3 - Pancreatitis And Cholecystitis Flashcards by Samuel Halajian

Most cases of pancreatitis are:

Mild - involve only mild inflammation of the pancreas

Generally resolves with supportive care

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Risk factors for pancreatitis

Smoking
DM
Obesity

Gallstones
Alcohol consumption

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MCC’s of pancreatitis

Gallstones
EtOH
Idiopathic

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Sxs of acute pancreatitis

Acute, severe, persistent abd pain

N/V

Anorexia

Decrease oral intake

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Pain of pancreatitis

Epigastrium or occasionally in the left or right upper quadrants

May radiate to the back, chest, or flanks

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What kind of pain is highly unlikely to be pancreatitis

Lower abdominal pain, dull or colicky pain

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Cullen’s Sign

Belly button

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Grey-Turner

Flanks

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Formal dx of pancreatitis

Looks like pancreatitis
Lipase/amylase high
Imaging

Need at least two of three criteria

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Gold standard for lab (pancreatitis)?

None

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Which is better - amylase or lipase?

Lipase better for dx’ing

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Imaging for pancreatitis

CT Abdomen pelvis with IV contrast

However, if they meet criteria, you don’t HAVE to get imaging - just treat it - you’ve clinically diagnosed it

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Characteristic findings on CT

Parenchymal inflammation
Parenchymal necrosis
Peripancreatic fluid collection
Pancreatic pseudocyst

(do not need to memorize)

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Txt for pancreatitis

Supportive

Rehydration

2 to 4 L of fluid q 12 to 24 hrs

Txt the pain and nausea

No ABX

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Local complications

Gastric outlet syndrome
Walled off necrosis
Splenic and portal vein thrombosis
Acute peripancreatic fluid collection

don’t need to memorize

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MC’ly used scoring for pancreatitis

Ranson

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SIRS (+) persistent for 48hrs good predictor of:

Acute pancreatitis

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Features of criteria for predicting pancreatitis severity

> 55yrs
Obese
AMS
Comorbidities
BUN > 20
Crit > 44%
Increase creat

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Consider admission for:

First time pancreatitis
Biliary pancreatitis
High pain med need
Not able to drink / eat
Persistent abnormal V/S
And sign of organ insufficiency

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When its biliary pancreatitis
And it don’t look good
Who you gonna call???

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Surgeon, not medicine

Or the Ghostbusters, providers choice

Mortality worse for acute or chronic pancreatitis?

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Acute

MC complication of gallstone disease?

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Biliary colic

What is uncommon but life-threatening for the gallbladder?

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Perforation

Emphysematous cholecystitis

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Gas-producing organisms

Acute acalculous cholecystitis occurs in the absence of:

Gallstones Much less common but more serious Occurs in the setting of critical illness like septic shock, burns, major trauma, or surgery Old age, DM, immunosuppression are risk factors

Biliary colic - pattern of pain

Coincides with meals, usually Typically mild RUQ tenderness without peritoneal signs MURPHY’S SIGN

What is rarely seen with acute cholecystitis?

Jaundice

Study of choice for acute cholecystitis

Charcot’s Triad

Fever RUQ pain Jaundice CHOLANGITIS Pentad? Add AMS and shock (seen in less than 10% of cholangitis patients)

Differential for gallbladder stuff (RUQ)

Could be appendix displaced superiorly Could be chest stuff

Labs for cholecystitis

WBC’s CRP Get LFT’s

Why are plain films pointless?

Most stones don’t have enough calcium to show up Thats why we use US (study of choice)

Sonographic Murphy’s sign

Find the gallbladder Compress the gallbladder with the probe (+) pain reproduced - identified gallbladder as source of inflammation

Good diagnostic tools for cholecystitis

Presence of stone on US Sonographic Murphy’s sign

If we see a large CBD, plan for:

MRCP (probably a stone causing obstruction)

Can i r/o choledocholithiasis with US or CT?

Nope

Normal common bile duct diameter

You’re allowed 6mm up to age 60yrs (i.e. 6.1mm = enlarged) You’re allowed another mm each decade after 60yrs If gallbladder was removed, they’re allowed up to 10mm of enlargement MEMORIZE THIS STUFF

Preferred initial imaging for acute cholecystitis

Slide 54

Good chart of what findings go with what tests

ED management for acute cholecystitis

Prophylactic ABX NPO mIVF NSAIDs / opioids (try to avoid opioids if possible)

If it’s biliary colic and they’re stable:

You can discharge to follow-up with a general surgeon (with instructions to return to ED if shit gets worse)

Pt with acute cholecystitis or cholangitis

ADMIT! They’re really sick Probably need CCU

Emphysematous cholecystitis - study of choice>?

IV contrast CT (to see air form gas-producing bacteria)

Emphysematous cholecystitis prognosis

15% mortality - yikes

Acalculous cholecystitis most commonly occurs in what setting?

Patients with critical illness

Complications of acalculous cholecysititis

Gangrene | Perf

If it looks like cholecystitis but they don’t have a gallbladder, consider:

Retained stone

Billy has 32 candy bars, he eats 28 of them. What does Billy have now?

Diabetes

3 - Pancreatitis And Cholecystitis Flashcards

(48 cards)