12.12.14 Cholecystitis

Differentials

• • Peptic ulcer

  • Pancreatitis

  • ACS

  • Mesenteric ischaemia

    • Constant severe pain

    • Disproportional to symptoms

  • Intestinal obstruction

  • Renal colic

    • Haematuria

    • Loin-to-groin pain

    • Urinary tenesmus

  • Malignancy

Modified Rankin score

• • 0 - No symptoms

  • 1 - No significant disability

    • Able to carry out all usual activities, despite some symptoms

  • 2 - Slight disability

    • Able to look after own affairs without assistance, but unable to carry out all previous activities

  • 3 - Moderate disability

    • Requires some help, but able to walk unassisted

  • 4 - Moderately severe disability

    • Unable to attend to own bodily needs without assistance, and unable to walk unassisted

  • 5 - Severe disability

    • Requires constant nursing care and attention, bedridden, incontinent

  • 6 - Dead

Ranson criteria

• • Non-gallstone pancreatitis:

    • At admission:

      • Age in years > 55 years

      • WBC > 16000 cells/mm3

      • Glucose > 10 mmol/L

      • Serum AST > 250 IU/L

      • Serum LDH > 350 IU/L

    • At any time within 48 hours:

      • Calcium (serum calcium < 2.0 mmol/L

      • Hematocrit fall > 10%

      • Oxygen (hypoxemia PO2 < 60 mmHg)

      • BUN increased by 1.8 or more mmol/L after IV fluid hydration

      • Base deficit (negative base excess) > 4 mEq/L

      • Sequestration of fluids > 6 L

  • Gallstone pancreatitis:

    • At admission:

      • Age in years > 70 years

      • White blood cell count > 18000 cells/mm3

      • Blood glucose > 12.2 mmol/L (> 220 mg/dL)

      • Serum AST > 250 IU/L

      • Serum LDH > 400 IU/L

    • Within 48 hours:

      • Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL)

      • Hematocrit fall > 10%

      • Oxygen (hypoxemia PO2 < 60 mmHg)

      • BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration

      • Base deficit (negative base excess) > 5 mEq/L

      • Sequestration of fluids > 4 L

  • Interpretation:

    • If the score ≥ 3, severe pancreatitis likely.

    • If the score < 3, severe pancreatitis is unlikely

  • Mortality:

    • Score 0 to 2 : 2% mortality

    • Score 3 to 4 : 15% mortality

    • Score 5 to 6 : 40% mortality

    • Score 7 to 8 : 100% mortality..

Glasgow criteria

• • P - P02 < 7.9kPa

  • A - Age > 55

  • N - Neutrophilia - White blood cells > 15

  • C - Calcium < 2 mmol/L

  • R - Renal Urea > 16 mmol/L

  • E - Enzymes - LDH >600, AST >200

  • A - Albumin < 32g/L

  • S - Sugar - Glucose > 10 mmol/L

Ascending cholangitis

• • MEDICAL EMERGENCY!

  • Aetiology

    • Gallstones

      • Check: Pale stools, Dark urine, etc

    • Bile duct stricture

    • Malignancy

  • Symptoms

    • Abdominal pain

      • Particularly in the right upper quadrant

    • Fever

    • Rigors

    • Malaise

    • Jaundice

  • Charcot's triad (only present in 15-20%)

    • Abdominal pain

    • Jaundice

    • Fever

  • Reynolds' pentad (indicates worsening)

    • Charcot's triad

    • Septic shock

    • Mental confusion

Gallbladder

• • Gallstones => Fibrosis

    • From repeated inflammation

  • Pancreatic cancer => Enlargement

    • From back-up

  • Courvoisier's law

    • Enlarged, non-tender gallbladder + jaundice is probably cancer, not gallstones

Notes

• • Peritonitis - Coughing will be painful (if you can't check rebound)

  • Pancreatitis scores

  • APACHE II, Ranson, Glasgow

• JACCOL

• High-dose steroids blunt responses

  • e.g. Peritonitis

• Inferior MI can => Epigastric/abdo pain

• Kidney thump for renal angle tenderness