Surgery - General Surgery (Abdomen) Flashcards
Causes of Generalised abdominal pain
Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
Causes of RUQ pain
Biliary colic
Acute cholecystitis
Acute cholangitis
Causes of epigastric pain
Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm
Causes of central abdominal pain
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
Early stages of appendicitis
Causes of right iliac fossa pain
Acute appendicitis Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion Meckel’s diverticulitis
Causes of left iliac fossa pain
Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Causes of suprapubic pain
Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis
Causes of loin to groin pain
Renal colic (kidney stones) Ruptured abdominal aortic aneurysm Pyelonephritis
Causes of Testicular pain
Testicular torsion
Epididymo-orchitis
Causes of peritonitis
Spontaneous bacterial peritonitis (ascites, liver disease)
Generalised peritonitis (abdominal organ perforation)
Localised peritonitis (underlying organ inflammation)
Investigations for acute abdomen
CBC Urea and electrolytes LFTR CRP Amylase INR Lactate Arterial blood gas Blood culture
Imaging for acute abdomen
Abdominal X-ray: bowel obstruction
Chest X-ray: air under diaphragm for intra-abdominal perforation/ pneumoperitoneum
Ultrasound: gallstones, biliary duct dilatation and gynaecological pathology
CT abdomen: acute abdomen and determine correct management
Initial management of acute abdomen
Nil by mouth NG tube IV resuscitation IV antibiotic coverage Analgesia
Venous thromboembolism risk assessment
Define McBurney’s point
area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus.
Classical features of appendicitis
Loss of appetite (anorexia)
Nausea and vomiting
Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)
Guarding on abdominal palpation
Peritonitis: Rebound tenderness in the RIF, Percussion tenderness
Ddx of acute appendicitis
Ovarian Cysts - pelvic and iliac fossa pain
Meckel’s Diverticulum - malformation of the distal ileum, inflamed, rupture or cause a volvulus or intussusception
Mesenteric Adenitis - inflamed abdominal lymph nodes, preceding URTI acute
Appendix Mass
Management of acute appendicitis
Open Appendicectomy
Laparoscopic appendectomy
Complications of appendectomy
Bleeding, infection, pain and scars
Damage to bowel, bladder or other organs
Anaesthetic risks Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
Causes of IO
Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)
Volvulus (large bowel)
Diverticular disease
Strictures (e.g., secondary to Crohn’s disease)
Intussusception
Causes of intestinal adhesion
Abdominal or pelvic surgery (particularly open surgery)
Peritonitis
Abdominal or pelvic infections (e.g., pelvic inflammatory disease)
Endometriosis
Causes of closed-loop obstruction
Adhesion
Hernia
Volvulus
Ileocaecal valve competency
Presentation of IO
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
“Tinkling” bowel sounds may be heard in early bowel obstruction
Upper limits of normal bowel diameter
3 cm small bowel
6 cm colon
9 cm caecum
Distinguish small and large bowel on X-ray
Valvulae conniventes and central - small bowel
Haustration and peripheral - large bowel
Complications of IO
Hypovolaemic shock due to fluid stuck in the bowel rather than the intravascular space (third-spacing)
Bowel ischaemia
Bowel perforation
Sepsis
Initial management of IO
Nil by mouth
IV fluid resuscitation
NG tube with free drainage
Abdominal x-ray
Erect chest x-ray
Contrast abdominal CT scan
Surgical intervention for IO
Conservative management as first instance in stable patients with obstruction secondary to adhesions or volvulus
Exploratory surgery in patients with an unclear underlying cause
Adhesiolysis to treat adhesions
Hernia repair
Emergency resection of the obstructing tumour
Causes of ileus
Injury to the bowel
Handling of the bowel during surgery
Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)
S/S of ileus
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)
Management of ileus
Nil by mouth or limited sips of water
NG tube if vomiting
IV fluids to prevent dehydration and correct the electrolyte imbalances
Mobilisation to helps stimulate peristalsis
Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function
2 major types of volvulus
Sigmoid volvulus
Caecal volvulus
Major cause of sigmoid volvulus
chronic constipation and lengthening of the mesentery attached to the sigmoid colon. The sigmoid colon becomes overloaded with faeces, causing it to sink downwards causing a twist.
