GI Key OSCE Overview Flashcards
1
Q
What is coeliac disease?
In what type of person is it a common presentation?
A
it is an autoimmune condition in which an individual becomes sensitive to gluten
- it is a common presentation in young Caucasians with general non-specific diarrhoea
- there is often abdominal discomfort too - this could be pain or bloating
2
Q
What are the most common symptoms of coeliac disease?
A
- chronic diarrhoea
- abdominal distention
- malabsorption (which can lead to constant fatigue)
- crampy abdominal pains
- loss of appetite
- weight loss
- dermatitis herpetiformis
- some people may be asymptomatic
3
Q
What is dermatitis herpetiformis and why does it have this name?
A
- pruritic papulovesicular lesions which present in a symmetrical distribution
- often present on the elbows, knees and buttocks
- it resembles herpes simplex
4
Q
What increases the genetic risk of coeliac disease?
What other autoimmune conditions is it associated with?
A
- HLA-DQ2 (95%) and HLA-DQ8 (80%)
- it is associated with dermatitis herpetiformis and other autoimmune conditions
- this includes type 1 diabetes, autoimmune hepatitis and autoimmune thyroid disease
5
Q
What do investigations and examinations tend to show in someone with coeliac disease?
A
- examination and imaging tends to be unremarkable
- blood tests will show iron-deficiency anaemia
- patient may also be vitamin D deficient due to malabsorption and diarrhoea
- this contributes to constant fatigue
6
Q
What happens when someone with coeliac disease eats gluten?
How does this lead to iron-deficiency anaemia?
A
- when gluten is consumed, an abnormal immune response leads to the production of autoantibodies
- these can attack various different organs
- in the small bowel, autoantibodies cause an inflammatory reaction that leads to shortening of the villi
- this is villous atrophy
- this means that less nutrients can be absorbed, leading to anaemia
7
Q
What are the first line investigations for someone with suspected coeliac disease?
A
ANTIBODY TESTS
- these are used to identify the presence of any antibodies against gluten
-
tissue transglutaminase (tTG) IgA antibodies
- this is highly sensitive and highly specific
-
endomysial IgA antibodies
- this is to exclude a selective IgA deficiency which could produce a false negative to tTG
8
Q
What is the gold standard test to diagnose coeliac disease?
What must the patient do prior to this test?
A
duodenal biopsy during endoscopy
- if the patient is on a gluten-free diet, they need to resume consumption of gluten >/= 6 weeks before the test
- otherwise they will not form antibodies against gluten and their bowels will look normal
9
Q
What 3 features are looked for on a biopsy in coeliac disease?
A
- blunted villi as a result of subtotal villus atrophy
- crypt hyperplasia
- increased intra-epithelial lymphocytes & infiltration of lamina propria lymphocytes
10
Q
What is meant by villous atrophy?
A
- this occurs when the finger-like villi of the small intestine erode away to leave a virtually flat surface
- this leads to reduced absorption of nutrients from the diet
11
Q
What is crypt hyperplasia and why does it occur in coeliac disease?
A
- the crypts are the site of epithelial stem cells in the intestine
- to replace the loss of enterocytes, the number of actively dividing cells in the crypts increases
- there is elongation of the crypts of Lieberkühn
12
Q
What is the first stage in the management of coeliac disease?
A
starting a gluten-free diet
this involves avoiding:
-
wheat
- e.g. pasta, bread, pastry
-
barley
- e.g. beer
- rye
- people with coeliac disease have variable tolerance to oats
- some people can eat these and some need to avoid them
13
Q
Despite having a gluten-free diet, what can people with coeliac disease still eat?
A
- whisky as this contains malted barley
- rice
- potatoes
- corn / maize
14
Q
What are the other stages involved in the management of coeliac disease?
A
- check for nutritional deficiencies
- iron, vitamin D, vitamin B12, folate
- offer the pneumococcal vaccine, followed by a booster every 5 years
15
Q
Why is the pneumococcal vaccine offered to patients with coeliac disease?
A
- coeliac disease is associated with functional hyposplenism
- the spleen is not functioning as well as normal
- patients are at increased risk of serious infections from encapsulated bacteria
16
Q
What is meant by inflammatory bowel disease (IBD)?
