DOCSLIB.ORG

Sample Chapter CHAPTER 16: Liver, Biliary Tract, & Pancreas Disorders BUY

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Sample Chapter CHAPTER 16: Liver, Biliary Tract, & Pancreas Disorders BUY Sample Chapter CHAPTER 16: Liver, Biliary Tract, & Pancreas Disorders BUY NOW mhprofessional.com 728129654 – ©2021 McGraw Hill LLC. All Rights Reserved. CMDT 2022 677 Liver, Biliary Tract, & Pancreas Disorders Lawrence S. Friedman, MD 16 JAUNDICE & EVALUATION OF ABNORMAL hepatic uptake of bilirubin due to certain drugs; or impaired LIVER BIOCHEMICAL TESTS conjugation of bilirubin by glucuronide, as in Gilbert syn- drome, due to mild decreases in uridine diphosphate (UDP) glucuronyl transferase, or Crigler-Najjar syndrome, ESSENTIALS OF DIAGNOSIS caused by moderate decreases (type II) or absence (type I) of UDP glucuronyl transferase. Hemolysis alone rarely elevates the serum bilirubin level to more than 7 mg/dL » Jaundice results from accumulation of bilirubin in (119.7 mcmol/L). Predominantly conjugated hyperbiliru- body tissues; the cause may be hepatic or binemia may result from impaired excretion of bilirubin nonhepatic. from the liver due to hepatocellular disease, drugs, sepsis, » Hyperbilirubinemia may be due to abnormalities or hereditary hepatocanalicular transport defects (such as in the formation, transport, metabolism, or excre- Dubin-Johnson syndrome, progressive familial intrahe- tion of bilirubin. patic cholestasis syndromes, and intrahepatic cholestasis of » Persistent mild elevations of the aminotransferase pregnancy) or from extrahepatic biliary obstruction. Fea- levels are common in clinical practice and caused tures of some hyperbilirubinemic syndromes are summa- most often by nonalcoholic fatty liver disease rized in Table 16–2. The term “cholestasis” denotes (NAFLD). retention of bile in the liver, and the term “cholestatic jaundice” is often used when conjugated hyperbilirubine- » Evaluation of obstructive jaundice begins with ultrasonography and is usually followed by mia results from impaired bile formation or flow. Media- cholangiography. tors of pruritus due to cholestasis have been identified to be lysophosphatidic acid and autotaxin, the enzyme that forms lysophosphatidic acid. Clinical Findings » General Considerations » Jaundice (icterus) results from the accumulation of A. Unconjugated Hyperbilirubinemia bilirubin—a product of heme metabolism—in body tissues. Stool and urine color are normal, and there is mild jaun- Hyperbilirubinemia may be due to abnormalities in the dice and indirect (unconjugated) hyperbilirubinemia with formation, transport, metabolism, or excretion of bilirubin. no bilirubin in the urine. Splenomegaly occurs in all hemo- Total serum bilirubin is normally 0.2–1.2 mg/dL (3.42– lytic disorders except in sickle cell disease. 20.52 mcmol/L). Mean levels are higher in men than women, higher in Whites and Hispanics than Blacks, and B. Conjugated Hyperbilirubinemia correlate with an increased risk of symptomatic gallstone disease and inversely with the risk of stroke, respiratory Cholestasis is often accompanied by pruritus, light-colored disease, cardiovascular disease, and mortality, presumably stools, and jaundice, although the patient may be asymp- because of antioxidant and intestinal anti-inflammatory tomatic. Malaise, anorexia, low-grade fever, and right effects. Jaundice may not be recognizable until serum bili- upper quadrant discomfort are frequent with hepatocellu- rubin levels are about 3 mg/dL (51.3 mcmol/L). lar disease. Dark urine, jaundice, and, in women, amenor- Jaundice may be caused by predominantly unconju- rhea occur. An enlarged tender liver, spider telangiectasias, gated or conjugated bilirubin in the serum (Table 16–1). palmar erythema, ascites, gynecomastia, sparse body hair, Unconjugated hyperbilirubinemia may result from over- fetor hepaticus, and asterixis may be present, depending on production of bilirubin because of hemolysis; impaired the cause, severity, and chronicity of liver dysfunction. BUY NOW CMDT22_Ch16_p0677-p0740.indd 677 29/06/21 8:39 PM mhprofessional.com 728129654 – ©2021 McGraw Hill LLC. All Rights Reserved. 