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GI, liver, kidney > Pancreatitis/Cholecystitis > Flashcards

Pancreatitis/Cholecystitis Flashcards

1
Q

What position often makes the pain improve in pancreatitis?

A

Sitting forward

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2
Q

What mimics sepsis and is a complication of pancreatitis?

A

ARDS/SERS
Acute respiratory distress syndrome
-> whole body oedema

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3
Q

Causes of Ileus

A

Intrabdominal problems
Post op
Electrolyte disturbances

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4
Q

What is ileus

A

where the gi tract doesnt function, ,pressure builds up as no absorption -> vomitting

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5
Q

How can lipase action cause hypocalcemia?

A

Lipase action on mesenteric fat causes release of free fatty acids which bind to calcium in blood -> insoluble calcium salts which decrease serum calcium levels

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6
Q

Why does hypercalcemia cause pancreatitis?

A

It activates enzymes oin the pancreas

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7
Q

What does th eGlasgow imry score suggest? What level is high risk?

A

24 hours risk of moving to ITU
3 + = high risk
In pancreatitis

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8
Q

Whta does ransons score predict in pancreatitis?

A

Mortality

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9
Q

Apatoni2 score when used

A

In ITU - multisystem scoring, accurate for pancreatitis

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10
Q

What is pancreatitis?

A

Acute inflammation of the pancreas causing release if exocrine enzymes that cause autodigestion of the organ - local tissues and distant organs.

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11
Q

Pathophysiology of pancreatitis?

A

Trigger eg alcohol -> marked elevation intracellular calcium -> activation of exocrine pancreatic enzymes -> acinar cell injury + necrosis, + migration inflammatory cells + sometimes systemic inflammatory response -> single or multi organ failure

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12
Q

Causes of pancreatitis

A

IGETSMASHED
Iatrogenic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune, ascaris infection
Scorpion venom
Hypertriglyceridemia, Hyperchylomicronawmia, hyhpercalcemia, hypothermia
ERCP
Drugs eg azathioprine, bendroflumethiazide, furosemide, mesalazine, steorids, sodium valproate

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13
Q

What is the glasgow imrie criteria?

A

PANCREAS @48 hour admission
PaO2 <8kpa
Age >55 years
Neutrophilia = WCC >15 x10’9/L
Calcium < 2.0mmol/L
Renal (serum urea) >16 mmol/L
Enzymes LDH >600IU/L
Albumin <32g/L
Sugar - glucose >10mmol/L

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14
Q

Cholecystitis on exam

A

=pain in the upper right quadrant that radiates tp back
-palpable mass
-Boas and Murphys sign
-Fever, HR

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15
Q

First line investigations cholecystitis

A

CT or MRI of the abdomen
abdominal ultrasound
FBC
CRP

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16
Q

Investigations to consider cholecystitis

A

magnetic resonance cholangiopancreatography (MRCP)
endoscopic ultrasound (EUS)

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17
Q

Boas’s sign

A

presence of an area of hyperaesthesia at the site of radiation of the pain to the back, typically, below the scapula.

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18
Q

Potential outcomes for acute cholecysitis

A

Self resolving - 1-7 dyas
25-30% people develop complications or require surgery

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19
Q

Acute cholecysitis complications

A

Necrosis of gallbladder wall
Perforation of the gallbladder
Biliary peritonitis
Pericholecystic abscess
Fistula - between gallbladder and duodenum
Jaundice - inflammation of adjoining biliary ducts - Mirizzis syndrome
-Sepsis

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20
Q

Symptoms of cholecystitis

A

fever, anorexia, nausea, vomiting, back or shoulder pain, right upper quadrant mass, and a positive Murphy’s sign.

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21
Q

What sign is positive on exam in cholecsyitis?

A

Murphys sign
-Pain and stop inspiration when press on RUQ

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22
Q

Why admit to hospital with cholecysitits?

