Upper Abdominal Pain Flashcards
Where is Hartmann’s pouch, and what is its relevance?
In gallbladder
Can get stone stuck in there > acute cholecystitis
What is inside Calot’s triangle?
Cystic artery
Cystic node
What is the venous drainage of the gallbladder?
Drained directly into liver via series of small veins
Therefore, cancer of gallbladder goes straight to liver
What is the clinical presentation of biliary colic?
Episodic In epigastrium and right subcostal to right infrascapular After fatty meals - 30 min-2 hours Lasts at least 15 min Associated nausea Usually abdominal exam normal
Why does biliary colic occur after fatty meals?
CCK released > gallbladder contracts > stone obstructs opening
Why can you sometimes get left-sided pain with gallstones?
Embryologically, gallbladder central organ, so pain can be either side
What is the gold standard for diagnosis of gallstones?
Ultrasound
Seen as acoustic shadow behind stone
What is the normal diameter of the bile duct?
Usually 3-4 mm
Dilates to 8-10 mm after cholecystectomy
What are cholestatic symptoms?
Jaundice
Dark urine
Pale stools
What is the clinical presentation of pancreatitis?
Sudden onset Severe epigastric pain radiating to back Nausea and vomiting Unwell Lying very still Raised lipase Deranged LFTs
Why can breath sounds be reduced at the bases in acute pancreatitis?
Big breath > diaphragm impinges on pancreas
What is the relationship between deranged serum calcium and pancreatitis?
Hyper-calcaemia rare cause of pancreatitis
Pancreatitis can cause hypocalcaemia
What are hypoxia and acidosis in acute pancreatitis markers of?
Severe pancreatitis
Why is an erect chest x-ray done whilst investigating upper abdominal pain?
?Free gas under diaphragm
Why are patients with their first bout of pancreatitis often sent to ICU?
Usually most severe episode
What are the four most common causes of acute pancreatitis?
Idiopathic
Gallstones
Ethanol
Trauma
What is LDH in acute pancreatitis a marker of?
Severity
Why is CT performed in acute pancreatitis?
Usually not needed to make diagnosis
Performed at weekly intervals in severe pancreatitis to demonstrate complications
What is a complication of ERCP?
Iatrogenic pancreatitis
What is the Ranson scoring system used for?
Assessing severity of pancreatitis
What is the management for mild pancreatitis?
Fasting
Analgesia
Gallstone pancreatitis
- Laparoscopic cholecystectomy + operative cholangiogram once pancreatitis resolved
What is the management for severe pancreatitis?
Supportive care - Admit to ICU - Fluid resuscitation - O2 +/- ventilation - Inotropes - Haemofiltration - Analgesia Specific measures - ERCP - Abx - Nutrition Treat complications
What are the complications of severe pancreatitis, and how are they treated?
Infected necrosis - Open, minimally invasive/endoscopic necrosectomy Pancreatic abscess - Ope/percutaneous drainage Pancreatic pseudocyst - Usually resolves if 6 cm or less - Otherwise, surgical drainage into stomach/small intestine/endoscopic drainage into stomach Haemorrhage - Embolisation
What is Charcot’s triad?
Pain
Fever
Obstructive jaundice
What do dark urine and pale stools mean?
Obstructive jaundice
What is Charcot’s triad a clinical presentation of?
Acute cholangitis
What is the management for cholangitis?
Life-threatening!
Resuscitation
Broad spectrum Abx
- Ampicillin + gentamicin +/- metronidazole/tazobactam + pipericillin
Early (within 24 hours) ERCP/endoscopic sphincterotomy/extraction of stone
Laporoscopic cholecystectomy (within 3 weeks)
How can cholangitis cause septicaemia?
Bile usually has low-grade bacteria > obstruction > stasis > bacteria multiply > high back pressure pushes bacteria to liver > enter blood stream > septicaemia
Of what is painless jaundice a hallmark?
Carcinoma of head of pancreas
What is Courvoisier’s sign?
Non-tender, palpable gallbladder under right costal margin
What is CA19.9 a tumour marker for?
Pancreatic
Gallbladder
Common bile duct
Why can you get coagulopathy if you have jaundice?
Bile not flowing > fat-soluble vitamins not being absorbed, including vitamin K
Which cancer survivals are measured in two years, not five?
Pancreatic cancer
Oesophageal
How is suitability for resection in pancreatic cancer assessed?
Actively look for reasons not to resect = metastases
Exclude advanced local disease
- Superior mesenteric artery encacement
- Coeliac/para-aortic lymphadenopathy
How is pancreatic cancer confirmed if resection is not possible?
Endoscopic US-guided fine needle aspiration
What does palliation for pancreatic cancer involve?
Relieve billiary obstruction, usually with ERCP
- Metal stent if reasonable expectation of survival
- Plastic stent if limited survival
+/- palliative chemotherapy
Supportive care