678 CMDT 2022 CHAPTER 16 Table 16–1. Classification of jaundice. Type of Hyperbilirubinemia Location and Cause Unconjugated hyperbilirubinemia Increased bilirubin production (eg, hemolytic anemias, hemolytic reactions, hematoma, pulmonary (predominantly indirect bilirubin) infarction) Impaired bilirubin uptake and storage (eg, posthepatitis hyperbilirubinemia, Gilbert syndrome, Crigler-Najjar syndrome, drug reactions) Conjugated hyperbilirubinemia Hereditary Cholestatic Syndromes (see also Table 16–2) (predominantly direct bilirubin) Faulty excretion of bilirubin conjugates (eg, Dubin-Johnson syndrome, Rotor syndrome) or mutation in genes coding for bile salt transport proteins (eg, progressive familial intrahepatic cholestasis syndromes, benign recurrent intrahepatic cholestasis, and some cases of intrahepatic cholestasis of pregnancy) Hepatocellular Dysfunction Biliary epithelial and hepatocyte damage (eg, hepatitis, hepatic cirrhosis) Intrahepatic cholestasis (eg, certain drugs, biliary cirrhosis, sepsis, postoperative jaundice) Hepatocellular damage or intrahepatic cholestasis resulting from miscellaneous causes (eg, spiro- chetal infections, infectious mononucleosis, cholangitis, sarcoidosis, lymphomas, hyperthyroidism, industrial toxins) Biliary Obstruction Choledocholithiasis, biliary atresia, carcinoma of biliary duct, sclerosing cholangitis, IgG4-related cholangitis, ischemic cholangiopathy, choledochal cyst, external pressure on bile duct, pancreati- tis, pancreatic neoplasms Ig, immunoglobulin. C. Biliary Obstruction expectancy. Truncal fat and early-onset paternal obesity are risk factors for increased ALT levels. Levels are mildly elevated There may be right upper quadrant pain, weight loss (sug- in more than 25% of persons with untreated celiac disease and gesting carcinoma), jaundice, pruritus, dark urine, and in type 1 diabetic patients with so-called glycogenic hepatopa- light-colored stools. Symptoms and signs may be intermit- thy and often rise transiently in healthy persons who begin tent if caused by a stone, carcinoma of the ampulla, or taking 4 g of acetaminophen per day or experience rapid cholangiocarcinoma. Pain may be absent early in pancre- weight gain on a fast-food diet. Levels may rise strikingly but atic cancer. Occult blood in the stools suggests cancer of transiently in patients with acute biliary obstruction from the ampulla. A palpable gallbladder (Courvoisier sign) is choledocholithiasis. NAFLD is by far the most common cause characteristic, but neither specific nor sensitive, of a pan- of persistent mildly to moderately elevated aminotransferase creatic head tumor. Fever and chills are more common in levels. Elevated ALT and AST levels, often greater than benign obstruction with associated cholangitis. 1000 units/L (20 mckat/L), are the hallmark of hepatocellular Diagnostic Studies necrosis or inflammation. Modest elevations are frequent in » systemic infections, including coronavirus disease 2019 (See Tables 16–3 and 16–4.) (COVID-19). The differential diagnosis of any liver test eleva- tion always includes toxicity caused by drugs, herbal and A. Laboratory Findings dietary supplements, and toxins. Elevated alkaline phosphatase levels are seen in cho- Elevated serum alanine and aspartate aminotransferase lestasis or infiltrative liver disease (such as tumor, granulo- (ALT and AST) levels reflect hepatocellular injury. Normal matous disease, or amyloidosis). Isolated alkaline reference values for ALT and AST are lower than generally phosphatase elevations of hepatic rather than