PANRE/PANCE – Gastroenterology part 5 – Choledocolithiasis, Cholecystitis, Appendicitis, Pancreatitis

by Isabella on June 16, 2012

Can you believe that we are already on part 5 of GI and still no end in sight…it’s almost over, I promise. GI and Cardio make up the majority of the exam, so these are the topics we have to tough through together.  Here’s a recap of Gastroenterology part 4 – what babies complain about when mom is not there ;)

babies with tummy problems (click to zoom)

As I was thinking of a lecture plan and somehow my extremely tired brain spaced out and traveled to September 20th, 2000, where my 18 year old self was having abdominal pain, vomiting and diarrhea at 2 am in the morning after eating a chilli hot dog for lunch at the cafeteria that afternoon :)  Long story short, I ended up driving myself to the hospital after the on call doc told me to take some Tylenol and go to sleep, and  when got there I told the ER doc there “listen Doctor, I have appendicitis and the oncall doc should have sent me here sooner”….after looking at me in disbelief and ordering a CT scan of the abd/pelvis…the ER doc and the surgeon came and said “kiddo, you were right, we’re taking you into surgery” and I felt very proud of myself.  As they were wheeling me into surgery, I started crying, and the kind nurse said “don’t be scared honey, it doesn’t hurt and the scar is very little” and I said “I’m not scared, that’s not why I”m crying”…she asked why I was crying…and I answered sobbing “I have 3 AP classes…and I’m going to miss SOO much at school”…. I still feel amused every time I think of that story :)  Who would have thought that 12 years later I would have survived the AP classes and that I’d be here, writing this lecture :)

So because my brain tends to space out and wander for absolutely no good reason….today’s lecture will cover all the “itises” :)  These can be slightly confusing, so ask questions if you need clarification! :)

Cholelithiais:

  • Cholelithasis is when stones occur in the gallbladder, docolithasis is when it is in the common bile duct
    • about 80% of stones are cholesterol stones, the rest are pigmented stones or calcium stones
  • Risk factors:
    • Usually patient is 30-50
    • obesity
    •  female
      • the crude way to remember is Fat, Female, 40, RUQ pain
    • Other risk factors include pregnancy (due to increased esterogen – which is a steroid – connected to cholesterol)
    • Type 2 diabetes and hyperlipidemia
    • birth control pills (estrogen again)
  • Symptoms/Signs:
    • Usually asymptomatic until it leads to cholecystitis (will discuss next)
    • Sometimes causes epigastric/ RUQ colicky(on/off) pain radiating to right scapula- after fatty meals – gallbladder contracts in response to fatty meal, trying to secrete bile – that contraction is painful due to stones in gallbladder that occasionally get stuck in cystic duct and unstuck when gallbladder is done contracting
  • Diagnosis:
    • Abdominal US is test of choice
  • Treatment:
    • Risk reduction: weight loss, cholesterol reduction, diabetes management
    • usually cholecystectomy although medical treatments are available

Cholecystitis:

  • Cholecystitis develops when a stone blocks the common bile duct, and inflammation occurs over time
    • risk factors are same as cholelithasis : female, overweight, 40s, pregnancy, birth control, DM2, hyperlipidemia
  • Symptoms/Signs:
    • RUQ pain that is now constant – as the stone is stuck in the cystic bile duct – radiating to the back and right scapula – due to irritation of the phrenic nerve
    • low grade fever
    • nausea/vomiting
    • on exam: pt will have RUQ tenderness and occasionall a positive Murphy’s sign
      • Murphy’s sign: press on right upper quadrant – ask patient to inhale – they will not be able to inhale all the way secondary to pain
  • Diagnosis:
    • Abdominal US with attention to gallbladder – pericholecystic fluid, thickened gallbladder wall
    • CBC – often shows leukocytosis, CMP – elevated Bilirubin
    • Can also do HIDA scan – nuclear test – dye is injected into liver, if there’s a stone there, the common bile duct will be dark, but since dye can’t get into the gallbladder, gallbladder won’t show up on the scan.
  • Treatment:
    • Surgical cholecystectomy
    • Also : NPO, Fluids, pain management – usually Demerol

Appendicitis:

  • Appendicitis happens when there is an obstruction of the appendix, leading to inflammation and infection
    • Most common cause is fecaliths – fecaliths can accumulate in the appendix due to a fecal impaction, constipation
    • other causes are IBD, neoplasms
    • Usually occurs in 10-30 yo  - the reason for this is that younger children have an underdeveloped appendix, and the elderly have a shriveled appendix – both of which are unlikely to get blocked
    • more often in male patients
  • Symptoms/Signs:
    • Periumbilical pain that is dull and about 12 hours later radiates to RLQ pain
      • It starts periumbilical due to T10 nerve bundle being irritated by the appendix and then as appendix becomes more inflamed, it causes RLQ peritonitis – and RLQ pain and tenderness
    • Lack of appetite – I usually ask a patient “what’s your favorite food?” and then ask them if they would eat it now if I gave it to them – the response is usually a definitive NO.
    • Nausea/vomiting
    • On exam:
      • Tender RLQ
      • Rebound tenderness over McBurney’s point – 2/3 between navel and hip
      • Positive Psoas Sign: pt on back, push against their right leg and have them raise it – painful RLQ
      • Positive obturator sign: pain with internal rotation at the hip (hip and knee flexed)
    • Leukocytosis – 10k-20k with a left shift
    • Urinalysis – WBC, RBC – due to ureters being irritated.
    • Pregnancy test: Make sure you order a pregnancy test on female with abd pain
  • Diagnosis: CT scan abd/pelvis
  • Treatment: surgical
    • NPO, IV hydration, abx

Acute Pancreatitis:

  • Pancreatitis is inflammation of the pancreas
    • Most common cause is cholelithiasis – stone blocks the sphincter of Oddi – pancreas tries to secrete its contents and gets inflamed because there’ s a bloackage
    •  chronic alcohol consumption
    • HIV antri-retroviral drugs are also linked to pancreatitis
  • Symptoms/Signs:
    • Epigastric/Periumbilical  pain that radiates to back, flanks and chest
    • Pain improves with flexing knees and curling them towards chest
    • Nausea/vomiting
    • fever
    • Grey Turner Sign: ecchymosis on the flank/bank
    • Cullen’s Sign: periumbilical ecchymosis
  • Labs:
    • Lipase – most sensitive/specific enzyme to pancreatitis – only produced in pancreas – will be elevated
    • Amylase – will be elevated – produced in mouth, esophagus and pancreas
    • WBC – elevated with left shift
    • Hypocalcemia – calcium goes to where inflammation is and drops in serum
    • Elevated Triglycerides
    • Elevated LFTS – blockage in biliary tree
  • Diagnosis:
    • CT scan
    • Abdominal US
  • Treatment:
    • NPO/Bowel rest – stop secretion of lipase and amylase
    • IV pain meds -Meperidine (Demerol) is drug of choice – Morphine spasms the sphincter of oddi and can cause more pain
    • IV fluids – normosaline
    • Enteral nutritional support
  • Complications:
    • Pancreatic pseudocyst – debris filled pocket (amylase, lipase, tissue matter, inflammatory fluids)
    • pancreatic abscess
    • hypocacemia

Chronic Pancreatitis:

  • Chronic pancreatitis occurs when there is repeated inflammation of the pancreas over time
    • most common cause of chronic pancreatitis is chornic alcohol abuse (90% of cases)
    • Gallstones, PUD
  • Symptoms/Signs:
    • Symptoms are the same as acute pancreatitis with addition of fatty floating poop
    • weight loss
    • Triad:
      • Calcification – inflammation attracts calcium and pancreas calcifies over time
      • Steatorrhea – inabilit to break down fat due to lack of lipase and fat passes into stool instead of being broken down
      • Diabetes – Pancreas is so scarred that it’s unable to make insulin
  • Diagnosis:
    • Abdominal xray : caclifications in about 20-30 %
    • amylase and lipase are no longer of signifcant use, as they drop with every attack
  • Treatment:
    • NPO, IV hydration, pain management
    • discuss cessation of alcohol use, discuss reduction in fat consumption (as body can’t process it anymore)
    • Discuss risk of pancreatic cancer with patient

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