Risk factors for volvulus
Neuropsychiatric disorders (e.g., Parkinson’s) Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions
Presentation of volvulus
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Imaging for volvulus
Abdominal x-ray can show the “coffee bean” sign in sigmoid volvulus
contrast CT scan for Dx
Management for volvulus
Laparotomy (open abdominal surgery)
Hartmann’s procedure for sigmoid volvulus (removal of the rectosigmoid colon and formation of a colostomy)
Ileocaecal resection or right hemicolectomy for caecal volvulus
Complications of hernias
Incarceration of bowel > obstruction and strangulation of the hernia
Obstruction > vomiting, generalised abdominal pain and absolute constipation
Strangulation > ischemic bowel
General management of abdominal wall hernias
Conservative management: hernia has a wide neck (low risk of complications)
Tension-free repair (surgery): mesh over the defect in the abdominal wall, sutured to the muscles and tissues on either side of the defect, tissues grow into the mesh
Tension repair (surgery): surgical operation to suture the muscles and tissue on either side of the defect back together
Ddx for lump in the inguinal region
Femoral hernia Lymph node Saphena varix (dilation of saphenous vein at junction with femoral vein in groin) Femoral aneurysm Abscess Undescended / ectopic testes Kidney transplant
Direct inguinal hernia:
- Location, boundaries
- Reducibility
Hesselbach’s triangle: (RIP mnemonic):
R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border
Pressure over the deep inguinal ring will not stop the herniation
Femoral hernia
- Explain the high risk of bowel complications (incarceration, obstruction, strangulation)
Involves herniation of bowel content through femoral canal
Opening of femoral ring is narrow, and femoral canal is long and narrow
Boundaries of femoral canal
Boundaries of the femoral canal (FLIP mnemonic):
F – Femoral vein laterally
L – Lacunar ligament medially
I – Inguinal ligament anteriorly
P – Pectineal ligament posteriorly
Boundaries of femoral triangle
SAIL mnemonic:
S – Sartorius – lateral border
A – Adductor longus – medial border
IL – Inguinal Ligament – superior border
Contents of the femoral canal
NAVY-C mnemonic
N – Femoral Nerve A – Femoral Artery V – Femoral Vein Y – Y-fronts C – Femoral Canal (containing lymphatic vessels and nodes)
Spigelian hernia
- Location
Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris. At the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall
Cause of diastasis recti
widening of the linea alba, the connective tissue that separates the rectus abdominis muscle
congenital (in newborns)
weakness in the connective tissue, for example following pregnancy or in obese patients
Obturator hernia
- Location
- Causes
- Presentation
through the obturator foramen at the bottom of the pelvis
defect in the pelvic floor and are more common in women, particularly in older age, after multiple pregnancies and vaginal deliveries
may present with irritation to the obturator nerve: Howship–Romberg sign: pain extending from the inner thigh to the knee when the hip is internally rotated
Hiatus hernia presentation
Hiatus hernias present with dyspepsia (indigestion), with symptoms of:
Heartburn Acid reflux Reflux of food Burping Bloating Halitosis (bad breath)
Repair of hiatus hernia
laparoscopic fundoplication
tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter
Risk factors for haemorrhoids
pregnancy, obesity, increased age and increased intra-abdominal pressure (e.g., weightlifting or chronic coughing), constipation
4 degrees of haemorrhoids
1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
4th degree: prolapsed permanently
Symptoms of haemorrhoids
onstipation and straining.
painless, bright red bleeding, typically on the toilet tissue or seen after opening the bowels. The blood is not mixed with the stool
Sore / itchy anus
Feeling a lump around or inside the anus
Examination for 2 types of haemorrhoids
External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa
Internal haemorrhoids may be felt on a PR exam
Prolapse if the patient is asked to “bear down” during inspection
Ddx of rectal bleeding
Haemorrhoids Anal fissures Diverticulosis Inflammatory bowel disease Colorectal cancer
Topical treatment of haemorrhoifs
Anusol (contains chemicals to shrink the haemorrhoids – “astringents”) Anusol HC (also contains hydrocortisone – only used short term) Germoloids cream (contains lidocaine – a local anaesthetic) Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only)
Non-surgical treatment of haemorrhoids
Rubber band ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply)
Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy)
Infra-red coagulation (infra-red light is applied to damage the blood supply)
Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)
Surgical options for haemorrhoid
Haemorrhoidal artery ligation - involves using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply.
Haemorrhoidectomy - involves excising the haemorrhoid. Removing the anal cushions may result in faecal incontinence.
Stapled haemorrhoidectomy - involves using a special device that excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal. The staples remain in place long-term.