A

Confirmation of the diagnosis, including abdominal ultrasound and blood tests (such as a white blood cell count, C-reactive protein, and serum amylase).
Monitoring (for example blood pressure, pulse, and urinary output).
Treatment (may include intravenous fluids, antibiotics, and analgesia).
Surgical assessment for cholecystectomy.

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23
Q

Oedematous cholecystitis is?

A

occurs after 2–4 days of obstruction. The gallbladder tissue is intact histologically, with oedema in the subserosal layer.

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24
Q

When does necrotising cholecystitis occur?

A

occurs after 3–5 days of obstruction and is characterized by oedematous changes in the gallbladder, with areas of haemorrhage and necrosis. Necrosis does not involve the full thickness of the gall bladder wall.

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25
Q

What is suppurative cholecystitis?

A

occurs after 7–10 days of obstruction and is characterized by thickened gallbladder wall with white cell infiltration, intra-wall abscesses, and necrosis. May result in perforation of the gallbladder and a pericholecystic abscess formation.

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26
Q

How is chronic cholecystitis defined?

A

occurs after repeated episodes of mild attacks and is characterized by mucosal atrophy and fibrosis of the gallbladder wall. Acute-on-chronic cholecystitis refers to an acute infection that has occurred in chronic cholecystitis.

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27
Q

How does acute cholecystitis become complicated?

A

As the gallbladder becomes more distended and inflamed, blood flow and lymphatic drainage are compromised, leading to mucosal ischemia.Secondary bacterial infection of the bile may occur.
Continued inflammation, ischemia, and/or infection can result in necrosis and gallbladder perforation.

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28
Q

Gallstone risk factors

A

gallstones include increasing age, female gender, obesity, and a low fibre diet.

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29
Q

Which type of cholecysitits is mortality highest in?

A

Acalculous - 10-50%

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30
Q

Which type of patient does acalculous cholecystitis often occur in?

A

Critically ill people
Combindation of factors -> bile stasis (gallbladder hypomotility/dysmotility) or thickening (dehydration)

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31
Q

Conditions ass with biliary stasis or thickening

A

Sepsis.
Extensive trauma.
Burns.
Major surgery.
Prolonged fasting or starvation.
Prolonged total parenteral nutrition use.

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32
Q

Risk factors for acalculous cholecystitis?

A

Diabetes, end stage renal disease, congestive HF/CAD, peripheral vascular disease
Drugs - cyclosporin, ceftriaxone
Infection eg EBV
HIV+ - cholangiopathy with microsporidia species

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33
Q

Nature of the pain in cholecystitis

A

A constant pain present for several hours is consistent with acute cholecystitis. The duration of pain can be shorter if the gallstone returns into the gallbladder lumen or passes into the duodenum.
The pain is severe, steady, and may radiate to the back.
Referred pain from the gallbladder may be felt in the right shoulder or interscapular region.

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34
Q

Symptoms to ask for in history for cholecystitis

A

Fever/chills
nausea
Vomitting
Anorexia

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35
Q

If have episode of biliary pain, how likely have another in 12 months?

A

50%

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36
Q

When is Murphys sign unreliable?

A

Older people or critically ill people

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37
Q

What is Mirizzis syndrome?

A

Gallstone impacted in gallbladder neck

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38
Q

How is acute analgesia managed conservatively?

A

Bed rest
Electrolyte compensation
Fasting
Analgesia with NSAIDs + opiates
Anti-emetics
IV fluids
Antibiotics - broad spectrum

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39
Q

Surgical management cholecystitis

A

Cholecystectomy - laproscopic - early has better outcomes - within 72 hours of admission

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40
Q

When do an emergency cholecystectomy

A

Fever
Marked leukocytsosi
Diffuse abdominal tenderness -> necrosis, empyema or rupture and surgery within 12 to 23 hours is indicated
Patients with diabetes
Elderly + immunocompromised patients

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41
Q

Grading of cholecystitis + when do Lap Cholecystectomy with each grade

A

Grades I - III
Urgent Lap C if patient has good status in Grade II + III + blood culture or bile culutre
Within 7 days if Grade I
Grade III also do urgent biliary drainage

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42
Q

What does Ransons score predict?