bone, intesti- reported when persons with risk factors for fatty liver are nal, or placental origin are confirmed by concomitant ele- excluded. The upper limit of normal for ALT is vation of gamma-glutamyl transpeptidase or 5′-nucleotidase 29–33 units/L in men and 19–25 units/L in women. Levels levels. Serum gamma-glutamyl transpeptidase levels decrease with age and correlate with body mass index and appear to correlate with the risk of mortality and disability mortality from liver disease and inversely with caffeine in the general population. consumption and physical activity. There is controversy about whether a persistently elevated ALT level is associ- B. Imaging ated with a low or high vitamin D level and, in the general population, with mortality from coronary artery disease, Demonstration of dilated bile ducts by ultrasonography or cancer, diabetes mellitus, and all causes; elevated AST lev- CT indicates biliary obstruction (90–95% sensitivity). els have been reported to be associated with shorter life Ultrasonography, CT, and MRI may also demonstrate CMDT22_Ch16_p0677-p0740.indd 678 29/06/21BUY 8:39 PM NOW mhprofessional.com 728129654 – ©2021 McGraw Hill LLC. All Rights Reserved. LIVER, BILIARY TRACT, & PANCREAS DISORDERS CMDT 2022 679 Table 16–2. Hyperbilirubinemic disorders. Type of Nature of Defect Hyperbilirubinemia Clinical and Pathologic Characteristics Gilbert syndrome1 Reduced activity of Unconjugated Benign, asymptomatic hereditary jaundice. Hyperbilirubinemia uridine diphosphate (indirect) bilirubin increased by 24- to 36-hour fast. No treatment required. Asso- glucuronyl transferase ciated with reduced mortality from cardiovascular disease. Dubin-Johnson Reduced excretory Conjugated (direct) Benign, asymptomatic hereditary jaundice. Gallbladder does syndrome2 function of bilirubin not visualize on oral cholecystography. Liver darkly pig- hepatocytes mented on gross examination. Biopsy shows centrilobular brown pigment. Prognosis excellent. Rotor syndrome3 Reduced hepatic reuptake Conjugated (direct)
Load more

Recommended publications
  • Vs. Endoscopic Retrograde Cholangiography in Biliary Sludge and Microlithiasis
    10/7/2015 6:29:47 AM 150111 Therapeutic Effects of Ursodeoxycholic Acid (UDCA) Vs. Endoscopic Retrograde Cholangiography in Biliary sludge and Microlithiasis ﻣﺠﺎﺭﯼ ﺻﻔﺮﺍﻭﯼ Category : 8 Introduction : Biliary microlithiasis and sludge has been considered as a main cause of cute biliary pain and pancreatitis. The standard therapeutic approaches are medical and interventional .There is not enough data regarding usage and chose one of them .To determine the therapeutic values of ursodeoxycholic acid Vs. endoscopic retrograde cholangiography Methods : Between 2013 to 2015, patients who were referred to gastrointestinal clinic for follow-up of biliary sludge and microlithiasis enrolled to this study. The exclusion criteria were presence of CBD stone, CBD dilatation, history of papillotomy, any related complications and need of intervention. All of them underwent physical exam, abdominal ultrasonography and endoscopic. They randomly divided in two groups; medical and ERCP. Patients follow-up for six months .The clinical manifestations as well as lab data was compared in the end of study. Results : A total 116 patients was enrolled in this study .24 patients excluded for complications or needs intervention also 8 patients refused to continue. 7 and 5 patients of UDCA and ERCP groups respectively underwent cholecystectomy during our follow-up. Pancreatitis was seen in 5 patients; 4 and 1 in UDCA and ERCP group .the clinical manifestation as well as lab data were improve in both group but this improvement was significant in ERCP group. Conclusion : Usage of UDCA improves all symptoms as well as lab test .It could be ordered in weak patients or who is in waiting list of ERCP or Surgery.
