Acute pancreatitis

● Non-infective inflammation
● CP: severe, constant epigastric pain, develops quickly, max intensity within minutes,
radiating to the back (50%), refractory to analgesics. N/V, retching. Burn marks in the
epigastrium → pt. is trying to relieve the pain.
O/E: SIRS, shock (depending on the extent of inflammation). ↑ HR, ↑ RR, ↓ BP, TLC,
temp.
● Diagnosis: any pt. w/ epigastric pain → MUST exclude AP (always order serum amylase)
○ Serum amylase and lipase
○ Severity assessment (imp)
■ Ransom, Glasgow scale, and others
■ Severe: hemorrhagic (Grey turner and Cullen
sign), necrotizing.
Tx for necrotizing pancreatitis → pancreatic
necrosectomy.
■ Severity investigations imp. (inflammation involving other organs)
○ Contrast CT (specific indications)
■ Diagnostic uncertainty, necrotizing pancreatitis, signs of organ
failure/sepsis/clinical deterioration, local complications.
○ ERCP (indications) within 72h
■ Evidence of CBD obstruction (gallstone pancreatitis, cholangitis, biliary obstruction) → hx of
jaundice, ↑ ALP, CBD diameter >6mm.
■ After ERCP → lap cholecystectomy (in gallstone pancreatitis).
● Management
○ Mild cases: conservative approach → IV fluids, analgesics, antiemetics, brief
period of fasting, observation. ATB only in case of severe pancreatitis, NG tube
not essential unless ileus or vomiting.
○ Severe: ICU admission and aggressive resuscitation.
● Complications
Pseudocyst
- Collection of amylase-rich fluid, occurs after AP or CP or pancreatic trauma.
Present in lesser sac behind stomach. M/c cause of epigastric swelling.
- Rule of 6: 6w after onset of AP, large size >6cm, wall thickness >6mm → open
- - -

surgery.
- Any cyst can be benign or malignant. Must exclude malignancy in case of
pseudocyst.
- In panc. trauma → damage to panc. duct requires surgery, otherwise conservative.
- Case: 55yo male pt., alcoholic, steatorrhea (so CP), now has epi swelling, on US →
10x10cm cystic swelling → Pseudocyst.
- Investigations (to exclude malignancy)
- CEA level (>400 ng/ml → neoplasm)
- Amylase level (usually high)
- Cytology
- Treatment resolves spontaneously
- When it becomes symptomatic (pressure
sx) or causes complications.
- 3 approaches → Percutaneous (percutaneous transgastric cystogastrostomy), transgastric,
surgical. Percutaneous if early case, noninfected, not communicating w/ PD.
Chronic pancreatitis
● CP: severe pain, recurrent attacks of AP, N/V, weight loss, steatorrhea, diabetes. Alcohol m/c cause. Fibrosis and
calcifications.
● Management (imp)

Pancreatic carcinoma
● If in the body or tail → late presentation. Head → obstructive jaundice (CBD obstruction), PD obstruction, or
duodenal obstruction.
● CP: painless jaundice, nausea, epigastric discomfort, pruritus, dark urine pale stools, weight loss, anorexia, doubt
Courvoisier sign. CT
~
FNAC
1
● Dx: Contrast CT scan (sometimes endoscopic US-guided FNAC biopsy if diagnostic doubt). 2 CT
.

argio
Check vascular involvement → CT angiography, duplex US.
Blood tests, US (to check BD involvement). CT (preferred test).
CA19-9 tumor marker (not diagnostic tho),
● Early tumor, no c/i, incidental finding on imaging, not T4, involving duo or stomach or colon etc., any size,
minimal PV or SMV involvement → surgical resection (PPPD or Whipple in some cases).
● C/i to surgical resection: hepatic/peritoneal mets, distant LN mets, encasement of SMA, hepatic a., celiac a.
(If N or M, or T4, vascular involvement → c/i.)
● Unresectable → palliation.
 · Extra info from Zulfi Disc 2 .
.

* ALAIPLA/ HL- > risk of rupture

breast
v .
imp .
multiple (w) septations) S
usually Apply same concept as skin infections (weak defenses -
DM, HIV, malnourished chemo ,
,
radio , etc
. )
vertical /straight
Liver abscess (pyogenic)
-

-
Most on R side as RHA more

g #
CP:Gdull pain in RHC or epigastrium, fever (70%), malaise, anorexia. Elderly, DM, immunocompromised
#
●
G local 6 SIRS
individuals.signs
Pt. will have SIRS (according to Zulfi). Polymicrobial → Klebsiella, E. coli, Strep milleri.
● Etiology (route of microorganisms) ~ sligors india
biliary spread ○ CBD → Ascending cholangitis (Infection ass. w/ obstruction. E. coli, Klebsiella, Enterobacter. Charcot
m/c (35 %
)
triad. ERCP & sphincterotomy can be risk factors). Can cause multiple abscesses
.