A

Mortality in pancreatitis

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43
Q

Features of ransons score

A

On admission - WCC
WBC > 16K
Age > 55
Glucose >200 mg/dL (>10 mmol/L)
AST > 250
LDH > 350
AFTER 48 hours
Hct drop >10% from admission
BUN increase >5 mg/dL (>1.79 mmol/L) from admission
Ca <8 mg/dL (<2 mmol/L) within 48 hours
Arterial pO2 <60 mmHg within 48 hours
Base deficit (24 - HCO3) >4 mg/dL within 48 hours
Fluid needs > 6L within 48 hours

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44
Q

What glasgow IMrie score suggests severe pancreatiits/

A

= or over 3

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45
Q

What new score is used in pancreatitis?

A

BISAP score

46
Q

What are the criteria for Glasgow imrie score?

A

PaO₂ <59.3 mmHg (7.9 kPa)

Age >55 years

WBC >15 x 10³/µL (10⁹/L)

Calcium <8 mg/dL (2 mmol/L)

BUN >44.8 mg/dL (serum urea >16 mmol/L)

LDH >600 IU/L

Albumin <3.2 g/dL (32 g/L)

Glucose >180 mg/dL (10 mmol/L)

47
Q

What use abdo X rays to investigate

A

Obstructed

Perforation

Toxic megacolon

Foreign body

48
Q

Abdo x ray approach

A
  • A - air
  • B - bowel
    • 3/6/9 rule
  • C - calcification
  • D - dense objects eg bones
  • E - external - everything else
49
Q

What is pneumobilia?

A
  • Air in biliary system = pneumobilia
50
Q

What condition occurs when UTI with bacteria which produce air → bladder perforation

A
  • Emphysematous cystitis/pyelonephritis
    • Emphysematous cholecysitis
51
Q

What does loin to groin pain signal?

A

Kindey stones

52
Q

Surgical sieve

A

VITAMIN Cmay come in handy.

V- Vascular– Stroke, MI – Can uncommonly present with this.

I – Infection(Primary CNS infection orsecondary to sepsis);

T – Trauma– Surgery, traumatic brain injuries (including subdural and extracranial hemorrhage)

A – Autoimmune– Vasculitis

M – Metabolic–Hypoglycemia, hyperglycemia, uremia, hepatic encephalopathy, electrolyte abnormalities (e.g. hypercalcemia, hyponatremia), constipation, urinary retention

I – Iatrogenic– Medications, illicit drugs

N – Neoplasia– CNS Tumours

C – Congenital Abnormalities

53
Q

What is renal stenosis

A

Construction of efferent blood vessels/ one or both renal arteries causing reduced blood flow to the kidneys, decreased perfusion and a build up of waste products and fluids

54
Q

What is renal stenosis caused by?

A
  • Atherosclerosis
  • Fivromuscular dysplasia (in younger ppl)
55
Q

Treatment and what Complications for renal stenosis

A
  • Angioplasty
  • Lifestyle
  • Diuretics

comp
- CKD
- Kidney failure

56
Q

What is rigglers sign?

A

SIgnals bowel perforation
Bowel wall appears as white line - dark air either side

57
Q

What is rigglers sign?

A

SIgnals bowel perforation
Bowel wall appears as white line - dark air either side

58
Q

What are the criteria for Glasgow imrie score?