    [Show full text]
  • A CASE REPORT Introduction Acute Pancreatitis Is an Inflammato
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Archivio istituzionale della ricerca - Università di Palermo Acta Medica Mediterranea, 2014, 30: 33 THE UNSOLVED QUESTION OF ACUTE PANCREATITIS. PROGNOSTIC CRITERIA: A CASE REPORT CLAUDIO ENNA, GIUSEPPE TAORMINA, AURELIO SEIDITA, ALBERTO D’ALCAMO, MIRIAM CARTA, FLORIANA ADRAGNA, PASQUALE MANSUETO Internal Medicine, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University Hospital of Palermo, Italy ABSTRACT Acute pancreatitis is a severe pathologic condition that requires an early identification of patients at risk of developing poten- tially lethal complications. To date, the use of clinical scoring systems and evaluation of biochemical parameters are, by far, the most widely used means to stratify the risk, even if they seem approximate and inadequate. The computed tomography severity index has proved to be superior in predicting acute pancreatitis outcome. Here we report the case of an adult male, admitted to our Department with the initial diagnosis of acute edematous pancreatitis, which was proved later to be a necrotizing pancreatitis, in which the clini- cal and laboratory prognostic scores were inadequate and discrepant with the more accurate computed tomography severity index. Key words: Acute pancreatitis, Ranson’s criteria Glasgow score APACHE II score Balthazar’s score. Received November 18, 2013; Accepted December 31, 2013 Introduction Patients with pancreatic necrosis require to be close- ly monitored in intensive care unit, with a strict clini- Acute pancreatitis is an inflammatory process cal and laboratory follow-up, associated with CT and of pancreas characterized by sudden onset and is, to MRI examination(3).
    [Show full text]
  • Surgery Notes IIIII a PPROACH to ABDOMINAL MASSES 1111 IV IV OESOPHAGEAL DISEASES 1212
    CONTENTS Page I TRAUMA (MULTI-SPECIALTY APPROACH) 22 IIII APPROACH TO ABDOMINAL PAIN 1100 Surgery Notes IIIII A PPROACH TO ABDOMINAL MASSES 1111 IIVV OESOPHAGEAL DISEASES 1122 For the M.B.B.S. VV UPPER BLEEDING GIT AND ITS CAUSES 2211 VVII COLORECTAL DISEASES 1199 By Andre Tan VII LIVER DISEASES 3399 VIII PANCREA TIC DISEASES 4455 IIXX BILIARY TRACT DISEASES 5511 XX BREAST DISEASES 6600 XXII HEAD AND NECK MASSES 6699 XII SALIVARY GLAND SWELLINGS 7744 XIII THYROID DISEASES 7788 XIV PERIPHERAL ARTERIAL DISEASE 8855 XV ABDOMINAL AORTIC ANEURYSM 9933 XVI PERIPHERAL VENOUS DISEASE 9955 XVII UROLOGICAL DISEASES 9999 XVIII SURGICAL INSTRUMENTS 111100 TRAUMA (MULTI-SPECIALTY APPROACH) Management o f breathing -- Supplemental oxygen -- Ventilate as required if patient requires assistance with breathing AADVANCED TTRAUMA LLIFEIFE SSUPPORT ALGORITHM -- Needle thoracotomy for tension pneumothorax, followed by chest tube MAIN PRINCIPLES: -- Occlusive dressing for open pneumothorax -- Treat greatest threat to life first -- Definitive diagnosis is less important 3.3. CIRCULATION -- Time is important – – the “golden hour” after trauma is when 30% of trauma deaths Assessment of organ perfusion occur, and are preventable by ATLS -- Level of consciousness -- Skin colour and temperature, capillary refill -- Pulse rate and character – – all major pulses APPROACH -- Blood pressure 1.1. Primary survey and Resuscitation with adjuncts 2.2. Re-evaluation of the patient Classes of haemorrhagic shock 3.3. Secondary survey with adjuncts I II III IVIV 4.4. Post-resuscitation monitoring and re-evaluation Bld loss 5.5. Optimise for transfer and definitive care Amt (ml) <750 750-1500 1500-2000 >2000 Percentage <15<15 15-30 30-40 >40>40 Ht rate <100 >100 >120 >140 PRIMARY SURVEY – – ABCDE BPBP Normal Normal Decreased Decreased Cap refill Normal Prolonged Prolonged Prolonged 1.1.
