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Abdominal Pain 7/18/2015 1 Pancreatitis Acute pancreatitis is a reversible inflammatory process of the pancreas, usually associated with persistent severe upper abdominal pain and marked abdominal tenderness. If, however, inflammatory changes persist after the acute attack subsides, it may evolve to chronic pancreatitis 7/18/2015 2 Etiologies Common causes of acute pancreatitis include gallstones (30%-70%), alcohol consumption (30%), and hyperlipidemia (4%). The cause is unknown in 30% of cases. Uncommon causes of acute pancreatitis include hereditary pancreatitis, hyperparathyroidism, hypercalcemia and medications 7/18/2015 3 Other Etiologies Infectious agents and toxins, postoperative pancreatitis, pancreatic trauma, pregnancy and cystic fibrosis Structural abnormalities such as 1)congenital duodenal lesions/tumors, 2)stenosis or dyskinesia of the sphincter of Oddi, 3) tumors, hook worms, and liver flukes in the main pancreatic duct How it relates to your audience 7/18/2015 4 Clinical Approach History- patients with acute pancreatitis experience diffuse upper abdominal pain. Pain may occasionally be localized to the epigastrium and left upper abdomen. Persistent nausea, vomiting and pain are frequent complaints. Pain may be aggravated by eating and partially relieved by sitting up and leaning forward. 7/18/2015 5 Clinical Approach Signs and physical findings- patients may be disoriented and agitated. Findings likely will include a low-grade fever, tachycardia, tachypnea and a minimal pleural effusion on the left side. Marked abdominal tenderness with guarding Bowel sounds are often feeble if not absent secondary to paralytic ileus Rarely Grey Turners sign (ecchymosis in one or both flanks or Cullen’s sign (ecchymosis of the periumbilical regions may be present 7/18/2015 6 Diagnostic Evaluation Serum amylase and lipase levels are sensitive and specific tests in the diagnosis of acute pancreatitis. When improved lipase assays are used, the lipase level is both more sensitive and more specific than the amylase level. With the availability of the new turbidimetric assay, lipase is the single best test to perform. 7/18/2015 7 Diagnostic Evaluation Other causes for increased lipase levels include cholelithiasis, nephrolithiasis, small bowel obstruction and ruptured aortic aneurysm, however the degree of elevation is less than in acute pancreatitis (three times vs. five times) Other causes for amylase elevation include salivary gland dysfunction, tumors of the lung or ovary, cholecystitis, intestinal obstruction. 7/18/2015 8 Diagnostic Evaluation Additional blood tests – white blood cell count, serum glucose, AST,Alk Phs and triglyceride levels may all be elevated. The serum hematocrit and BUN should be obtained for consideration of prognosis with Ranson’s Criteria of severity 7/18/2015 9 Radiologic Studies Contrast-enhanced CT is the imaging procedure of choice. It may show inflammatory swelling or pancreatic parenchymal necrosis Abdominal ultrasound is excellent for serial evaluation of pseudocysts, gallstones, dilation of the common bile duct and ascites. ERCP may be indicated when detection and remaoval of gallstones in the common bile duct is necessary. 7/18/2015 10 Complications Indicators of severity 1. Low hematocrit 2. Oliguria <30 ml/hr 3. Systolic blood presure< 90mmHg 4. Pulse > 120 beats per minute 5. O2 saturation < 90% An uncomplicated acute pancreatitis subsides with conservative measures in 48 to 72 hours. 7/18/2015 11 Complications Ranson’s crtieria of severity 1. Criteria: Age>55, WBC’s > 16,000/mm3, glucose > 200 mg/dl, LDH > 350 IU/L, AST > 250 IU/L 2. During the initial 48 hours: hematocrit decreases>10mg/dl, BUN increases > 5 mg/dl (despite fluids), calcium < 8mg/dl, 3. Mortality ranges from 1% in mild cases (<3 Ranson’s criteria) to 50% in severe cases (>4 Ranson’s criteria) 7/18/2015 12 Treatment 1. Total elimination of oral feeding (NPO) until pain subsides 2. Nasogastric tube aspiration of the stomach 3. Intravenous fluids to maintain fluid and electrolyte balance 4. Parenteral anlagesics to relieve pain 5. Surgical treatment when indicated 6. Endoscopic stone extraction when common bile duct is impacted and dilated. 