/inflammation

Question 21

What 2 distinctions can be made in ARDS depending on the underlying mechanism?

Answer 21

Differentiate acute hydrostatic pulmonary oedema (associated with elevated LAP) from pulmonary oedema associated with low LAP as a result of increased capillary permeability

Question 22

Causes of ARDS

Answer 22

Severe pancreatitis

??

Question 23

How is ARDS managed?

Answer 23

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)

Question 24

If a patient with severe pancreatitis, what Ix should be considered and what complications are you looking for?

Answer 24

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??

Question 25

What is a pseudocyst?

Answer 25

Persistent fluid collection after 4 weeks

Question 26

How do patients with a pseudocyst present?

Answer 26

Pain

Gastric outlet obstruction

Question 27

How are pseudocysts managed?

Answer 27

Only treated if symptomatic or enlarging (>6cm)

May be treated endoscopically, radiologically or surgically… how??

Question 28

When would you consider IV Abx in patients admitted with pancreatitis? Which Abx therapy is used?

Answer 28

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

Question 29

When is NJT indicated over NGT?

Answer 29

In setting of gastric stasis
Other indications??
Usually try NGT initially and monitor response

Question 30

Describe the “step up” approach in management of pancreatic necrosis

Answer 30

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

Question 31

Management of acute pancreatitis

Answer 31

Conservative/supportive (analgesia, IV fluids, ?O2)
Interventions for complications
Long term: identify and treat cause

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