What are the clinical features of gallstones?
- RUQ pain
- Most are cholesterol, minority are pigment
- Abdominal US will detect 90%
- EUS can detect microlithiasis
What are the clinical features of biliary colic?
- Gallstones usually present (stone obstructing GB neck or cystic duct)
- Acute onset severe RUQ/epigastric pain lasting 4-6hrs
- Pain is usually steady (colic is misnomer)
- Pain relieved as stone passes
What are the clinical features of acute cholecystitis?
- 90% secondary to gallstones
- Risk factors include being female, fat, increasing age, rapid weight loss, pregnancy and drugs (hormonal therapy)
- Pain in epigastrium/RUQ that may worsen on inspiration (Murphy's sign)
- Associated with fever and nausea
- LFTs often deranged (elevated transaminases and ALP, mild hyperalbuminaemia and hyperamylasaemia)
- Jaundice if CBD obstruction
- Usually resolves in 4 days (antibiotics and analgesia)
- GB wall thickened on US
What are the clinical features of biliary sepsis?
- Charcots triad (fever, jaundice, RUQ pain)
- Reynolds pentad includes mental confusion and septic shock
- Causes include gallstones, biliary manipulation and hepatobiliary malignancy
- Obstructive LFTs with raised bilirubin
- May have raised amylase
- Broad spectrum antibiotics and ERCP/PTC
What are the clinical features of acute pancreatitis?
- Acute severe upper abdominal pain, 50% radiates to back and partially relieved by bending forwards
- In severe cases multi organ failure, pleural effusions and ascites
- Jaundice may be present (gallstone disease)
- Cullen's sign (bruising on umbilical region)
- Grey Turner's sign (bruising on flanks)
How is acute pancreatitis diagnosed?
- Elevated serum amylase >3x ULN
- Amylase half-life short so may be on way back down by time measured
- Alcoholic pancreatitis and hypertriglyceridaemia pancreatitis may have lower amylase
- Serum lipase elevated for longer
- Imaging involves CT
What is the aetiology of acute pancreatitis? I GET SMASHED
- Scorpion sting
- Drugs (azathioprine)
What are the clinical features of chronic pancreatitis?
- Inflammatory condition
- Parenchyma replaced with fibrous tissue
- Increased risk of pancreatic cancer
- Erythema ab igne seen in patients using hot water bottle for pain
What is the aetiology of chronic pancreatitis? TIGARO
- Toxic/metabolic (alcohol, tobacco, hyperlipidaemia, CKD)
- Genetic (PRSS1, CTFR, SPINK1)
- RAP/SAP associated (post-necrotic, vascular, post-irradiation)
How is chronic pancreatitis diagnosed?
- Calcification on imaging (100% specific)
- Aspiration of duodenal secretions post secretin/CCK at ERCP
- Secreting enhanced MRCP
- EUR (Rosemount criteria)
- Labelled carbon breath test (test for PEI)
- Wedge biopsy or section of resected pancreas
How is chronic pancreatitis treated?
- Potent analgesia
- Duct drainage
- Address exocrine and endocrine needs
- Smoking cessation
- Alcohol cessation
What is the pathogenesis of pancreatic exocrine insufficiency?
- Reduced secretion due to pancreatic disease
- Low CCK due to duodenal disease
- Acidic duodenal pH due to gastric hypersecretion or low bicarbonate secretion
- Abnormal transit due to surgery
How is pancreatic cancer graded?
- PDAC grading
- A and B are resectable
- C are borderline
- D1, D2 and E are irresectable
What genetic risk factors are associated with pancreatic cancer?