    [Show full text]
  • Ministry of Healthcare of Ukraine Danylo Halytsky Lviv National Medical University
    MINISTRY OF HEALTHCARE OF UKRAINE DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY DEPARTMENT OF SURGERY № 1 ACUTE PANCREATITIS Guidelines for Medical Students LVIV – 2019 2 Approved at the meeting of the surgical methodological commission of Danylo Halytsky Lviv National Medical University (Meeting report № ___ on __________ ____, 2019) Guidelines prepared: CHOOKLIN Sergiy Mykolayovych – PhD, professor of Department of Surgery №1 at Danylo Halytsky Lviv National Medical University KHOMYAK Volodymyr Vsevolodovych – PhD, associate professor of Department of Surgery №1 at Danylo Halytsky Lviv National Medical University Referees: ANDRYUSHCHENKO Viktor Petrovych – PhD, professor of Department of General Surgery at Danylo Halytsky Lviv National Medical University OREL Yuriy Glibovych - PhD, professor of Department of Surgery №1 at Danylo Halytsky Lviv National Medical University Responsible for the issue first vice-rector on educational and pedagogical affairs at Danylo Halytsky Lviv National Medical University, corresponding member of National Academy of Medical Sciences of Ukraine, PhD, professor M.R. Gzegotsky 3 I. Background The incidence of acute pancreatitis (AP) has increased during the past 20 years. Most patients develop a mild and self-limited course; however, 10% to 20% of patients have a rapidly progressive inflammatory response associated with prolonged length of hospital stay and significant morbidity and mortality. Patients with mild pancreatitis have a mortality rate of less than 1% but, in severe pancreatitis, this increases up to 10% to 30%.3 The most common cause of death in this group of patients is multiorgan dysfunction syndrome. Mortality in pancreatitis has a bimodal distribution; in the first 2 weeks, also known as the early phase, the multiorgan dysfunction syndrome is the final result of an intense inflammatory cascade triggered initially by pancreatic inflammation.
    [Show full text]
  • Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital
    World J Surg (2019) 43:2994–3002 https://doi.org/10.1007/s00268-019-05114-8 ORIGINAL SCIENTIFIC REPORT Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital 1 2 1 Alvaro Robin-Lersundi • Ana Abella Alvarez • Carlos San Miguel Mendez • 1 1 1 Almudena Moreno Elalo-Olaso • Arturo Cruz Cidoncha • Asuncio´n Aguilera Velardo • 2,3 1,4 Federico Gordo Vidal • Miguel-Angel Garcı´a-Uren˜a Published online: 22 August 2019 Ó Socie´te´ Internationale de Chirurgie 2019 Abstract Background Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. Methods We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. Results Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis.
    [Show full text]
  • Clinical Biliary Tract and Pancreatic Disease
    Clinical Upper Gastrointestinal Disorders in Urgent Care, Part 2: Biliary Tract and Pancreatic Disease Urgent message: Upper abdominal pain is a common presentation in urgent care practice. Narrowing the differential diagnosis is sometimes difficult. Understanding the pathophysiology of each disease is the key to making the correct diagnosis and providing the proper treatment. TRACEY Q. DAVIDOFF, MD art 1 of this series focused on disorders of the stom- Pach—gastritis and peptic ulcer disease—on the left side of the upper abdomen. This article focuses on the right side and center of the upper abdomen: biliary tract dis- ease and pancreatitis (Figure 1). Because these diseases are regularly encountered in the urgent care center, the urgent care provider must have a thorough understand- ing of them. Biliary Tract Disease The gallbladder’s main function is to concentrate bile by the absorption of water and sodium. Fasting retains and concentrates bile, and it is secreted into the duodenum by eating. Impaired gallbladder contraction is seen in pregnancy, obesity, rapid weight loss, diabetes mellitus, and patients receiving total parenteral nutrition (TPN). About 10% to 15% of residents of developed nations will form gallstones in their lifetime.1 In the United States, approximately 6% of men and 9% of women 2 have gallstones. Stones form when there is an imbal- ©Phototake.com ance in the chemical constituents of bile, resulting in precipitation of one or more of the components. It is unclear why this occurs in some patients and not others, Tracey Q. Davidoff, MD, is an urgent care physician at Accelcare Medical Urgent Care in Rochester, New York, is on the Board of Directors of the although risk factors do exist.