A
- this is an umbrella term for 2 conditions - Crohn’s & UC
- it is characterised by chronic inflammation of the GI tract, with unknown aetiologies
- prolonged inflammation results in damage to the GI tract
17
Q
What are the non-specific symptoms associated with inflammatory bowel disease (IBD)?
A
- diarrhoea
- abdominal pain
-
PR bleeding / bloody stools
- this is much more common in ulcerative colitis than Crohn’s
- weight loss
- fatigue
18
Q
What % of IDB is either Crohn’s or UC?
What is the other %?
A
- 90% of IBD is either Crohn’s or UC
- 10% is indeterminate colitis
- patient has symptoms and diagnostic test results that show IBD, but do not definitively place them into Crohn’s or UC
19
Q
A
20
Q
Which parts of the GI tract are affected in Crohn’s disease?
A
- affects the entire GI tract
- produces patchy inflammation throughout small and large bowel
- it is characterised by the presence of skip lesions
- lesion in one part of the bowel, skip some bowel and then a lesion further on
- there is usually involvement of the distal ileum / ileocaecal junction
21
Q
What type of inflammation is present in Crohn’s disease?
A
transmural inflammation
- this describes inflammation across all layers of the GI tract
22
Q
What is involved in the pathophysiology of ulcerative colitis?
A
- this only affects the large bowel / colon
- there is continuous and uniform inflammation in the large bowel
- sometimes it can extend to the caecum & ileum, but it often does not progress this far
- it continues distally from the anus
23
Q
What type of inflammation is present in ulcerative colitis?
A
inflammation does not go past the submucosa
24
Q
What are the risk factors for inflammatory bowel disease that are the same for both Crohn’s and UC?
A
-
age of onset - there is a biphasic distribution
- it is more common between 15 to 30 and 50 to 80
- Jewish > white > black / hispanic
- positive family history
25
How does smoking impact inflammatory bowel disease?
* smoking **_INCREASES_** the risk of **Crohn's disease**
* smoking **_DECREASES_** the risk of **ulcerative colitis**
* if someone has many vague symptoms and a strong smoking history, it is more likely to be Crohn's disease
26
What are other risk factors that are specific for Crohn's disease?
* **refined sugar**-rich diet
* **oral contraceptive pill**
* **not being breastfed** as a child
* **NSAID** use
27
What are other risk factors that are specific to ulcerative colitis?
* NSAID use
28
What acronym can be used to remember presenting features that occur in both Crohn's and UC?
the acronym **DWARF** can be used
* D - **_Diarrhoea_**
* **UC** is more likely to have **bloody** diarrhoea
* W - **_Weight loss_**
* A - **_Abdominal pain_**
* in **Crohn's**, this is a **crampy RLQ pain** (over ileocaecal valve)
* in **UC**, this pain starts as **crampy** and becomes **very severe**
* R - **_Rectal bleeding_**
* F - **_Fatigue_**
29
What are some presenting features that are specific to Crohn's disease?
* **_aphthous ulcers_**
* **__**ulcers in the mouth as Crohn's can affect the entire GIT
* **arthritis** (in 20% cases)
* cutaneous lesions
* **erythema nodosum**
* **pyoderma gangrenosum**
* features indicating **_fistulae_**
30
What are some presenting features that are specific to ulcerative colitis?
* arthritis / ankylosing spondylitis
* this is less likely than in Crohn's
* **fever**
* cutaneous lesions
* erythema nodosum
* pyoderma gangrenosum
* **episcleritis / uveitis**
31
Why is fistulae formation a risk in Crohn's disease?
* Crohn's disease can affect **_all layers_** of the GI tract
* fistulas form between **2 epithelial surfaces**
* an ulcer/sore forms on the epithelial surface of the gut and **_extends through the entire thickness_** of the bowel wall
32
What is erythema nodosum?
* it is a **panniculitis** - an inflammatory disorder affecting **_subcutaneous fat_**
* it presents as **_tender red nodules_** on the **anterior shins**
* the nodules are due to inflammation of fat cells under the skin
33
What is pyoderma gangrenosum?
