Abdominal Pain

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Abdominal Pain
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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

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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

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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

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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.

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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 Cullens sign (ecchymosis of the
  periumbilical regions may be present

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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.

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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.

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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 Ransons Criteria of severity

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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.

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Complications

• Indicators of severity
• 1. Low hematocrit
• 2. Oliguria lt30 ml/hr
• 3. Systolic blood presurelt 90mmHg
• 4. Pulse gt 120 beats per minute
• 5. O2 saturation lt 90
• An uncomplicated acute pancreatitis subsides with
  conservative measures in 48 to 72 hours.

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Complications

• Ransons crtieria of severity
• 1. Criteria Agegt55, WBCs gt 16,000/mm3, glucose
  gt 200 mg/dl, LDH gt 350 IU/L, AST gt 250 IU/L
• 2. During the initial 48 hours hematocrit
  decreasesgt10mg/dl, BUN increases gt 5 mg/dl
  (despite fluids), calcium lt 8mg/dl,
• 3. Mortality ranges from 1 in mild cases (lt3
  Ransons criteria) to 50 in severe cases (gt4
  Ransons criteria)

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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.

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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.

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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.

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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

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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.

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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
• .

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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.

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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.

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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 (Murphys sign)
• 4. Progressive disease results in increased
  tenderness with guarding and rebound.

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Clinical Evaluation

• Lab tests CBC, LFTs, amylase
• Marked elevation of transminases gt 1000 IU)
  usually indicates hepatic injury
• Mild elevations of bilirubin may reflect acute
  cholecystitis but common duct stones should be
  considered.

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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 Murphys sign, gallbladder
  gt5cm, fluid around the gallbladder and
  thickening.

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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
  gt4 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