EOR GI part 10- acute pancreatitis Flashcards by Deborah Karp

What are the big 4 RFs for cholelithiasis?

Female
Fat
Forty
Fertile (multiparity)

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What are the types of gallstones?

Cholesterol (75%)

Pigment (25%)

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What are the types of pigmented gallstones?

Black stones (contain calcium bilirubinate)
Brown stones (associated with biliary tract infection)

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What are the causes of black pigmented stones?

Cirrhosis

Hemolysis

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What is the pathogenesis of cholesterol stones?

Secretion of bile supersaturated with cholesterol

Then, cholesterol precipitates out and forms solid crystals, then gallstones

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S/sx of cholelithiasis

Biliary colic
cholangitis
Choledocholithiasis
Gallstone
Pancreatitis

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What percentage of pts with gallstones are asympmtomatic?

80% of pts with cholelithiasis are asymptomatic

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What is thought to cause biliary colic?

Gallbladder contraction against a stone temporarily at the gallbladder/cystic duct junction
A stone in the cystic duct
A stone passing through the cystic duct

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What are the five major complications of gallstones?

Acute cholecystitis
Choledocholithiasis
Gallstone pancreatitis
Gallstone ileus
Cholangitis

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How is cholelithiasis diagnosed?

Hx
PE
U/s

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How often does u/s detect choledocholithiasis?

~33% of the time, not a very good study for it

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How are symptomatic or complicated cases of cholilithiasis treated?

Cholecystectomy

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What are the possible complications of a lap chole?

Common bile duct injury
Right hepatic duct/artery injury
Cystic duct leak
Biloma (collection of bile)

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What are the indications for cholecystectomy in the asymptomatic pt?

Sickle-cell dz
Calcified gallbladder (porcelain gallbladder)
Pt is a child

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What is the management of choledocholithiasis?

ERCP with papillotomy and basket/balloon retrieval of stones
Laparoscopic transcystic duct or trans common bile duct retrieval
Open common bile duct exploration

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What medication may dissolve a cholesterol gallstone?

Chenodeoxycholic acid, ursodeoxycholic acid

But, if meds are stopped, gallstones often recur?

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Whatis the major feared complication of ERCP?

Pancreatitis

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Pathogenesis of acute cholecystitis

Obstruction of cystic duct leads to inflammation of the gallbladder
~95% of cases result from calculi
~5% from acalculous obstruction

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RFs for acute cholecystitis

Gallstones

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S/sx of acute cholecystitis

Unrelenting RUQ pain or tenderness
Fever
N/V
Painful palpable gallbladder in 33%
Pos Murphy's sign
R subscapular pain (referred)
Epigastric discomfort (referred)

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What is Murphy’s sign?

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Acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration

Complications of acute cholecystitis

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Abscess
Perforation
Choledocholithiasis
Cholecystenteric fistula formation
Gallstone ileus

What lab results are associated with acute cholecystitis?

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Increased WBC
May have:
Slight elevation in alkaline phosphatase, LFTs
Slight elevation in amylase, total bilirubin

What are the signs of acute cholecystitis on ultrasound?

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Thickened gallbladder wall (>3 mm)
Pericholecystic fluid
Distended gallbladder
Gallstones present/cystic duct stone
Sonographic Murphy's sign

What is the difference between acute cholecystitis and biliary colic?

Biliary colic has temporary pain Acute cholecystitis has pain that does not resolve, usually with elevated WBCs, fever, and signs of acute inflammation on u/s

Tx of acute cholecystitis

IVFs Abx Early chole

What is cholangitis?

Bacterial infection of the biliary tract from obstruction

Common causes of cholangitis

``` Choledocholithiasis Stricture (usually postop) Neoplasm (usually ampullary carcinoma) Extrinsic compression (pancreatic pseudocyst/pancreatitis) Instrumentation of the bile ducts Biliary stent ```

What is the MCC of cholangitis?

Gallstones in common bile duct (choledocholithiasis)

S/sx of cholangitis

Charcot's triad: Fever/chills RUQ pain Jaundice

What is Reynold's pentad?

Charcot's triad plus: Mental status changes Shock

Which organisms are commonly associated with cholangitis?

Gram-neg organisms (E. coli, Klebsiella, Pseudomonas, Enterobacter, Proteus, Serratia) are the most common

Diagnostic tests of choice for cholangitis

Ultrasound and contrast study (e.g. ERCP or IOC) after pt has "cooled off" with IV abx

What is suppurative cholangitis?

Severe infection with sepsis

Management of cholangitis

Nonsuppurative: IVF and abx, with definitive tx later Suppurative: IVF, abx, and decompression can be obtained with ERCP with papillotomy, PTC with cath drainage, or laparotomy with T-tube placement

What are the MC etiologies of acute pancreatitis in the US?

EtOH abuse (50%) Gallstones (30%) Idiopathic (10%)

Sx of acute pancreatitis

``` Epigastric pain (frequently radiates to the back) Nausea and vomiting ```

Signs of acute pancreatitis

``` Epigastric tenderness Diffuse abdominal tenderness Decreased bowel sounds (adynamic ileus) Fever Dehydration/shock ```

What lab tests should be ordered for acute pancreatitis?

Amylase/lipase

What are the associated diagnostic findings for acute pancreatitis?

Lab- High amylase, high lipase, high WBC AXR- sentinel loop, colon cutoff, possibly gallstones U/s- phlegmon, cholelithiasis CT- phlegmon, pancreatic necrosis

What is the MC sign of acute pancreatitis on AXR?

Sentinel loop(s)

Tx of acute pancreatitis

``` NPO IVF NGT if vomiting Postpyloric tube feeds H2 blocker/PPI Analgesia (not morphine) Correction of coags/electrolytes +/- alcohol withdrawal prophylaxis "Tincture of time" ```

Possible complications of acute pancreatitis

``` Pseudocyst Abscess/infection Pancreatic necrosis Splenic/mesenteric/portal vessel rupture or thrombosis Pancreatic ascites/pancreatic pleural effusion Diabetes ARDS/sepsis/MOF Coagulopathy/DIC Encephalopathy Severe hypocalcemia ```

Prognosis of acute pancreatitis

Based on Ranson's criteria

Are postpyloric tube feeds safe in acute pancreatitis?

Yes

What are Ranson's criteria for acute pancreatitis at presentation?

``` Age >55 WBC >16,000 Glucose >200 AST >250 LDH >350 ```

What are Ranson's criteria for acute pancreatitis during the intial 48 hrs?

``` Base deficit >4 BUN increase >5 mg/dL Fluid sequestration >6 L Serum Ca <8 Hct decrease >10% PO2 (ABG) <60 mm Hg ```

What is the etiology of hypocalcemia with pancreatitis?

Fat saponification: fat necrosis binds to calcium

What complication is associated with splenic vein thrombosis?

Gastric varices (tx with splenectomy)

Can TPN with lipids be given to a pt with pancreatitis?

Yes, if the pt does not suffer from hyperlipidemia (triglycerides >300)

What is the least common cause of acute pancreatitis?

Scorpion bite

EOR GI part 10- acute pancreatitis Flashcards

(51 cards)