* an inflammatory skin disease where **painful pustules or nodules** become **_ulcers_**, which **_progressively grow_**
* it is an enlarging ulcer, but is **not infective**
* it is a **_full thickness ulcer_** with **_blue undermined borders_**
34
What investigations are performed in primary care for suspected Crohn's disease?
* comprehensive blood panel
* **stool sample testing**
this is to rule out infection with ***Yersinia enterocolitica***
35
What are the investigations performed for UC in primary care?
* comprehensive blood panel
* **stool sample testing**
this is to look for the presence of **_faecal calprotectin_**
* this is a sensitive marker for **inflammation of the GI tract**
36
What is the importance of testing for faecal calprotectin in primary care?
* this is used to distinguish between **inflammatory bowel disease (IBD)** and **irritable bowel syndrome (IBS)**
* it is a sensitive marker for **_inflammation of the GI tract_** that will be **_raised in IBD_**
37
What is the gold standard diagnostic test for Crohn's disease and ulcerative colitis?
***_Crohn's disease:_***
* this can be diagnosed based on **colonoscopy**
***_Ulcerative colitis:_***
* colonoscopy alone is not sufficient to diagnose Crohn's
* a **biopsy** is also needed
38
What does Crohn's disease look like on colonoscopy?
* it has a characteristic **_cobblestone_ appearance**
* there will be **_skip lesions_**
* there may also be **ulcerations** and **strictures**
39
What does ulcerative colitis look like on colonoscopy?
* there tends to be **_white plaques of ulceration_**
* these would be biopsied
* there are sometimes **_polyps_**
* more severe cases are associated with **erosions, ulcers** and **spontaneous bleeding**
40
What are the 4 stages of treatment escalation in inflammatory bowel disease?
* **supportive** treatment
* treatment to induce **remission**
* **maintenance** treatment
* **surgery**
* you need to first **_induce remission_** of the inflammation and then try to **_maintain this remission_**
41
What supportive treatment is recommended in Crohn's disease?
smoking cessation
42
What is the stepwise approach to achieving remission in Crohn's disease?
* start with a corticosteroid such as **_prednisolone_** or **_budesonide_**
* **aminosalicylate** (5-ASA) such as **_mesalazine_**
* **azathioprine / mercaptopurine**
* **methotrexate**
* monoclonal antibodies such as **Infliximab / adalimumab**
43
What is involved in the maintenance treatment of Crohn's disease?
* **azathioprine / mercaptopurine**
* **methotrexate**
* methotrexate is needed to induce remission
* this is used in people who are intolerant to thioprines
44
When is surgery considered in Crohn's disease?
* it is considered in patients where the disease is **limited to the _distal ileum_**
* this means that all of the diseased area can be removed
* need to balance between the risks and benefits, plus the risk of recurrence
45
What treatments are involved in the stepwise approach to the remission of ulcerative colitis?
* **_topical_ aminosalicylate (5-ASA)**
* **_oral_ 5-ASA**
* topical / oral **corticosteroids**
* immunomodulative therapies
* anti-TNFa (infliximab / adalimumab)
* anti-integrin (vedolizumab)
* janus kinase inhibitors
46
What treatments are involved in the maintenance of ulcerative colitis remission?
* **topical / oral 5-ASA**
* oral **azathioprine** / **mercaptopurine**
47
What treatment is given for acute severe admission of ulcerative colitis?
* when UC flares up, this is known as **_fulminant colitis_**
* **IV corticosteroids / ciclosporin** will reduce the inflammation
* surgical intervention, which is curative in UC
48
49
What are the acute complications of Crohn's disease?
* **intestinal obstruction**
* **sinus tracts**
* ****this is fistula formation but when the sinus develops into fascia / tissue / muscle rather than just into epithelium
* **toxic megacolon**
50
What is toxic megacolon?
In what IBD is this more common?
* IBDs cause the colon to **expand, dilate** and **distend**
* when this happens, the colon **_traps all the gas and faecal material_** and this **cannot pass out** of the body
* **peristalsis / bowel movements** are still occurring
* this can lead to **_rupture of the colon_**, which is life threatening
51
What are the chronic complications of treatment for Crohn's disease?
