OJ +Pancreatitis (Group 3 & 6)

8/3/2019 OJ +Pancreatitis (Group 3 & 6)

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Date: 12th

October 2011

Bedside: Group 3

Lecturer/Doctor: Dr Suneet

Person in charge: Naqirah

OBSTRUCTIVE JAUNDICE

CASE SUMMARY:

Mrs. ABC, a 59 years old, Chinese lady, was admitted on 11th

October 2011, with 3 days history of

abdominal pain, specifically on umbilical region, associated with jaundice and itchiness, with unsure of

duration. Patient also unsure of history of passing dark urine or pale coloured stool,has had no fever, no

nausea or vomiting, no weight loss or loss of appetite, and no lethargy.Upon examination, patient is

middle size women, look conscious, responsive,and jaundiced over sclera and skin up to abdomen. No

pedal edema, and no lymph nodes palpable. Abdominal palpation revealed tenderness over right

hypochondrium, with palpable, soft liver, 2cm below costal margin and presence of shifting dullness,

suggestive of mild ascites.

Differential diagnosis:

Obstructive jaundice secondary to:

1-Choledocholithiasis

Points support: hx of acute abdominal pain, jaundice, with no hx to suggest malignancy.

2-Ca of head of pancreas

Points support: pain, jaundice,and most importantly ,age- elderly ( it is a must to include it!)

3-Medical jaundice (hepatitis/chronic liver disease)

Points support: abdominal pain, palpable liver, with shifting dullness, (possible)no pale stool or

tea colored urine.

Partial obstruction:

- x pale stool, x dark urine

-on US- prevent dilation of bile duct, thus normal IHD, CBD seen.

Normal diameter of CBD: 5mm, given r=2mm

Flow = 1/ radius (flow is proportional to radius 4th power)

Flow=

=1/16

(semakin kecik radius, semakin tinggi resistance of flow, semakin decrease bile

flow ) lead to stasis.

Stasisinfectioncholangitis (Charcot s triad) =fever, abdo pain, jaundice


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Investigation:

Imaging-Abdominal Ultrasound

-purpose:

1) to differentiate between medical or surgical jaundice

Surgical jaundice, features: -dilated CBD, while no in medical jaundice

2) If surgical jaundice, to differentiate whether it is benign (stone) or malignant cause

Benign (stone)-dilated CBD, with thick wall and shrunken gallbladder

Malignancy- dilated CBD, with thin wall and distended gallbladder

Blood investigation

1. LFT-high ALP, maybe high gama glutamyl transferase (but also raised in medical jaundice)

- Normal AST/ALT

-high total bilirubin, conjugated bilirubin.

2. Coagulation profile-coagulopathy- unable to absorb fat soluble vitamin K

US findings of Cholecystitis:

-thick wall, shrunken GB, pericholecystic fluid (as edema is there)

Why unable to absorb vitamin K?

-Vitamin K requires bile to be absorbed from the small intestine.

Treatment:

-1 ampoule(10mg)/day for 3 days by IM.

@regular intermittent dose (1 ampoule alternate day/ twiceweekly

What actually cause pain in gallstone disease?

Stone in the GB, cause of spasm of GB

(not due to stone in CBD because, lack of muscular layer, and this visceral tissue not well innervated )

Spasm of GBIschemia sudden and severe pain


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PE: may feel tender mass ( fusion of omentum)

Is CT-scan required for this patient?

-elderly: TRO malignancy (possible dual pathology)

-however, in youger patient with clear history suggestive of gallstone disease, NO need to proceed with

CT.

Management:

1. ERCP-remove CBD stone

2. Lap. Cholecystectomy(after 1 or few days, some surgeon prefer to do immediately or 2 weeks later )

PANCREATITIS

GIVEN CASE SENARIOs:

1) Male, 40 y/o, alcoholic, come with acute abdominal pain.Amylase: 2000IU/L

Dx?

=acute pancreatitis

Is this patient require CT? =No.

2) Male, 40 y/o, alcoholic, smoker, and has chronic use of NSAIDs,history of gout, come withacute abdominal pain.

Amylase: 600IU/L

D/dx?

1=perforated peptic ulcer

2=acute pancreatitis

Because of in doubt, try to exclude perforated p.ulcer first by doing:

CXR (air under diaphragm)If still couldnt see the air,

just proceed with CT-scan

-can see pneumoperitoneum (if perforation occur)


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Pancreatitis per se does not require CT investigation unless there is doubt in diagnosis.

HOWEVER, CT is require (especially, if patient present late, weeks later) to investigate the

complications:( findings you can see on CT)

1-Left pleura effusion (common)

2-acute fluid collection

3-pseudocyst (after 3-4 weeks of acute fluid collection wall form around the collection)

-> sometimes may see presence of air (as in this patient), which 99% suggest infection...

where pt started to have:

-full blown septicaemia (fever, etc)

OJ +Pancreatitis (Group 3 & 6)

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