    [Show full text]
  • Endoscopic Management of Pancreatitis
    2001 년 도 대한쉐당도연구회 학술대회 口특 강口 Endoscopic Management of Pancreatitis Joseph W. Leung, M.D., FRCP., FACP., FACG C.W. Law Professor of Medicine, Chief, Division of Gastroenterology, University of California, Davis Health System and VA Northem Califomia Health Care System Leaming objectives: distal common duct. Characteristic EUS appearance 1. Understand the role of ERCP in the diagnosis has also been described in the diagnosis of pancreas and treatment of pancreatic diseases divisum. In addition, EUS guided fine needle aspi­ 2. Discuss the pathophysiology of acute and chro­ ration cyto10gy or biopsy is an effective too1 for the mc pancreatltls diagnosis of underlying pancreatic malignancy. Des­ 3. Discuss the management of pain associated with pite the advances in pancreaticobili앙y imaging, thera­ pancreatic diseases peutic ERCP continues to play an important role in 4. Endoscopic management of acute biliary pancre­ the treatment of pancreatic diseases. Endoscopy is atitis, idiopathic pancreatitis and pancreas divisum useful to rule out the presence of an ampullary 5. Endoscopic management of chronic pancreatitis tumor as a cause of pancreatitis. Endoscopic brush in c1uding strictures, stones and pseudocysts cytology, aspiration bile cytology and needle biopsy 6. Discuss parasitic infestation of the pancreatic also aid in the diagnosis of under1ying pancreatic system malignancies. INTRODUCTION DEFINITIONS Diagnostic and therapeutic ERCP play an im­ Acute pancreatitis is defined as inflammation of portant role in the management of patients with pan­ the pancreas with no residual damage upon reco­ creaticobiliaη problems. Diagnostic pancreatogram veη ， except in cases complicated by strictures or compliments ultrasound scan and CT scan in the pseudocyst formation.
    [Show full text]
  • Dentistry – Surgery IV Year
    Dentistry – Surgery IV year Which sign is not associated with peptic ulcer perforation: A 42-year-old male, with previous Sudden onset ulcer history and typical clinical picture of peptic ulcer perforation, on Cloiberg caps examination, in 4 hours after the Positive Blumberg sign beginning of the disease, discomfort in Free air below diaphragm on plain right upper quadrant, heart rate - abdominal film 74/min., mild abdominal wall muscles rigidity, negative Blumberg sign. Free Intolerable abdominal pain air below diaphragm on X-ray abdominal film. What is you diagnosis? Which ethiological factors causes Peptic ulcer recurrence peptic ulcer disease most oftenly? Acute cholecystitis Abdominal trauma, alimentary factor Chronic cholecystitis H. pylori, NSAID's Covered peptic ulcer perforation H. pylori, hyperlipidemia Acute appendicitis (subhepatic Drugs, toxins location) NSAID's, gastrinoma Most oftenly perforated peptic ulcers are located at: A 30-year-old male is operated on for peptic ulcer perforation, in 2,5 hours Posterior wall of antrum after the beginning of the disease. Fundus of stomach Which operation will be most efficient (radical operation for peptic ulcer)? Cardiac part of stomach Simple closure and highly selective Posterior wall of duodenal bulb vagotomy Anterior wall of duodenal bulb Simple closure Simple closure with a Graham patch Penetrated ulcer can cause such using omentum complications: 1). Abdominal abscess; Stomach resection 2). Portal pyelophlebitis; 3). Stomach- organ fistula; 4). Acute pancreatitis; 5). Antrumectomy Bleeding. 1, 2, 3; It has been abandoned as a method to treat ulcer disease 2, 3, 5; 1, 3, 5; A 42-year-old executive has refractory 3, 4, 5; chronic duodenal ulcer disease.