* **_pregnancy_** - **methotrexate**, which is used in treatment, is **teratogenic**
* **anaemia**
* malabsorption ./ **_short bowel syndrome_**
* having a shorter bowel following surgery means patient is **absorbing less nutrients & water**
* this leads to **imbalanced U&Es**
52
What are the acute complications of ulcerative colitis?
* **fulminant colitis**
* **toxic megacolon**
* this is more likely to occur in UC than Crohn's
53
What is meant by fulminant colitis?
* this occurs in about 10% of patients with UC when they have:
* **more than 10 stools per day**
* **continuous bleeding**
* abdominal **pain**
* **distention**
* acute, severe toxic symptoms such as fever and anorexia
54
What are the chronic complications of ulcerative colitis?
* **colonic adenocarcinoma**
* colonoscopy surveillance is 10 years post-onset to look for any changes
* **primary sclerosing cholangitis**
55
What is primary sclerosing cholangitis?
a long-term progressive disease of the **liver and gallbladder**
it is characterised by **_inflammation_** and **_scarring of the bile ducts_**
the bile ducts eventually become **blocked**, meaning that **bile can build up** in the liver and cause damage
56
What is the mean age of onset for colorectal carcinoma?
* the mean age of onset is **_67_**
* 60-70% of cases affect the **colon** and 20-30% are **rectal**
57
What are the 3 pathways by which colorectal cancer can develop?
* **chromosomal instability**
* occurs through oncogene and tumour suppressor gene mutations
* **CpG island methylator phenotype**
* promoter methylation epigenetically silences tumour suppressor and mismatch repair genes
* **microsatellite instability**
* this involves inactivated mismatched repair genes
58
What gene can usually be involved in the chromosomal instability pathway leading to colorectal carcinoma?
* **_APC_** is a **tumour suppressor gene**
* if it becomes mutated, this leads to **_epithelial dysplasia_**
* this then leads to **adenoma** and then **carcinoma**
59
What familial condition is mutations in the APC gene linked to?
**_familial adenomatous polyposis_**
this involves numerous small polyps developing in the epithelium of the large intestive
60
What syndrome is CpG island methylator phenotype linked to?
it is linked to **_serrated polyposis syndrome_** that usually affects the **proximal colon**
this leads to the presence of **serrated polyps** in the colon and increases risk of colorectal cancer
61
What syndrome is microsatellite instability linked to?
**_Lynch syndrome_** (also known as HNPCC)
this is a **hereditary predisposition to colorectal cancer**, in which patients are more likely to get cancer before the age of 50
62
What are the risk factors for colorectal cancer?
* **_increasing age_**
* **_family history_** of:
* polyps / colorectal cancer (\<30%)
* Lynch syndrome (\<3%)
* FAP (1%)
* PMH of **polyps**, **chronic IBD** or **acromegaly**
* obesity, smoking & diet
* particularly a diet high in saturated animal fats, red meat
* abdominal radiotherapy or ureterosigmoidostomy
63
What are the key features to pick out in the history of someone with colorectal carcinoma?
* **_PR bleeding_** (this is the major red flag)
* any **_change in bowel habit_**
* diarrhoea
* rectal or stool bleeding / presence of mucus
* tenesmus
* **FLAWS**
* fever, lethargy, appetite change, weight loss, night sweats
* **right-sided disease** tends to have an **_iron-deficiency anaemia_** presentation, rather than changes in bowel habit
64
How do 20% of colorectal cancer cases present acutely?
they may present as **emergency obstruction**, **haemorrhage** or **perforation**
there is a risk of peritonitis (inflammation of the peritoneum) with perforation
65
What are the clinical features of colorectal cancer that will be present on examination?
* clinical features of **_anaemia_**
* conjunctival pallor / pale skin
* cold peripheries
* fatigue
* when **digital rectal exam** is done there will be an **_abdominal or rectal mass_**
* if there are **metastases** there may be **_hepatomegaly, ascites_** or **_palpable abdominal masses_**
66
What test is done in the GP surgery when there is suspected colorectal cancer?