7/18/2015 13 Gallbladder Disease Gallbladder pathology encompasses a handful of diseases that may originate with gallstones or in the absence of gallstones. Over 400,00 cholecystectomies are performed in the United States each year. 7/18/2015 14 Gallbladder Disease Cholescintigraphy is the sinle best test for the diagnosis of acute cholecystitis Real time ultrasound provides more information about other causes ERCP remains the test of choice for thos patients with high likelihood of choledocholithiasis. 7/18/2015 15 Gallbladder Disease Cholelithiasis A. Seventy per cent cholesterol based, predisposing factors: obesity, estrogen, pregnancy, genetics (Pima Native Americans) Thirty per cent pigment based, predisposing factors: cirrhosis, hemolysis(sickle cell disease, thalassemia, spherocytosis, prosthetic valves 7/18/2015 16 Gallbladder Disease Noncalulous gallbladder dysfunction-may comprise 10% of gallbladder disease Acalculous cholecystitis-5% of gallbladder disease, usually in elderly or diabetic, associated with underlying vascular disease Carcinoma of the gallbladder-only 1% of patients with gallstones. 7/18/2015 17 Clinical Approach Cholelithiasis- classic biliary colic is characterized by a steady, sever aching inthe epigastrium or right upper quadrant, frequently radiating to the inter scapular area or the right scapula. The pain usually begins suddenly, persists for 1 to 3 hours, and often leaves residual discomfort after subsiding. Among patients who under go real time ultrasonography(RTUS) for suspected biliary colic, nearly 40 % have stones . 7/18/2015 18 Clinical Approach Acute Cholecystitis- Most patients with acute cholecystitis have a history of previous episodes of biliary colic. The attack of acute cholecystitis may begin similarly but does not remit and is associated with fever, leukocytosis, and a mild elevation of liver function tests. 7/18/2015 19 Choledocholithiasis Fewer than 10% of patients with symptomatic gallstones will have common bile duct stones. Patients with stones in the common bile duct may also have elevations of liver function tests indicative of cholestasis (typically elevated alkaline phosphatase and bilirubin) or with signs of pancreatitis. 7/18/2015 20 Clinical Findings 1. Epigastric/RUQ tenderness 2. Specific tenderness over the gallbladder fundus just medial to the anterior axillary line 3. Exquisite tenderness of gallbladder fundus on palpation (Murphy’s sign) 4. Progressive disease results in increased tenderness with guarding and rebound. 7/18/2015 21 Clinical Evaluation Lab tests – CBC, LFT’s, amylase Marked elevation of transminases > 1000 IU) usually indicates hepatic injury Mild elevations of bilirubin may reflect acute cholecystitis but common duct stones should be considered. 7/18/2015 22 Diagnostic Studies- Radiology Real-time ultrasonography has become the standard of evaluation for patients in whom gallstone disease is suspected. The procedure is painless and virtually risk free. The preparation reqires a 6 hour fast, but the test takes only 15 minutes to perform. The ultrasonographic criteria that indicate acute cholecystitis are the presence of gallstones along with signs of gallbladder inflammation – inlcuding sonographic Murphy’s sign, gallbladder >5cm, fluid around the gallbladder and thickening. 7/18/2015 23 Diagnostic Studies Oral Cholecystography assesses gallbladder anatomy and function HIDA scan assesses bile circulation with radioactive isotopes. If the cystic duct is obstructed the gallbladder fails to visualize. If >4 hours the test is 98% sensitive. If tracer fails to empty into the duodenum, common duct obstruction should be assumed. ERCP- usually reserved for those patients in whom common bile duct stones are suspected. Stone removal is an added benefit of ERCP. 7/18/2015 24 Sensitivity approx. 90%