1 complication of haemorrhoids
Presentation
Thrombosed Haemorrhoids
caused by strangulation at the base of the haemorrhoid, resulting in thrombosis
appear as purplish, very tender, swollen lumps around the anus.
Define diverticulum, diverticulosis, diverticulitis
diverticulum (plural diverticula) is a pouch or pocket in the bowel wall
Diverticulosis refers to the presence of diverticula, without inflammation or infection.
Diverticulitis refers to inflammation and infection of diverticula
Risk factors of diverticulosis
increased age. Low fibre diets, obesity and the use of NSAIDs
Typical presentation of diverticulosis
Management
Presentation: lower left abdominal pain, constipation or rectal bleeding
Mx: increased fibre in the diet and bulk-forming laxatives, weight loss
Presentation of acute diverticulitis
Pain and tenderness in the left iliac fossa / lower left abdomen
Fever
Diarrhoea
Nausea and vomiting
Rectal bleeding
Palpable abdominal mass (if an abscess has formed)
Complications of acute diverticulitis
Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction
Define foregut, midgut and hindgut blood supply
The foregut includes the stomach and part of the duodenum, biliary system, liver, pancreas and spleen. This is supplied by the coeliac artery.
The midgut is from the distal part of the duodenum to the first half of the transverse colon. This is supplied by the superior mesenteric artery.
The hindgut is from the second half of the transverse colon to the rectum. This is supplied by the inferior mesenteric artery.
Chronic mesenteric ischaemia
- cause
- typical triad of presentation
- Diagnosis
Cause: narrowing of the mesenteric blood vessels by atherosclerosis
- Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours)
- Weight loss (due to food avoidance, as this causes pain)
- Abdominal bruit may be heard on auscultation
Diagnosis is by CT angiography.
Risk factors for Chronic mesenteric ischaemia
Increased age Family history Smoking Diabetes Hypertension Raised cholesterol
Surgical Management of chronic mesenteric ischaemia
Endovascular procedures first-line (i.e. percutaneous mesenteric artery stenting) Open surgery (i.e endarterectomy, re-implantation or bypass grafting)
Acute mesenteric ischaemia
- Cause
- Presentation
- Complication
- Diagnosis
rapid blockage in blood flow through the superior mesenteric artery, thrombus or embolus
acute, non-specific abdominal pain
shock, peritonitis and sepsis, necrosis of the bowel tissue and perforation, metabolic acidosis and raised lactate
Contrast CT is the diagnostic test
Risk factors for CRC
Family history of bowel cancer
Familial adenomatous polyposis (FAP)
Hereditary nonpolyposis colorectal cancer (HNPCC),
Inflammatory bowel disease (Crohn’s or ulcerative colitis)
Increased age Diet (high in red and processed meat and low in fibre) Obesity and sedentary lifestyle Smoking Alcohol
Red flag signs for CRC
Change in bowel habit (usually to more loose and frequent stools)
Unexplained weight loss
Rectal bleeding
Unexplained abdominal pain
Iron deficiency anaemia (microcytic anaemia with low ferritin)
Abdominal or rectal mass on examination
Screening test for CRC
Faecal immunochemical tests (FIT)
Investigations for CRC
Colonoscopy is the gold standard
Sigmoidoscopy (for rectal bleeding only presentation)
CT colonography
Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP) - metastasis
Carcinoembryonic antigen (CEA) - tumour marker
Surgical treatment options for CRC
Open or Laparoscopic
5 types of colon resection
Right hemicolectomy - removal of the caecum, ascending and proximal transverse colon.
Left hemicolectomy - removal of the distal transverse and descending colon.
High anterior resection - removing the sigmoid colon (may be called a sigmoid colectomy).
Low anterior resection - removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.
Abdomino-perineal resection (APR) - removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus
Complication of bowel surgery
Bleeding, infection and pain Damage to nerves, bladder, ureter or bowel Post-operative ileus Anaesthetic risks Laparoscopic surgery converted during the operation to open surgery (laparotomy) Leakage or failure of the anastomosis Requirement for a stoma Failure to remove the tumour Change in bowel habit Venous thromboembolism (DVT and PE) Incisional hernias Intra-abdominal adhesions
4 types of stoma, compare function and differences
Colostomy - LIF, flush to skin, solid stool
Ileostomy - RIF, sprouted, liquid stool
Gastrostomy (PEG) - feeding directly into stomach
Urostomy - RIF, ileal conduit, after cystectomy
Surgeries that precede end ileostomy/ end colostomy
End colostomies are permanent after resection of abdomino-perineal resection (APR) - entire rectum and anus removed
End ileostomies are permanent after a panproctocolectomy (total colectomy with removal of the large bowel, rectum and anus)
Function of loop colostomy/ loop ileostomy
temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery
“covering” or “defunctioning” loop colostomy or ileostomy, as they allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function.