**FIT (faecal immunochemical) test** to detect for **_blood in the stool_**
if this is positive, there is a **2 week wait referral pathway** for suspected cancer
67
68
What components are looked at in the FBC of someone with suspected colorectal cancer?
FBC is done to identify the **type / presence of anaemia**
* haematocrit
* haemoglobin
* MCV
* Fe studies
* not CEA !!!
69
When is a CEA blood test done in colorectal cancer?
* this is not sensitive or specific enough to be used as a marker for colorectal cancer
* this is used when there is a **_confirmed diagnosis_ of CRC**
* it is used to test **_how well treatment is working_** for certain types of cancer
70
What does the CEA test look for?
* CEA stands for **_carcinoembryonic antigen_**
* carcinoembryonic antigens are **proteins** that are produced by **certain types of cancers**, particularly colorectal cancer
* in response to antigens, the body produces antibodies to fight them
71
What is the gold standard treatment for diagnosing colon cancer?
**_colonoscopy and biopsy_**
* biopsy is needed for histological confirmation
* CT / MRI can be used to identify large tumours for staging
72
What is the surgical management for colorectal cancer?
* localised CRC is treated with **_surgical resection_**
* **laparoscopic resection** is being increasingly used
* shorter post-op pain
* shorter hospital stay
* shorter recovery period
* **rectal cancer** is more complex
* this depends on staging and location but often a total mesorectal excision is done
73
When do chemotherapy and radiotherapy tend to be used to treat colorectal cancer?
* it depends on tumour staging
* later stages often require chemotherapy as adjuvant therapy
* **_chemotherapy_** is more commonly used in **_colon cancer_**
* **_radiotherapy_** is more commonly used to treat **_rectal cancer_**, alongside surgical resection
74
What mutation makes colorectal cancers much more resistant to chemotherapy?
BRAF V600E mutations
75
What is currently involved in the colorectal cancer screeing programme in the UK?
* people **_\>60_** are invited to take part in screening
* a **FIT test** will be sent to the home address
* if this comes back as **positive**, then the person is invited for a **colonoscopy**
76
What are the main risk factors for peptic ulcer disease?
* the most common is **_H. pylori_**
* **_medications_**
* NSAIDs
* steroids
* bisphosphonates (used to treat osteoporosis / bone diseases)
* SSRI
* **_Zollinger-Ellison syndrome_**
77
What is Zollinger-Ellison syndrome?
* there is the presence of a neuroendocrine tumour, called a **_gastrinoma_**
* gastrinomas secrete the hormone **_gastrin_**
* this causes the stomach to produce **_too much acid_**, resulting in the formation of **peptic ulcers**
78
What are the symptoms of peptic ulcer disease?
* **_burning epigastric pain_**
* **nausea** and/or **vomiting**
* if there is bleeding, there will be **_haematemesis_** and or/**_melaena_**
* if there is bleeding, there will be **_anaemia_**
* this presents as **tiredness / lethargy**
79
How is the burning epigastric pain different in gastric and duodenal ulcers?
* the pain is **_worse after eating_** if there is a **_gastric ulcer_**
* the pain is **_relieved by eating_** if it is a **_duodenal ulcer_**
80
What is haematemesis and what does it suggest?
this is the **_vomiting of blood_**
it is different to haemoptysis, which is the coughing up of blood
if it has a **_"coffee ground" appearance_**, this is typically associated with **_upper GI bleeding_**
81
What is melaena?
**dark black faeces** that have a **_tarry appearance_**
this is associated with **upper GI bleeding**
82
What are the clinical signs of peptic ulcer disease?
What about if there is a bleed?
* **pallor**
* **epigastric tenderness**
* if bleeding and patient is in **_shock_**, there will be **tachycardia** and **hypotension**
* if bleeding, there may be **_melaena on PR examination_**
83
What 3 non-invasive blood tests are done in suspected peptic ulcer disease?
