Jaundice and pancreatitis

Question 1

pancreatitis presentation

Answer 1

epigastric pain
radiates to the back - retroperitoneal
N+V
systemically unwell

Question 2

blood tests for pancreatitis

Answer 2

FBC 
U+E, LFT 
CRP 
serum amylase 
lipase (later peak)

Question 3

features of amylase

Answer 3

goes up after 9-12 hours
stays up for around 3 days
3 times upper limit is usually diagnostic

Question 4

differential of slightly raised amylase in epigastric pain radiating to the back

Answer 4

perforated duodenal ulcer
MI
mesenteric ischaemia
pneumonia

Question 5

what should you get in these patients who you are unsure of a diagnosis of pancreatitis

Answer 5

diagnostic CT scan
get CT early if you are unsure
get it after 5 days if you are pretty sure when they present

Question 6

USS for pancreas - what is involved

Answer 6

biliary USS 
bile duct dilatation (normal 6mm add 1mm for each decade after 60)
presence of gallstones 
GB inflammation - might not be 
if not - alcohol or idiopathic

Question 7

Causes of pancreatitis

Answer 7

I GET SMASHED
Idiopathic 
Gallstones 
Ethanol 
Trauma 
Steroids 
Mumps, coxsackie, viral hepatitis 
Autoimmune 
Scorprion bite 
Hypercalcaemia/PTH/lipids/triglycerides
ERCP 
Drugs - AZA, Na valproate, mesalazine, furosemide, bendroflumethiazide
pancreas divisum

Question 8

management of gallstone pancreatitis

Answer 8

supportive measures
IV fluids, analgesia
No antibiotics

Question 9

severity predictor for pancreatitis

Answer 9

Modified Glasgow Score
predictor that patient may develop severe pancreatitis, not that they actually have severe disease
CRP >150 predicting severe

Question 10

what do you do if the patient has a severe prediction score

Answer 10

CT scan WITH contrast after 5 days to assess complications

Question 11

complications of severe acute pancreatitis seen on CT with contrast

Answer 11

oedema around pancreas
peri pancreatitis fluid collections 
ischaemic (non-enhancing pancreas)
pseudocyst (after 6 weeks)
infective pancreatic fluid 
infective pancreatic necrosis (takes a few weeks to develop)

Question 12

other complications of pancreatitis

Answer 12

respiratory failure - ARDS
renal failure - dialysis
inotrope support

Question 13

what do you do for a gallstone in the CBD

Answer 13

MRCP - imaging investigation

ERCP - therapeutic

Question 14

if MRCP comes back normal, what do you do

Answer 14

cholecystectomy on same admission if fit and healthy

Question 15

investigations for recurrent pancreatitis

Answer 15

serology / immunology
MRCP - structural abnormalities
EUS - endoscopic - microcrystals –> lap chole
triglycerides

Question 16

management of alcoholic pancreatitis

Answer 16

stop drinking

Question 17

raised amylase and epigastric pain, is it always pancreatitis?

Answer 17

no
amylase can be raised from other things - dead bowel, perforated ulcer
it is sensitive, not specific

Question 18

surgical causes of jaundice

Answer 18

post hepatic

Question 19

causes of post hepatic jaundice

Answer 19

stones 
strictures 
external compression 
malignancy 
cholangiocarcinoma, head of pancreas adenocarcinoma (PDAC, PNET) 
ampullary (duodeunal) adenocarcinoma
lymphadenopathy

Question 20

what is pancreas divisum

Answer 20

variation in pancreatic ductal anatomy (duct drains into minor papilla) associated with abdominal pain and idiopathic pancreatitis

Question 21

what symptom should you ask patients about if they have jaundice

Answer 21

itch