Severe upper abdominal pain

Question 1

(4) Signs/Ix results for acute gallstone pancreatitis

Answer 1

High lipase
Epigastric pain
Background history of biliary pain
Abnormal LFTs

Need: biliary ultrasound to confirm presence of gallstones

Question 2

Is pancreatitis a serious condition?

Answer 2

potentially, mortality varies with severity

• Overall mortality 7-9%
• Most attacks are mild & recover w/in 5-7 days
• a/w severe necrotizing pacreatitis (25-30% mortality)

Predict severity with: Ranson criteria, Glasgow score, APACHE II/O, CT index (Baltazar) etc.

Question 3

Describe Ranson scoring system

Answer 3

Used to predict severity of pancreatitis

For non-gallstone parameters:
On admission.
Age > 55 years
Blood glucose > 11 mmol/L
LDH > 300 IU/L
ALT > 250 U/L
WCC > 16x10^g/L

At 48 hr.
Hct fall > 10%
Urea rise > 0.8 mmol/L
Ca less than 2.0 mmol/L
PO2 less than 60 mmHg
Base deficit > 4 meq/L
Fluid sequestration > 6 L

For gallstone parameters: a bit more lenient. >70yo for age, etc.

> 3 factors = predicted severe pancreatitis

Question 4

What are the early Cx of acute pancreatitis?

Answer 4

• Hypoxia
• Renal failure/impairment
• Hypovolaemic shock
• Pancreas necrosis & sepsis

Question 5

Describe a pseudocyst

• definition
• Px
• Mx

Answer 5

• Definition: persistent fluid collection after 4 weeks
• Px: pain, gastric outlet obstruction,and found on CT or US
• Mx: treat only if symptomatic or enlarging (>6cm)

Question 6

What is the IV antibiotic of choice in pts with associated cholangitis/necrotising pancreatitis with suspicion of infection/abscess?

Answer 6

IV meropenem.

Involve ID team early

Question 7

Discuss the step up Mx approach of pancreatic necrosis

Answer 7

1. IV antibiotics.
2. Percutaneous drainage of peripancreatic space/collections
3. Up size the drain
4. Consider percutaneous necrosectmoy (retroperitoneal, intraperitoneal or open)

Note: Cause of pancreatitis needs to be identified and treated to prevent a second attack. Symptomatic gallstones need to be removed before complications arise

Question 8

(3) causes of abdo pain & hypotension

Answer 8

Ruptured AAA
severe pancreatitis
Ectopic pregnancy

Question 9

How do you diagnose pancreatitis?

Answer 9

2 out of 3:

• abdominal pain
• CT finding of pancreatitis
• increased lipase

Question 10

How would you manage pancreatitis?

Answer 10

Admit to ICU if severe for monitoring & administration of fluids. (give replacement fluids NOT maintenance due to 3rd spacing).

Question 11

Is non-invasive ventilation (CPAP, BiPAP) helpful for T2 respiratory failure?

Answer 11

Yes as it is a ventilatory problem. Not as helpful for T1RF.

Question 12

(2) When would you use IV antibiotics in pancreatitis?

Answer 12

• Associated cholangitis

- Necrotising pancreatitis + suspicion of infection/abscess

Question 13

What are the 2 types of fungi and give a common example of each.

Answer 13

• Yeast: Candida

- Mould: Aspergillus

Question 14

Should you take the gallbladder out in pancreatitis that was induced by gallstones?

Answer 14

Yes even if it was mild as recurrence is high.