* **_FBC_** to check for **anaemia**
* **_U&Es_** which could identify either **dehydration** or **upper GI bleed**
* **_CRP / ESR_**
84
What could U&E abnormalities show in peptic ulcer disease?
a urea level of **_\> 7 mmol/L_** can indicate that the patient is either **_dehydrated_** or there is an **_upper GI bleed_**
urea will not be high in a lower GI bleed
85
What is the first line test in a haemodynamically stable patient with suspected peptic ulcer disease?
What is the gold-standard test?
* first line tests are **_stool antigen_** or **_urea breath tests_**
* this is to detect the presence of **H. pylori**
* the gold standard test is **_upper GI endoscopy and biopsy_**
* this is not routinely performed in a non-bleeding ulcer
86
What instructions are given to patients prior to having an upper GI endoscopy and biopsy for peptic ulcer disease?
* if they are taking a **_PPI_**, this needs to be **_stopped 2 weeks prior_** to the procedure
* the PPI could mask the presence of an ulcer
87
When might Zollinger-Ellison syndrome be suspected?
What is the test for this?
* ZE syndrome is suspected when the patient is **_resistant_ to all treatment** given for peptic ulcer disease
* i.e. does not respond to PPIs
* a **_fasting gastrin level_** is measured
88
What is involved in the conservative treatment for peptic ulcer disease?
removing any risk factors
this includes stopping taking NSAIDs
89
What is involved in the management of peptic ulcer disease in H. pylori positive patients?
this involves **_triple eradication therapy_**
* **PPI** + **clarithromycin** + **_amoxicillin_**
OR
* **PPI** + **clarithromycin** + **_metronidazole_** (if penicillin allergy)
90
What are the stages involved in the treatment of someone with peptic ulcer disease who has had an acute upper GI bleed?
* whenever someone is haemodynamically unstable, the first step is the **ABCDE approach**
* then first line treatment is **endoscopic intervention** (diagnostic and therapeutic)
* mechanical - clipping +/- adrenaline
* thermal coagulation + adrenaline
* sclerotherapy + adrenaline
* a **_high dose IV PPI_** is given after endoscopy
91
What is the mnemonic to remember the causes of acute pancreatitis?
What are the most important / common causes?
**I GET SMASHED**
* **I** - Idiopathic
* **G** - Gallstones
* **E** - Ethanol
* **T** - Trauma
* **S** - Steroids
* **M** - Mumps
* **A** - Autoimmune conditions
* **S** - Scorpion stings
* **H** - Hypercalcaemia, hyperlipidaemia, hypothermia
* **E** - ERCP
* **D** - Drugs
* e.g. azathioprine
* diuretics
* valproate
* the most important / common causes are **_alcohol_** and **_gallstones_**
92
What are the symptoms of acute pancreatitis?
* **anorexia**
* **nausea** and/or **vomiting**
* **_severe epigastric pain_** that may **radiate through to the _back_**
93
What are the signs of acute pancreatitis?
* **_epigastric tenderness_**
* low grade **fever** / signs of **shock**
* **_bluish discolouration_** around the **umbilicus (Cullen's sign)** or **flank (Grey-Turner's sign)**
94
What other condition might you be worried about when there is epigastric pain that radiates to the back?
this could also be a sign of **_abdominal aortic aneurysm_**
95
What are the first line investigations for acute pancreatitis?
What other investigations might be done?
***_First line investigations:_***
* serum **_amylase_** and serum **_lipase_**
* lipase of more sensitive and more specific than lipase
* if gallstone is suspected, then an ultrasound is also done
***_Other investigations:_***
* FBC, U&Es, LFTs
* MRCP if a gallstone is confirmed
* CT scan
96
What criteria is used to assess the severity of acute pancreatitis?
the modified **_Glasgow Criteria (PANCREAS)_**
* **P - PaO2**
* less than 8 kPa
* **A - Age**
* age \> 55 years
* **N - Neutrophils**
* neutrophils \> 15 x 109 mmol/L
* **C - Calcium**
* calcium \< 2 mmol/L
* **R - Renal function**
* urea \> 16 mmol/L
* **E - Enzymes**
* LDH \> 600 iu/L or
* AST \> 100 iu/L or
* ALT \> 100 iu/L
* **A - Albumin**
* albumin \< 32 g/L
* **S - Sugar**
* glucose \> 10 mmol/L
97
Using the Glasgow criteria, how is severe pancreatitis diagnosed?