○ Portal vein → gangrenous/suppurative acute appendicitis (SMV), sigmoid diverticulitis (IMV),

strangulated hemorrhoids s
○ Hepatic artery → infective endocarditis (from heart)
-

○ Direct → liver trauma or direct stab wound, hematoma

-
● Ascending cholangitis complication → liver abscess.
○ 35 yo female pt. w/ obs jaundice, HG fever, chills, underwent sphincterotomy. Now after 1y presents w/
liver abscess. (Asc cholangitis causing liver abscess). T ATB after 2/5 -

● Investigations (as screening) (T When doubt

O-initial
inf
.

CBC CRP will only detect

○ US/CT → multiloculated cystic mass (hypoechoic/hypodense lesion) but won't localize
,

○ Aspiration (confirmation) → send for culture and sensitivity.

● Treatment -closed drainage pt Prolonged * If .
INR or PT (22 or

mudle -
○# Aspiration (percutaneous drainage) go20s)for possible pass
culture instead
>
- not to

(take bod ATB

after the
aspiration
○ ATB (metronidazole, clindamycin, 3G cephalosporins, aminoglycosides)
○ Recurrent/refractory abscess: if initial abscess was large, multiple, or continued comms w/ biliary tract.
Treat the cause. and fond
* If treat PLA w/ PD
you that
● Differentials: simple cyst, hydatid cyst, necrotic tumors, hematomas stores also remove ,

Sometimes abscess lyst may suptun

Laparotony washing , packing
+x cause . *
Rupture - · >
into CBD
,
,

- jaundice.
Leg chologis
1 .
Pain + fever (local + SRS)
in me

-
Amoebicte
~ liverprim-usually single s t tis.
us
CBD,
us

(w/septs)
>
.
-

abscess
● Entamoeba histolytica spread by eating (fecr-oral)
SE Asia

● Hx of travel (e.g., Asia), hx of colitis, diarrhea, dysentery

-
size location
(Llobe)
,

● Tx: Metronidazole. If large (>5 cm) and risk of rupture → aspiration.

fresh stool ex within
·
Mostly asx but sometime can cause
bloody stools ->

3-4ht microscopy.
-
Hydatid cyst
Felo-oral
Echinococcus tapeworm parasite Farmers taking can of pigs
.
● · ,

● Tx: drugs (albendazole/mebendazole) + percutaneous PAIR (puncture of cyst, aspiration of contents, instillation
of hypertonic saline, re-aspiration). PAIR /PAIR-PD
- entered
into pleral canity pleral empyerna. >
-

Implications of PAIR: may introduce pus into pleura if needle above 10th
MAL
rib. If abscess on left lobe, difficult to
aspirate directly → may need to go anteriorly (not preferable), or open surgery.
● Calcified cyst (dead) → follow-up with US. need for ex
sensation + palpable
no .

> dragging
-
- stretch liver capsule
muss
When big
usually
.

· Hx+ asx .

in live
PAIR/PAIR-PD
· Tx +
Drugs (small)
·

Surgical (big) -

lactive) close

Risk Llobe >

-
segmenectory/lobectory open drainage desting we om

rupture
, , ,
of
· , patch

Acute Asc

~
acueeast cholangitis cholangitis
PLA stone, drosecutions,
·
- >
-

chologitis (dl]
=>

* Charcot triad >

- Acute worm
,
problem in

(9 110 clock position) strict ta sphincter

CBD ERCP + sphincterotomy
or
store in >
-
need for
>
- no
-
ERCP LC .
AP is a complication ATBe ERIP-LC
ERCP or

ATB.
ONLY
Recurrent problem .
Asc cholargitis.
* DIt
sphincteratory dromations >
-
go up
.

mandatory for asc-ch sometimes genetic predisposition

LERLP and sphincterotony he not .,

creakness on sphincter) is a factor).

 -Aye /Aspiration + ATB after drainage.

for ) only ATB . If 73cm >D

s abscesses
+

- Small (-hum ,
ex .

first
Chil conguiapathy
.

>
-

A cal (metronidazole)
>
- If risk of rupture ( > Sun ,
L lobe >
- aspiration
etc .
peritonal carity pericadium
lugs
.

,
into
>
- Can
capture ,

fluid.
size dif hypertonic phy retaining
gradually
↑ in
* All absusses

* FIRST Mr ·

for PLATALA- .

t specific (TCRP all info conditions)

CCBC is in

-
DEFINITIVE CT (most of the time not
always
* Risk of rupture for both ALA/PLA >
- Aspiration.
* You have to the complicatives. If complication
print
present >
-> treat then surgery
.

* LFTs could be near normat or elevated .

inf
AST ,
ALT >
-

- obs.
5 NU
ALD , 44T
-

- D
Bilimbin
- I

PT/INR
Albumin
obsess
Intice abscess them be mixed pic . Focus on

may
resolve
Treat abscess >
- LFTS will

.
(PT/INR) before putingrdle
*
Always
check
coagulopathy
etc. but do
If PT/INR prolonged , you con
give FFP/litk

NOT put the needle.