    [Show full text]
  • Acute Pancreatitis 18/04/2012
    Version 2.0 Acute Pancreatitis 18/04/2012 Acute inflammation of the pancreas, releasing exocrine enzymes that cause autodigestion of the organ. There may be involvement of local tissues and distant organs e.g. ARDS. Epidemiology • Common. 3% of all cases of abdominal pain admitted to hospital. Causes (Mnemonic - I GET SMASHED) Gallstones or EtOH (>80%) & Idiopathic (10%) most common. • Idiopathic • Gallstone • Ethanol (alcohol) • Trauma • Steroids • Mumps (paramyxovirus) and other viruses (Coxsackie, hepatitis, EBV, CMV) • Autoimmune disease/vasculitis (Polyarteritis nodosa, Systemic lupus erythematosus) • Scorpion sting (e.g. Tityus trinitatis), and also snake bites • Hypercalcemia, hypertriglyceridemia and hypothermia • ERCP, estrogens • Drugs (SAND - Steroids & sulfonamides, Azathioprine, NSAIDS, Didanosine & diuretics such as frusemide and thiazides), and duodenal ulcers Also hereditary pancreatitis and malignancy (1º or 2º pancreatic Ca) Presentation History: Most commonly constant epigastric/upper abdominal pain, sudden onset ± radiation to back, vomiting, history of EtoH use, gallstones. Take drug history. Exam: Epigastric tenderness, may have absent BS, moderate pyrexia, looking unwell with probable tachycardia with some dehydration. Cullen’s sign (flank) & Grey Turner’s (umbilicus) if haemorrhagic pancreatitis. Investigations Urine: U/A for bilirubin. Urinary trypsinogen activation peptide - but rarely done. Bloods: FBC, UEC, CMP, BSL, LFT, lipase/amylase (lipase ↑sensitive), CRP, ABG, coags, cultures ECG: non-specific ST-T wave
    [Show full text]
  • Review of Current Evidence in the Etiopathogenesis, Epidemiology, Diagnosis and Management of Acute Pancreatitis
    Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 29 March 2019 doi:10.20944/preprints201903.0282.v1 Review Review of Current Evidence in the Etiopathogenesis, Epidemiology, Diagnosis and Management of Acute Pancreatitis Samantha Varley 1*, Kirsten Rossi 2, Meghan Murray 3 and Alissa Nichole 4 1 Department of Gastroenterology, University Hospital of Udine, Udine, Italy; [email protected] 2 Department of Medicine, University Hospital of Udine, Udine, Italy; [email protected] 3 Department of Medicine, University Hospital of Udine, Udine, Italy; [email protected] 4 Department of Gastroenterology, University Hospital of Udine, Udine, Italy; [email protected] * Correspondence: [email protected]; Tel.: +39 (0) 432 552751 Abstract: Acute pancreatitis (AP) is an inflammatory condition of the pancreas and is one of the most common ailments of the gastrointestinal system that results in significant morbidity and mortality. The main etiologic causes of AP are alcohol consumption, gallstones, hypertriglyceridemia, and biliary stones. The clinical signs and symptoms, and diagnostic criteria of AP are well established in the literature and multiple studies. Multiple scoring systems have been used to predict the severity, prognosis, and mortality associated with AP. The present review of the literature brings to light the significant and recent contributions in the etiology, risk factors, epidemiology, diagnosis, complications, prognosis and newest modalities in treatment that could be beneficial in the management of AP. Keywords: pancreatitis; epidemiology; diagnosis; complications; treatment; prognosis 1. Introduction Acute pancreatitis (AP) results from the premature activation of digestive enzymes released by the exocrine pancreas, mainly trypsinogen to trypsin, inside the acinar cells causing their self- digestion and stimulation of macrophages that induce the production of proinflammatory cytokines, Tumor necrosis factor-alpha (TNF- α), interleukins (IL) play a vital role in the pathogenesis of AP [1,2].