A

PaO₂ <59.3 mmHg (7.9 kPa
Age >55 years
WBC >15 x 10³/µL (10⁹/L)
Calcium <8 mg/dL (2 mmol/L)
BUN >44.8 mg/dL (serum urea >16 mmol/L)
LDH >600 IU/L
Albumin <3.2 g/dL (32 g/L)
Glucose >180 mg/dL (10 mmol/L)

58
Q

3,6,9rule

A
  • 3cm for small cowel
    - 6cm for colon
    - 9cm for caecum
59
Q

How can you score severity of pancreatitis?

A

Ransons score
APACHE II
Glasgow Imrie criteria
CRP emasurement
BISAP score

60
Q

How much higher does serum amylase need to be to be considered diagnostic?

A

3 x baselline

61
Q

Which is more sensitive and specific, amylase or lipase?

A

Lipase

62
Q

What does raised serum aminotransferase and/or bilirubin suggest?

A

Gallstones

63
Q

Why do you measure calcium in acute pancreatitis?

A

Hypocalcemia is relatively common in acute pancreatitis - may help prognosis

64
Q

Symptoms of pancreatitis

A

Acute severe upper abdo pain radiating to back
N+V
Anorecia
Pyrexia

65
Q

Signs of pancreatitis

A

Fever, hypotension, tachycardia,pnoe
Epigastric tenderness, guaring on exam
Decreased bowel sounds
Jaundice
Grey Turners sign
Cullens sign

66
Q

What is Cullens sign

A

Bruises periumbilical circle suggestive of pancreatitis

67
Q

What is Grey Turners sign

A

Bruises around flank

68
Q

What are cullens and greys signs indicative of

A

Retroperitoneal haemorrhage
LATE presentation of acute pancreatitis

69
Q

Imaging investigations ofr pancreatitis

A

AXR erect
CXR
CT pancreas - contrast enhanved
US abdomen - first line
MRI pancreas

70
Q

Which investigation is used prior to pancreatic surgery?

A

CT pancreas with contrast
-Pancreatic swelling, fluid collections and density changes

71
Q

What can be seen on a US abdomen of the pancreas in pancreatitis?

A

Swollen pancreas, dilated CBD, free peritoneal fluid
Gallstones

72
Q

sWhat is seen in severe pancreatitis on CXR?

A

Hemidiaphragm elevation, infiltrates, ARDS, pleural effusions

73
Q

What is chronic pancreatitis defined as?

A

Chronic irreversible inflammation of the pancreas +/or fibrosis
Severe abdo pain and progressive endocrine and exocrine insufficiency

74
Q

Pathophysiology of chronic pancreattitis

A

Pancreatic enzyme activation (trauma, CF, unknown) -> tissue injury and necrosis -? fibrogenesis in respnse, releasing growth factors, cytokines, chemokines - ECM depositions
Oxidative stress?

75
Q

Pathophysiology of alcohol on the pancreas

A

Proteins precipitate in ductular structure -> dilatation and fibrosis, direct effects of alcohol toxic on pancreas

76
Q

Common complications of pancreatitis

A

Malabsorption
DM
Chronic pain
Osteoporosis
Pseudocyst formation
Pancreatic calcification

77
Q

Common complications of pancreatitis

A

Malabsorption
DM
Chronic pain
Osteoporosis
Pseudocyst formation
Pancreatic calcification

78
Q

Why can jaundice be a feature of pancreatitis?

A

Complciation of biliary obstruction

79
Q

If a patient presents with vommittting and anorexia and are not passing faeces with pancreatitis what is the concern?

A

Duodenal or gastric outlet obstruction
Bowel obstruction due to metastases from pancreatic cnacer

80
Q

How can pancreatitis affect the venal supply to the lvier?

