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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
  • JACCOL
  • High-dose steroids blunt responses
    • e.g. Peritonitis
  • Inferior MI can => Epigastric/abdo pain
  • Kidney thump for renal angle tenderness
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