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cholecystitis and pancreatitis clinical
GI
30
Medical
Graduate
09/18/2010

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Term
what is cholecystitis?
Definition
inflammation of the gall bladder
Term
what are the different kinds of cholecystitis?
Definition
acalculous cholecystitis, acute cholecystitis, and chronic (6 wks +) cholecystitis
Term
what is acalculous cholecystitis?
Definition
inflammation of the gall bladder with a high mortality rate - pts with this present as critically ill and with signs of sepsis w/out an obvious source - *there are no gallstones involved*. suspected causes are bile stasis, chemical inflammation, and mucosal ischemia secondary to major sx, critical illness, trauma, *burns, TPN, and PEEP. complications include: gangrene, empyema, and perforation of the gall bladder.
Term
how is acalculous cholecystitis diagnosed?
Definition
on ultrasound/CT, the gallbladder wall will be thickened, there may be pericholecystic fluid - but *no ascites.
Term
how is acalculous cholecystitis treated?
Definition
the gallbladder has to be drained via cholecystostomy (laparoscopy)
Term
what is acute cholecystitis?
Definition
acute inflammation of the gallbladder, the most common cause of which is obstruction of the cystic duct by *gallstones.
Term
how does acute cholecystitis present?
Definition
n/v, murphy sign (*arrest of inspiration w/palpation of RUQ), jaundice and/or a palpable mass.
Term
how is acute cholecystitis diagnosed?
Definition
hepatobiliary scintigraphy, which after a 2-4 hr fast, IV technetium is excreted through bile ducts and the gall bladder, common bile duct and small intestine should be visible w/in 90 min. if a person has acute cholecystitis, the gallbladder will not be visible after 90 min, even if the other structures are.
Term
what is chronic cholecystitis?
Definition
this is associated with gallstone complications such as recurrent pancreatitis, choledocholithiasis (stones in the ducts), and cholangitis (inflammation of the ducts) (6 wks +). the gallbladder often appears *thickened and fibrotic w/invaginated mucosal pouches (rokitansky-aschoff sinuses)
Term
if an HIV pt presents with abdominal pain, what should be at the top of the ddx?
Definition
AIDs related cholangiopathy. CMV and cryptosporidum can also infect the biliary system and producee cholecystitis and cholangitis.
Term
if an HIV pt presents with abdominal pain, what should be at the top of the ddx?
Definition
AIDs related cholangiopathy. CMV and cryptosporidum can also infect the biliary system and producee cholecystitis and cholangitis.
Term
what is tx for chronic cholecystitis?
Definition
cholecystectomy, either via laproscopic or open
Term
what is acute pancreatitis?
Definition
inflammation of the pancreas, which can be due to alcohol, cholelithiasis, post-op, ERCP (no longer standard for dx), trauma (#1 in kids), metabolic, acute fatty liver of pregnancy, infections, drugs, PUD, pancreatic divisium (congentital malformation), and hereditary pancreatitis. it can be either edematous (mild, self-limiting) or necrotizing (severe)
Term
what is the mechanism believed to be the cause of acute pancreatitis?
Definition
autodigestion. this is when proteolytic enzymes (trypsinogen, chymotrypsinogen, proelastase, and phospholipase A) are activated. also, bradykinin peptides and vasoactive substrates can cause vasodilation, increased vascular permeability and edema. this eventually results in necrotizing pancreatitis.
Term
what are the clinical features associated with acute pancreatitis?
Definition
abdominal pain is the major symptom, which can be mild to severe. steady and boring in the epigastrium/periumbilical and radiating back to the back, chest, flanks and lower abdomen. this *pain worsens w/supine position, pts prefer flexed trunk w/knees drawn up. pts will often present with n/v.
Term
how will pts with acute pancreatitis present?
Definition
distressed/anxious w/low grade fever, tachycardia, hypotension and possible shock. pts may also have erythematous skin nodules, cullen's sign (blue discoloration around the umbilicus) and/or turner's sign (blue-red/green-brown discoloration of the flanks). the last two are indicative of hemorrhagic pancreatitis.
Term
how is acute pancreatitis diagnosed?
Definition
elevated serum lipase (most specific), trypsin, amylase (appears first).
Term
what is in the ddx for acute pancreatitis?
Definition
PUD w/perforation, small bowel obstruction (particularly if pt presents with n/v - check hx and scarring), inferior MI, renal colic, dissecting aortic aneurysm, DKA, acute cholecystitis, and biliary colic
Term
what are the ranson criteria for admission of acute pancreatitis pts?
Definition
> 55 yrs, > 16 WBC, > 200 glucose, 400 LDH, and > 250 AST. if 3+ of these criteria are met - pt needs to be admitted for monitoring.
Term
if a acute pancreatitis pt has qualified for ranson criteria of admission, what needs to be checked w/n 48 hrs?
Definition
if there is: > 10% call in Hct, > 4 L fluid deficit, <8 mg/dl Ca+, < 60 mmHg pO2, > 5 mg/dl BUN increase, and <3.2 gm/dl albumin
Term
what are complications of acute pancreatitis?
Definition
pleural effusion (left), ARDS, hypotension, DIC, renal artery/vein thrombosis, purtscher's retinopathy, abscess, pseudocysts, pancreatic ascites, psychosis, fat emboli, acute tubular necrosis, sudden death, PUD, and erosive gastritis.
Term
what is the level of acute pancreatitis incidence in AIDS pts?
Definition
increased. CMV/cryptosporidium/MAI infections are also increased. tx: didanosine, pentamidine, and bactrim.
Term
how is necrotizing pancreatitis diagnosed?
Definition
CT scan with contrast.
Term
what is the morbidity for necrotizing pancreatitis? how is it treated?
Definition
> 20% in 1-2 wks. surgical debridement may be necessary if infected (40-60% of the time) and antibx are obviously used.
Term
what are pseudocysts?
Definition
necrotic tissue, granulation tissue and fibrous tissue *w/no epithelial cells*. these can occur up to 4 wks after onset of acute pancreatitis, and if still present after 6 wks - need to be drained. if the pseudocyst ruptures and there is blood, there is a 60% chance of rupture (if no blood, less of a chance of rupture)
Term
what is an abcess?
Definition
an ill defined collection of pus which can appear up to 6 wks after onset of acute pancreatitis. it is treated via sx or percutaneous drainage and is less life threatening than infected necrosis. it may be the result of a pseudocyst communicating with the colon.
Term
what is the most common cause of chronic pancreatitis in adults? children?
Definition
adults: alcohol abuse. children: CF
Term
how does chronic pancreatitis present? what can it lead to?
Definition
pts present with severe abdominal/back pain. chronic pancreatitis can lead to malabsorption syndrome (diarrhea, electrolyte imbalance), DM, calcifications, and increased CA risk.
Term
how is chronic pancreatitis treated?
Definition
narcotics, enzymes, sx resection, ERCP stent, antibx, iv fluids/NPO (no solid food to give pancreas rest). 85-90% of cases are self-limited.
Term
what is an infectious concern with acute necrotizing pancreatitis?
Definition
candida
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