Abdominal Pain 11/17/2018

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 11/17/2018

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 11/17/2018

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 11/17/2018

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. 11/17/2018

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 11/17/2018

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. 11/17/2018

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. Lipase is invariably elevated on the first day and remains elevated longer than serum amylase. Serum amylase is increased by at least three times the normal level in 75% of cases of acute pancreatitis and remains elevated in most patients for 5-10 days. A pancreatitis-associated proteiin and pancreatic-specific protein are as accurate as serum amylase. There is evidence that serum pancreatitis-associated protein may help in establishing prognosis Trypsinogen assay, if available, is comparable to both lipase and amylase 11/17/2018

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 11/17/2018

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. Abdominal flat plate- gallstones, pancreatic stone, abnormalities of stomach, small orlarge bowel may be present 11/17/2018

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. The severity of acute pancreatitis can be assessed by clinical evaluation or scoring systems including the Ranson critieria, the Glasgow system, and the Acute Physiology and Chronic Health Evaluation (APACHE) II system. 11/17/2018

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) C-reactive protein elevation has also been shown to correlate with clinical outcome 11/17/2018

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. Demerol 75 to 100 mg intramuscularly q 4h 11/17/2018

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. 11/17/2018

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. 11/17/2018

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 11/17/2018

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. Calcified gallbladders are thougth to have a higher risk of carcinoma and should be removed. 11/17/2018

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 . 11/17/2018

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. Caused by obstruction of the cystic duct, usually with superimposed bacterial infection (escherichia coli, Klebsiella, Enterococcus, and Clostridium). Warning epigastric pain radiating straight through to the back may represent biliary colic , but can also be caused by common duct obstruction orpancreatitis. 11/17/2018

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. 11/17/2018

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. Jaundice is an atypical finding- most common with common duct obstruction. Also atypical is infarction of the gallbladder or iinter position of the omentum beteween the inflamed gallbladder and the pariete resulting in decreased tenderness. 11/17/2018

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. 11/17/2018

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. 11/17/2018

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. Sensitivity approx. 90% Stone removal is an added benefit of ERCP. Sensitivity approx. 90% 11/17/2018