Acute pancreatitis
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Etiology Cholelithiasis & EtOH (most common), can also be hyperlipidemia, trauma, drugs, hypercalcemia, penetrating PUD, antiretroviral HIV meds
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Clinical Presentation Ranges from mild episodes of deep epigastric pain w/ N/V to the sudden onset of severe pain with shock
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Clinical Features Epigastric pain radiating to the back, improves with leaning forward or lying in fetal position, N/V, fever, leukocytosis,sterile peritonitis
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Indicators of a Poor Prognosis Severe hypovolemia, ARDS, tachycardia > 130bpm
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Lab Studies Elevated serum amylase, lipase, WBC, LFTs if biliary obstruction, Ranson's criteria = poor prognosis
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Treatment NPO (to prevent secretion of pancreatic juices), restore and maintain fluid volume, and start parenteral hyperalimentation
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Pain Management & Monitoring Meperidine +/- abx. Monitor pt. for complications (pancreatic pseudocyst, renal failure, pleural effusion, hypocalcemia, pancreatic abscess)
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Choledolithiasis
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Definition Gallstones
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Treatment Only treat the complications, because most people with gallstones never develop the disease
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Complications Cholecystitis, pancreatitis, acute cholangitis
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Primary Sclerosing Cholangitis
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Definition A chronic thickening of the bile duct walls of unknown etiology (but 80% of cases are associated with IBD, specifically ulcerative colitis)
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Strongly associated with Cholangiocarcinoma + increased risk of pancreatic and colorectal carcinoma
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Typical patient M>>F, mean age 39
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Clinical Presentation Jaundice + pruritis (also fatigue malaise, weight loss), hepatomegaly, splenomegaly
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Treatment Ursodiol + endoscopic management of stricture
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Only treatment with a known survival benefit Liver transplant
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Chronic Pancreatitis
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Etiology EtOH (almost 90% of cases, can also be from gallstones, PUD, etc.)
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Clinical Features Epigastric pain radiating to the back, improves with leaning forward or fetal position, N/V, + fat malabsorption steatorrhea later in disease
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Classic Triad Pancreatic calcifications, steatorrhea, diabetes mellitus
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Lab Studies Amylase level elevated early in disease, abdominal plain film radiography shows calcification in 20-30% of pts
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Lab Studies Amylase level elevated early in disease, abdominal plain film radiography shows calcification in 20-30% of pts
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Treatment Address underlying cause (EtOH), NPO, fluid volume restoration, parenteral hyperalimentation, low-fat diet upon discharge. Surgical removal for pain control.
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Acute Cholecystitis
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Definition Caused by obstruction of the bile duct (usually by a gallstone) leading to chronic inflammation
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Clinical Presentation Colicky epigastric or RUQ pain, becomes steady and increases in intensity. Often happens after a fatty meal, ?right shoulder/subscapular pain, N/V, low-grade fever, constipation, mild paralytic ileus
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Lab Findings Bilirubin levels increase in blood and urine after 24 hours, leukocytosis, gallstones, HIDA, ERCP
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Treatment Surgery (cholecystectomy)
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Pancreatic Neoplasm
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General 5th leading cause of cancer death in US
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Risk Factors Older age, obesity, tobacco, chronic pancreatitis, previous abdominal radiation, family history
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Clinical Presentation Abdominal pain +/- radiating pain, jaundice, palpable gallbladder (Courvoisier's sign) if cancer of pancreatic head
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Diagnostic Studies CT to delineate disease and look for mets, angiography to look for vascular invasion
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Treatment Surgical resection (modified Whipple's procedure) if no mets, ?subsequent radiation/chemo. Poor prognosis.
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Acute Cholangitis
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Definition Potentially deadly condition of common bile duct obstruction combined with ascending infection (most commonly caused by E. coli, Enterococcus, Klebseille, Enterobacter --> can lead to sepsis and death
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Etiology Most often caused by choledocholithiasis
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Clinical Presentation RUQ tenderness + jaundice + fever (Charcot's Triad), +/- AMS & hypotension (Reynold's pentad)
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Lab Findings RUQ U/S shows biliary dilation or stones, good initial test. Leukocytosis + left shift, increased bilirubin, increased LFTs. ERCP best for dx + tx of stable pt (unless urgent compression necessary)
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Treatment Antibiotics (fluroquinolone, ampicillin, gentamycin +/- metronidazole), fluid & electrolytes, analgesia. ERCP for stable patiends. Cholecystectomy after acute syndrome resovled when there is choledocholilithiasis
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