Severe Upper Abdominal Pain

Question 1

In which abdominal pathology can you have flank tenderness and bruising?

Answer 1

Haemorrhagic pancreatitis

Question 2

What is the significance of serum calcium levels in pancreatitis?

Answer 2

Hypercalcaemia can rarely cause pancreatitis

Pancreatitis can cause hypocalcaemia

Question 3

Why is a chest x-ray ordered in the case of epigastric pain, of whose you think is an abdominal pathology?

Answer 3

To check for free gas under diaphragm, in case of perforated ulcer

Question 4

What score is used to measure severity of pancreatitis?

Answer 4

Ranson score

Question 5

What is the Ranson scoring system?

Answer 5

On admission
- Age >55
- Blood glucose >11
- LDH >300
- ALT >250
- WCC >16
At 48 hours
- Hct fall >10%
- Ureaa rise >0.8
- Ca <2.0
- PO2 <60
- Base deficit >4
- Fluid sequestration >6
3+ factors predicts severe pancreatitis

Question 6

What fluids are required in pancreatitis?

Answer 6

Normal saline

Hartmann’s solution

Question 7

What are the early complications of acute pancreatitis?

Answer 7

Hypoxia
Renal failure/impairment
Hypovolaemic shock
Pancreas necrosis and sepsis

Question 8

What is systemic inflammatory response to shock (SIRS)?

Answer 8

Identical clinical syndrome to sepsis, but complicates noninfectious infectious insult

Question 9

What is sepsis?

Answer 9

Clinical syndrome complicating severe infection
Characterised by signs of inflammation occurring in tissues remote from infection
- Vasodilation
- Leukocyte accumulation
- Increased microvascular permeability

Question 10

What is septic shock?

Answer 10

Sepsis + shock needing resuscitation

Question 11

What is adult respiratory distress syndrome (ARDS)?

Answer 11

Lung’s generic response to insult/injury/inflammation

High FiO2 and low pO2

Question 12

What are the principles of management of ARDS?

Answer 12

Treat underlying cause
Avoid further damage to lungs - protective ventilation
Supportive intensive care

Question 13

What are the acute complications of pancreatitis?

Answer 13

Necrotising pancreatitis
Infected pancreatic necrosis
Pancreatic fluid collections

Question 14

What complication can follow the acute complications of pancreatitis?

Answer 14

Pseudocyst

Question 15

What is a pseudocyst?

Answer 15

Persistent fluid collection in lesser omentum, due to obstruction of foramen of Winslow, after 4 weeks

Question 16

What is the clinical presentation of a pseudocyst?

Answer 16

Pain
Gastric outlet obstruction
Found on CT/US

Question 17

What are the principles of management of a pseudocyst?

Answer 17

Treat only if symptomatic/enlarging >6 cm

Question 18

When are antibiotics indicated in pancreatitis?

Answer 18

If have associated cholangitis

Necrotising pancreatitis with suspicion of infection/abscess

Question 19

What are the surviving sepsis guidelines?

Answer 19

Within 3 hours of presentation
- Measure lactate levels
- Blood cultures
- Administer broad spectrum Abx
- Fluids for hypotension
Within 6 hours of presentation
- Vasoconstrictors if hypotension not responding to fluid resuscitation
- If hypotension persistent/high lactate > re-assess fluid status and tissue perfusion > document findings
- Remeasure lactate if initially high