Complications of stomas
Psycho-social impact
Local skin irritation
Parastomal hernia
Loss of bowel length leading to high output, dehydration and malnutrition
Constipation (colostomies)
Stenosis
Obstruction
Retraction (sinking into the skin)
Prolapse (telescoping of bowel through hernia site)
Bleeding
Granulomas causing raised red lumps around the stoma
Risk factor for gallstones
F – Fat
F – Fair
F – Female
F – Forty
Typical presentation of gallstones
biliary colic
Severe, colicky epigastric or right upper quadrant pain
Often triggered by meals (particularly high fat meals)
Lasting between 30 minutes and 8 hours
May be associated with nausea and vomiting
Complications of gallstones
Acute cholecystitis
Acute cholangitis
Obstructive jaundice (if the stone blocks the ducts)
Pancreatitis
Investigations and treatment for gallstones
Ultrasound (first-line) - diagnostic only
A magnetic resonance cholangio-pancreatography (MRCP) - diagnostic only
endoscopic retrograde cholangio-pancreatography (ERCP) - diagnostic and therapeutic
Cholecystectomy (open or laproscopic) - therapeutic only
Complications of ERCP
Excessive bleeding
Cholangitis (infection in the bile ducts)
Pancreatitis
Procedures performed through ERCP
Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures)
Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow)
Clear stones from the ducts
Insert stents to improve bile duct drainage (e.g., with strictures or tumours)
Take biopsies of tumours
Complications of cholecystectomy?
Bleeding, infection, pain and scars
Damage to the bile duct including leakage and strictures
Stones left in the bile duct
Damage to the bowel, blood vessels or other organs
Anaesthetic risks
Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
Post-cholecystectomy syndrome
Define post-cholecystectomy syndrome
Symptoms after cholecystectomy, may be attributed to changes in the bile flow after removal of the gallbladder
Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence
Acute cholecystitis
- Causes (2)
- Typical presentation
gallstones (calculous cholecystitis) - 95%
acalculous cholecystitis - functional disability due to TPN or long fasting periods
right upper quadrant (RUQ). This may radiate to the right shoulder.
Fever
Nausea
Vomiting
Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate)
Right upper quadrant tenderness
Murphy’s sign
Raised inflammatory markers and white blood cells
Specific sign for acute cholecystitis
Murphy’s sign is suggestive of acute cholecystitis:
- Place a hand in RUQ and apply pressure
- Ask the patient to take a deep breath in
- The gallbladder will move downwards during inspiration and come in contact with your hand
- Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration
Investigations for acute cholecystitis
1) abdominal ultrasound scan:
Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder
2) Magnetic resonance cholangiopancreatography (MRCP)
Management of acute cholecystitis
Conservative management involves: Nil by mouth IV fluids Antibiotics (as per local guidelines) NG tube if required for vomiting
Endoscopic retrograde cholangio-pancreatography (ERCP)
Cholecystectomy
Complications of acute cholecystitis
Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation
2 main causes of acute cholangitis
Common pathogens (3)
Obstruction in the bile ducts
Infection introduced during an ERCP procedure
Escherichia coli
Klebsiella species
Enterococcus species
Triad of symptoms for acute cholangitis
Right upper quadrant pain
Fever
Jaundice (raised bilirubin)
Acute management and initial investigations of acute cholangitis
1) Acute management of sepsis and acute abdomen, including:
Nil by mouth
IV fluids
Blood cultures
IV antibiotics (as per local guidelines)
Involvement of seniors and potentially HDU or ICU
2) Imaging to diagnose common bile duct (CBD) stones and cholangitis
Magnetic resonance cholangio-pancreatography (MRCP)
Endoscopic ultrasound
Treatment of acute cholangitis
endoscopic retrograde cholangio-pancreatography (ERCP): contrast, stone removal, balloon dilatation, stenting, biopsy
Percutaneous transhepatic cholangiogram (PTC) involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts
Cholangiocarcinoma
- Histological type
- Location (most common)
- Risk factors
adenocarcinomas inside the liver (intrahepatic ducts) or outside the liver (extrahepatic ducts)
most common site is in the perihilar region
Ulcerative colitis
Primary sclerosing cholangitis
Liver flukes (a parasitic infection)
Presentation of cholangiocarcinoma
Obstructive jaundice:
Pale stools
Dark urine
Generalised itching
Unexplained weight loss
Right upper quadrant pain
Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
Hepatomegaly
Explain courvoisier’s law
palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic head cancer.