A

Splenic or portal VTE

81
Q

Conservative management of pancreatitis

A

Stop alcohol and smoking
Dietician support

82
Q

Risk factors pancreatitis

A

Male
Age
Smoking
Obestiy

83
Q

What need for a diagnosis of pancreatitis

A

Abdominal pain plus a history suggestive of acute pancreatitis
Serum amylase/lipase of over three times the upper limit of normal
Imaging findings characteristic of acute pancreatitis

84
Q

Differentials for sudden onset severe epigastric pain

A

Leaking abdominal aortic aneurysm
Aortic dissection
Myocardial infarction
Perforated gastric/duodenal ulcer
Oesophageal rupture

85
Q

Atlanta criteria for classification of pancreatitis

A

Mild: no organ dysfunction/complications, resolves 1 week
Moderate: some evidence organ failure improves 48 hours
Severe: persistent organ dysfunction > 48 hours, with local or systemic complications

86
Q

Bedside investigations for pancreatitis

A

ECG
Urinalysis n

87
Q

Pain relief of chronic pancreatitis

A

Simple analgesia - aparacetemol and NSAIDs
Opiates - tramadol
Coeliac plexus block - ensocopy
ERCP = dilate strictures of ducts

88
Q

Managing pancreatic insufficiency

A

Replacing pancreatic enzymes - malabsorption and reduce pain
Fat soluble vitamins - A, D, E, K
DM - insulin, blood sugar monitoring

89
Q

Why do you need to monitor blood sugar in a=chronic pancreatitis?

A

Damage to beta cells in severe disease can cause diabetes

90
Q

Surgical options pancreatitis

A

Cholecystectoy - gallstones
Sphincterextomy
Percutaneous or surgical drainage
Partial pancreatic resection
Extracorpereal shockwave lithrotripsy -
Total pancreatotomy

91
Q

What is Extracorpereal shockwave lithrotripsy used ofr

A

Gallstone blocking the pancreatic duct

92
Q

What drugs can cause pancreatitis?

A

Thiazide like diuretics, azathioprine, tetracyclines, valproic acid and DDP-4 inhibitors

93
Q

What is azathioprine?

A

a DMARD immunosuppressant used in RA, organ transplant, IBD and vasculitis’s

94
Q

What are tetracyclines?

A

Class of antibiotic
Doxycycline, tetracycline
inhibit protein synthesis in the microbial RNA

95
Q

Congenital causes of pancreatitis

A

Pancreas divisum, annular pancreas

96
Q

Autoimmune disorders that can cause pancreatitis

A

Sjrogen syndrome, IBD, primary biliary cirrhosis

97
Q

Imaging for chronic pancreatitis

A

AXR
Abdo US
Abdo CT - 1st LINE
MRCP/ERCP
Endoscopic US

98
Q

Features of chronic pancreatitis

A

As acute plus
Malabsorption with weight loss, diarrhoea, steatorrhea and protein deficiecny
DM

99
Q

Nutrition in severe pacreatitis

A

Nil by mouth - NBM until pain improves
Nasojejunal feeding
or total parenteral nutrition

100
Q

Management of gallstone pancreatitis

A

ERCP
Cholecystectomy

101
Q

Alcohol induced pancreatitis management

A

CIWA score for alcohol withdrawal
Benzodiazpines to treat withdrawal agitation and seizures
Thiamine, folate and vit B12 replacement

102
Q

Early complications pancreatitis

A

Necortising
Infected pancreatic necrosis
Pancreatic abscess
ARDS = boilateral infiltrates on CXR

103
Q

ARDS on CXR

A

Widespread bilateral pulmonary infiltrates

104
Q

Late complciations of pancreatitis

A

Pancreatic pseudocysts
Portal vein/splenic thrombosis
Chronic pancreatittis
Pancreatic insufficiency

105
Q

Score used for SERS

A

QSOFA

106
Q

What is diclophenac used in?

A

Renal colic - antispasmodic

107
Q

What score on glasgow imrie means patient should move to ITU?

A

3

108
Q

What score predicts mortality in pancreatitis?

A

Ransons

109
Q

What scores predict ITU in pancreatitis? which is better and why

A

Glasgow imrie
Apatoni2score - done in ITU, multisystem consideration

GI, liver, kidney (50 decks)

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