Hydatid cyst 2 PAIR complication pleval empyema

DeadIcalcifiede follow-up -small
ex .
in * >
-
,

* )
* Big cavity drain
-

> lear a
etc
Medical (albendazole
.

(PAR PARD (PAIR-PD)

> SurgicalMinimally
inv
-

Active
.

* L
always Est option if Same concept for PLA
.

no cli ·

Lenlarged/ruptured
Pyogenic liver abscess scenarios
● 60 yo male, pain in the RIF, diagnosed w/ gangrenous appendicitis. 1w later presents w/ dull pain in RUQ
and fever.anorexia .

○ PLA d/t PV spread - SMV sigmoid

● 60 yo male, LIF pain → features of diverticulitis (may be w/ diarrhea, bleeding per rectum, fever, etc.).
○ PLA d/t PV spread - IMV
● 40 yo female, presented w/ Charcot triad (fever, jaundice, RUQ pain), now has a liver abscess.
○ PLA d/t CBD spread (ascending cholangitis) must give ATB according to the mos in CBD
.

● 50 yo male, dull RUQ pain, fever, imaging shows hypoechoic lesion in the R lobe, and uses medications for a
cause abscess anywhere
heart disease. can
○ PLA d/t Hepatic artery spread (IE, aortic aneurysm, etc.)
● Pt. presents w/ HG fever, chills, RUQ pain, US shows hypoechoic lesion. There’s hx of RTA 2w ago and
right lower ribs fracture.
○ PLA d/t Hematoma (direct spread - trauma to the liver)

Amoebic liver abscess

● Hx of travel (e.g., Southeast Asia), bloody stools/colitis, single cavity on US without septations.

Review
● 40 yo female, 5 children, uses OCPs. Now presents w/ RUQ pain and fever.
○ Acute cholecystitis.
● 50 yo female, hx of gangrenous appendicitis, now presents w/ RUQ pain and fever.
○ PLA.
● 60 yo female, LIF pain (think about diverticulitis). 1w later presents w/ RUQ pain and fever.
○ PLA.
● 30 yo male, traveler (think about where he went). Now has RUQ pain and fever.
○ ALA.

Hydatid cyst .
US
● Occupation → Common in farmers. Palpable mass .

Hypoechoic lesion on

HCC
● Hx of CLD d/t hepatitis B or C.
SUMMARY
- Acute pancreatitis
- Noninfective autodigestive inflammation
- Amylase and lipase (if high no need for CT)
- Severity assessment (WBC, AST, LDH, glucose, O2, Ca, fluid sequestration, shock, etc.)
- Hemorrhagic (Grey turner, Cullen signs), necrotizing, shock → severe pancreatitis → ICU admission and
invasive monitoring and CT.
- Chronic pancreatitis
- Severe out of proportion pain, therefore pain management important and management in general
- Relieve obstruction w/ ERCP, etc. for pain relief. No obs → stepwise analgesia, celiac axis block. Know
how to relieve duo or CBD obstruction
- Tx of DM, other tx measures
- Pancreatic head carcinoma
- Painless jaundice (painful is for stone obstruction) however ⅓ can be painful if surrounding structures
involved
- Tumor involving any structure other than major midgut arteries, no LN, no mets → resection. Otherwise
palliation (if major arteries involved, LN, mets).
- Liver abscess dull pain + fever.

- More systemic signs, less pain

- Dx confirmed by imaging. Confirm and tx w/ aspiration.
- Causes of pyogenic abscess (4 routes). E.g., h/o gang appendicitis or diverticulitis and 1w later dull pain
in RHC and fever.
- Amoebic abscess
- Aspiration may be successful sometimes but it can still introduce infection, so just give metronidazole
(complication → irreversible neuro damage).
- Hydatid cyst
- Not all require tx, calcified cysts just need follow-up
- Active cysts (floating membrane on CT) → tx which is PAIR (nonsurgical first priority).
- Surgery → lobectomy, deroofing risk of mptire)
* As
longas no
/i (L lobe ,

rupture
Ar t
.
HCC
● Hypervascular lesion → on auscultation, RUQ bruits are heard.
● CT scan performed in arterial phase.
● HBV, HCV, CLD/cirrhosis (alc or non-alc), NAFLD, ALD, etc.
● Screening: USG & AFP
● Imaging
○ USG: suspicious lesion >1 cm → Multiphasic CT (w/o contrast, w/ contrast → arterial, venous, and
delayed venous).
○ HCC is most prominent in the arterial phase. CRLM (liver mets) more in venous phase.
● Suspected HCC localized on US + AFP level → CT.
● CT (diagnostic) → treatment or biopsy. (Biopsy not recommended d/t tumor cell implantation, but can still be
performed if CT inconclusive).
● Barcelona staging management
○ Single, < 2cm, or =< 3cm → resection.
○ 3 nodules (2-3 nodules), =< 3cm → liver transplantation (no ass. active CLD), RFA/PEI (ass. dis)
○ Multinodular → TACE.
○ Advanced stage → sorafenib
○ Terminal (unfit, child PUGH-C) → supportive care