Investigations for cholangiocarcinoma
Diagnosis is based on imaging (CT or MRI) plus histology from a biopsy.
Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP)
CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in cholangiocarcinoma. It is also raised in pancreatic cancer
Magnetic resonance cholangio-pancreatography (MRCP)
Endoscopic retrograde cholangio-pancreatography (ERCP)
Management of cholangiocarcinoma
Stents inserted to relieve the biliary obstruction
Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
Palliative chemotherapy
Palliative radiotherapy
End of life care with symptom control
Pancreatic cancer
- Typical presentation
- Painless obstructive jaundice: Yellow skin and sclera Pale stools Dark urine Generalised itching
- other presenting features:
Non-specific upper abdominal or back pain
Unintentional weight loss
Palpable mass in the epigastric region
Change in bowel habit
Nausea or vomiting
New‑onset diabetes or worsening of type 2 diabetes
Trousseau’s sign of malignancy?
refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma
Investigations for pancreatic cancer
imaging (usually CT scan) plus histology
Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP)
CA 19-9 (carbohydrate antigen)
Magnetic resonance cholangio-pancreatography (MRCP)
Endoscopic retrograde cholangio-pancreatography (ERCP)
Biopsy under US or CTG
Management of pancreatic cancer (4 types of surgical treatment)
Total pancreatectomy
Distal pancreatectomy
Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
Radical pancreaticoduodenectomy (Whipple procedure)
Palliative treatment for pancreatic cancer
Stents inserted to relieve the biliary obstruction
Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
Palliative chemotherapy (to improve symptoms and extend life)
Palliative radiotherapy (to improve symptoms and extend life)
End of life care with symptom control
Describe extent of organ removal in whipple procedure
Whipple procedure (pancreaticoduodenectomy)
Head of the pancreas Pylorus of the stomach Duodenum Gallbladder Bile duct Relevant lymph nodes
Describe modified whipple procedure
pylorus-preserving pancreaticoduodenectomy (PPPD).
Removing: Head of the pancreas Duodenum Gallbladder Bile duct Relevant lymph nodes
3 most common causes of acute pancreatitis
Gallstones (bile reflux back into pancreas)
Alcohol (direct toxicity)
Post-ERCP
Others: S – Steroids T – Trauma A – Autoimmune M – Mumps
Typical presentation of acute pancreatitis
Severe epigastric pain Radiating through to the back Associated vomiting Abdominal tenderness Systemically unwell (e.g., low-grade fever and tachycardia)
Investigations for acute pancreatitis
- Glasgow score: FBC (for white cell count) U&E (for urea) LFT (for transaminases and albumin) Calcium ABG (for PaO2 and blood glucose)
- Severity:
serum amylase 3x upper limit of normal
CRP
Ultrasound
CT abdomen for complications (such as necrosis, abscesses and fluid collections)
Criteria for Glasgow score
PANCREAS mnemonic (1 point for each answer):
P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10)
Management of acute pancreatitis
Management involves:
Initial resuscitation (ABCDE approach)
IV fluids
Nil by mouth
Analgesia
Careful monitoring
Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
Complications of acute pancreatitis
Necrosis of the pancreas Infection in a necrotic area Abscess formation Acute peripancreatic fluid collections Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis Chronic pancreatitis
Complications of chronic pancreatitis
Chronic epigastric pain lack of pancreatic enzymes Loss of insulin, leading to diabetes strictures resulting in obstruction of pancreatic juice and bile pseudocysts or abscesses
Management of chronic pancreatitis
Abstinence from alcohol and smoking
Analgesia
Replacement pancreatic enzymes (Creon)
Subcutaneous insulin regimes
ERCP with stenting
Surgery for complications (chronic pain, biliary obstruction, abscess…)
Contraindication for liver transplant
Significant co-morbidities (e.g., severe kidney, lung or heart disease)
Current illicit drug use
Continuing alcohol misuse (generally 6 months of abstinence is required)
Untreated HIV
Current or previous cancer (except certain liver cancers)