if there are 3 or more of any of the criteria, this is severe pancreatitis and the patient goes to ICU
98
If no gallstone is identified, what is the treatment for acute pancreatitis?
treatment is **_supportive_** and involves:
* **oxygen** if sats \< 94%
* **IV fluids**
* **analgesia**
* **antiemetic** if patient is vomiting
* **antibiotics**
* **nutritional support**
* this can be oral, enteral or parenteral
99
What is the treatment for acute pancreatitis if a gallstone is identified?
* after MRCP, if LFTs do not spontaneously resolve then an **_ERCP_** is performed
* a **stent** is left in place for **6 weeks**
* there is also **supportive treatment**
100
What are the local complications of acute pancreatitis?
* **_peripancreatic fluid collections_**
* **_pleural effusions_** (exudative)
* pancreatic **_pseudocyst_**
* pancreatic **necrosis**
* pancreatic **abscess**
* **haemorrhage**
101
What is an acute peripancreatic fluid collection?
How is it usually treated?
this involves a **_collection of fluid_** around the inflamed pancreas
* this is an **early complication** of acute pancreatitis that tends to develop in the **first 4 weeks**
* there is **no necrosis** involved
* they result from **_pancreatic inflammation_** and/or **_rupture_ of one of the small _pancreatic side ducts_**
* most resolve so **_do not_** require **aspiration / drainage**
102
What is a pancreatic pseudocyst and how is this different to a peripancreatic fluid collection?
* this involves a **collection of _peripancreatic fluid**_ that is walled off by _**fibrous_ or _granulation tissue_**
* the fluid is rich in **pancreatic enzymes, blood** and **necrotic tissue**
* it typically occurs **_4 weeks or more after_** acute pancreatitis
103
What is the main systemic complication of acute pancreatitis?
**_acute respiratory distress syndrome_**
this has a very high mortality rate
104
What are the 4 different causes of chronic pancreatitis?
***_Metabolic / toxic:_***
* alcohol (80% of cases)
* haemochromatosis
***_Obstruction:_***
* gallstone
* cystic fibrosis
***_Tumour_***
***_Idiopathic (autoimmune)_***
105
What are the symptoms of chronic pancreatitis?
* **_dull_ epigastric pain**
* nausea and/or vomiting
* **_steatorrhoea_**
* foul-smelling stools which are difficult to flush
* features of **_diabetes_** including **polydipsia** and **polyuria**
chronic pancreatitis is characterised by a triad of **_epigastric pain + steatorrhoea + diabetes_**
106
What are the clinical signs of chronic pancreatitis?
* **epigastric _tenderness_**
* **weight loss** and **lethargy**
107
What blood tests and functional tests are performed in the investigation of chronic pancreatitis?
***_Blood tests:_***
* LFTs are done as an **_AST : ALT ratio \> 2_** indicates **_alcoholic_ liver disease**
* **_HbA1c_** is performed to investigate for **diabetes**
***_Functional tests:_***
* **_faecal elastase_** - a **_REDUCTION_** indicates chronic pancreatitis
* the pancreas makes elastase and it is poorly functioning in this condition
108
What imaging investigations are performed in chronic pancreatitis?
* first line is **_ultrasound scan_**
* CT scan
* **abdominal X-ray** may show **_calcifications_** of the pancreas
109
What is the treatment for chroinic pancreatitis?
treatment is **conservative** and involves:
* **_smoking_** and **_alcohol cessation_**
* a **_low fat_** but **_high calorie diet_** with **fat-soluble vitamins**
* it needs to be high calorie as the patient cannot reabsorb much of the energy from their diet
* they also cannot digest fat
110
What are the medical treatments for chronic pancreatitis?
* **analgesia** for associated pain
* a **_pancreatic enzyme supplement_**, such as **Creon**
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What are the complications of chronic pancreatitis?
* **malabsorption**
* **diabetes mellitus**
* **pseudocyst** of the pancreas
* **carcinoma** of the pancreas
