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GI V: Pancreas & Biliary Tract Cheat Sheet by

Gastroenterology

Primary Sclerosing Cholan­gitis

Definition
A chronic thickening of the bile duct walls of unknown etiology (but 80% of cases are associated with IBD, specif­ically ulcerative colitis)
Strongly associated with
Cholan­gio­car­cinoma + increased risk of pancreatic and colorectal carcinoma
Typical patient
M>>F, mean age 39
Clinical Presen­tation
Jaundice + pruritis (also fatigue malaise, weight loss), hepato­megaly, spleno­megaly
Treatment
Ursodiol + endoscopic management of stricture
Only treatment with a known survival benefit
Liver transplant

Acute pancre­atitis

Etiology
Chole­lit­hiasis & EtOH (most common), can also be hyperl­ipi­demia, trauma, drugs, hyperc­alc­emia, penetr­ating PUD, antire­tro­viral HIV meds
Clinical Presen­tation
Ranges from mild episodes of deep epigastric pain w/ N/V to the sudden onset of severe pain with shock
Clinical Features
Epiga­stric pain radiating to the back, improves with leaning forward or lying in fetal position, N/V, fever, leukoc­yto­sis­,st­erile perito­nitis
Indicators of a Poor Prognosis
Severe hypovo­lemia, ARDS, tachyc­ardia > 130bpm
Lab Studies
Elevated serum amylase, lipase, WBC, LFTs if biliary obstru­ction, Ranson's criteria = poor prognosis
Treatment
NPO (to prevent secretion of pancreatic juices), restore and maintain fluid volume, and start parenteral hypera­lim­ent­ation
Pain Management & Monitoring
Meperidine +/- abx. Monitor pt. for compli­cations (pancr­eatic pseudo­cyst, renal failure, pleural effusion, hypoca­lcemia, pancreatic abscess)

Choled­oli­thiasis

Definition
Gallstones
Treatment
Only treat the compli­cat­ions, because most people with gallstones never develop the disease
Compli­cations
Cholec­yst­itis, pancre­atitis, acute cholan­gitis
 

Chronic Pancre­atitis

Etiology
EtOH (almost 90% of cases, can also be from gallst­ones, PUD, etc.)
Clinical Features
Epigastric pain radiating to the back, improves with leaning forward or fetal position, N/V, + fat malabs­orption steato­rrhea later in disease
Classic Triad
Pancreatic calcif­ica­tions, steato­rrhea, diabetes mellitus
Lab Studies
Amylase level elevated early in disease, abdominal plain film radiog­raphy shows calcif­ication in 20-30% of pts
Lab Studies
Amylase level elevated early in disease, abdominal plain film radiog­raphy shows calcif­ication in 20-30% of pts
Treatment
Address underlying cause (EtOH), NPO, fluid volume restor­ation, parenteral hypera­lim­ent­ation, low-fat diet upon discharge. Surgical removal for pain control.

Acute Cholec­ystitis

Definition
Caused by obstru­ction of the bile duct (usually by a gallstone) leading to chronic inflam­mation
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
Lab Findings
Bilirubin levels increase in blood and urine after 24 hours, leukoc­ytosis, gallst­ones, HIDA, ERCP
Treatment
Surgery (chole­cys­tec­tomy)
 

Pancreatic Neoplasm

General
5th leading cause of cancer death in US
Risk Factors
Older age, obesity, tobacco, chronic pancre­atitis, previous abdominal radiation, family history
Clinical Presen­tation
Abdominal pain +/- radiating pain, jaundice, palpable gallbl­adder (Courv­ois­ier's sign) if cancer of pancreatic head
Diagnostic Studies
CT to delineate disease and look for mets, angiog­raphy to look for vascular invasion
Treatment
Surgical resection (modified Whipple's procedure) if no mets, ?subse­quent radiat­ion­/chemo. Poor prognosis.

Acute Cholan­gitis

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
Etiology
Most often caused by choled­och­oli­thiasis
Clinical Presen­tation
RUQ tenderness + jaundice + fever (Charcot's Triad), +/- AMS & hypote­nsion (Reynold's pentad)
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)
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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