    [Show full text]
  • Dr. Sreedevi* Dr. Santhaseelan Dr. Hema Vijayalakshmi V ABSTRACT KEYWORDS INTERNATIONAL JOURNAL of SCIENTIFIC RESEARCH
    ORIGINAL RESEARCH PAPER Volume-8 | Issue-11 | November - 2019 | PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH EVALUATION OF UGI SCOPY FINDINGS FOR PRE- ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY TO PREVENT POST CHOLECYSTECTOMY SYNDROME General Surgery Dr. Ankush Misra Department Of General Surgery, Sree Balaji Medical College And Hospital, Chennai. Professer, Department Of General Surgery, Sree Balaji Medical College And Hospital, Dr. Sreedevi* Chennai. * Corresponding Author Professer, Department Of General Surgery, Sree Balaji Medical College And Hospital, Dr. Santhaseelan Chennai. Dr. Hema Department Of Medical Gastroenterology, Sree Balaji Medical College And Hospital, Vijayalakshmi V Chennai. ABSTRACT Background: Laparoscopic cholecystectomy is gold standard surgery for symptomatic gall stone disease which is the commonest disease needs surgical management. Symptomatology of the patients having upper GI pathologies can mimick the symptomatic gall stone disease and vice versa. Though biliary colic is specific for gallstones. Patients presenting with other gastrointestinal symptoms can also have gall stones. In this study UGI endoscopy was done for all patients with symptomatic and investigation proved gall stone disease to rule out other pathological causes of gastrointestinal tract and prevent post cholecystectomy syndrome. Methods: Patients with Ultrasonography suggestive of single or multiple gall stones were included. Upper GI Scopy was done prior to laparoscopic cholecystectomy as per inclusion and exclusion criteria. All patients above 18years, with ultrasonographically proven diagnosis of cholelithiasis Results: In present study, 153 patients were included. Pain in abdomen was present in 88.2% of patients. Nausea/vomiting was second most common symptom and seen in 60.78%. It is also seen that OGD findings were abnormal in 108 patients (i.e.70.58%) and OGD findings were normal in 45 patients.
    [Show full text]
  • Validity of Ranson's Score for Predicting Mortality and Morbidity in Acute Pancreatitis
    ProceedingS.Z.P.G.M.l. vol: 17(2): pp. 67-70, 2003. Validity of Ranson's Score for Predicting Mortality and Morbidity in Acute Pancreatitis Shandana Tarique, Shahid Sarwar and Farrukh Iqbal Department of Medicine Jinnah Hospital Lahore and Department of Gastroenterology and Hepatology Shaikh Zayed Hospital Lahore SUMMARY Acute pancreatitis is one of the acute abdominal emergencies that need protracted hospital stay and intensive care. Degree of severity has to be assessed to gauge the severity of illness. Ranson scoring system is used to assess the severity and predict prognosis. Study was carried out to assess the validity of Ranson's criteria in patients with acute pancreatitis. Thirty patients of acute pancreatitis were enrolled. Ranson's criteria were applied to all of them. Patients were monitored and managed according to their condition. Out of thirty patients, 46.6% were above 55 years of age. Thirteen (43.3%) patients did not develop any complication. Ranson's score of 0-2 was found in 15 (50%) patients, of which 2 (13.3%) died. Complications occurred in 5 (33.3%). A score of 3-4 was seen in 9 (30%) cases and survival rate was I 00% despite complications. Score of 5-6 was seen in 5 (16.66%) cases. All had complications and 3 (60%) died. A score of 7-8 was found in one patient who survived. The score was insignificant in predicting the mortality with a p-value of 0.371, but had comparatively significant p-value of 0.062 in predicting development of complications. Ranson's criteria is not significant in predicting the outcome in the form of death from acute pancreatitis though there is some significance in predicting the occurrence of compI ications.
    [Show full text]