Gastroenterology and hepatology for MRCP Part 1

A 52-year-old man with a heavy alcohol history has 12 hours of severe epigastric pain boring through to the back, with vomiting. He is tachycardic and tender in the epigastrium. Serum lipase is five times the upper limit of normal, and an ultrasound shows no gallstones. What is the most likely diagnosis?

1. Acute cholecystitis or cholangitis Right upper quadrant pain with fever. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones raises it.
2. Acute pancreatitis correct Correct. Epigastric pain radiating to the back with a lipase over three times normal is acute pancreatitis, here alcohol-related.
3. Perforated peptic ulcer Sudden pain with peritonism and free air. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones separates it.
4. Ruptured abdominal aortic aneurysm Back and abdominal pain with shock. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones must be excluded.
5. Mesenteric ischaemia Pain out of proportion with a raised lactate. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones points elsewhere.

The point: Acute pancreatitis is acute inflammation of the pancreas, most often caused by gallstones or alcohol in the UK (the mnemonic captures the rarer causes, including drugs, hypercalcaemia, hypertriglyceridaemia and ERCP). It presents with severe epigastric pain radiating to the back, vomiting and tenderness, and the diagnosis needs two of three: characteristic pain, a serum amylase or lipase more than three times the upper limit, and cross-sectional imaging findings, with lipase being more specific. Severity is scored (for example with the Glasgow or APACHE II score) and drives the level of care. Management is supportive: aggressive fluid resuscitation, analgesia, oxygen and careful monitoring, with early enteral nutrition and treatment of the cause. Antibiotics are not given routinely and are reserved for proven infection, such as infected pancreatic necrosis. A CT at 48 to 72 hours assesses for necrosis in severe disease. Gallstone pancreatitis is followed by cholecystectomy, and an obstructing stone with cholangitis needs urgent ERCP. Complications include necrosis, pseudocyst, systemic inflammatory response with organ failure, and in chronic disease, diabetes and malabsorption.

Source: British Society of Gastroenterology — acute pancreatitis guidelines British Society of Gastroenterology · tier 2, specialty society or college

A 52-year-old man with a heavy alcohol history has 12 hours of severe epigastric pain boring through to the back, with vomiting. He is tachycardic and tender in the epigastrium. Serum lipase is five times the upper limit of normal, and an ultrasound shows no gallstones. What is the most appropriate investigation?

1. Arterial blood gas and inflammatory markers Gauge the systemic response. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones makes them supportive.
2. Severity score (Glasgow or APACHE II) Grades severity and guides care. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones makes it decisive.
3. Contrast CT at 48 to 72 hours in severe disease Assesses for necrosis. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones makes it selective.
4. Ultrasound for gallstones Identifies a gallstone cause. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones makes it targeting.
5. Serum lipase or amylase correct Correct. A lipase over three times the upper limit is one of the diagnostic criteria and is more specific than amylase.

The point: Acute pancreatitis is acute inflammation of the pancreas, most often caused by gallstones or alcohol in the UK (the mnemonic captures the rarer causes, including drugs, hypercalcaemia, hypertriglyceridaemia and ERCP). It presents with severe epigastric pain radiating to the back, vomiting and tenderness, and the diagnosis needs two of three: characteristic pain, a serum amylase or lipase more than three times the upper limit, and cross-sectional imaging findings, with lipase being more specific. Severity is scored (for example with the Glasgow or APACHE II score) and drives the level of care. Management is supportive: aggressive fluid resuscitation, analgesia, oxygen and careful monitoring, with early enteral nutrition and treatment of the cause. Antibiotics are not given routinely and are reserved for proven infection, such as infected pancreatic necrosis. A CT at 48 to 72 hours assesses for necrosis in severe disease. Gallstone pancreatitis is followed by cholecystectomy, and an obstructing stone with cholangitis needs urgent ERCP. Complications include necrosis, pseudocyst, systemic inflammatory response with organ failure, and in chronic disease, diabetes and malabsorption.

Source: British Society of Gastroenterology — acute pancreatitis guidelines British Society of Gastroenterology · tier 2, specialty society or college

A 52-year-old man with a heavy alcohol history has 12 hours of severe epigastric pain boring through to the back, with vomiting. He is tachycardic and tender in the epigastrium. Serum lipase is five times the upper limit of normal, and an ultrasound shows no gallstones. What is the most appropriate management?

1. Antibiotics only for proven infection Such as infected necrosis. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones makes it selective.
2. Treat the cause Treating the cause, here alcohol cessation, prevents recurrence, and epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones here points elsewhere.
3. Aggressive intravenous fluid resuscitation correct Correct. The mainstay of early treatment is aggressive fluid resuscitation with supportive care.
4. Analgesia and oxygen with close monitoring Supportive care. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones makes it standard.
5. Early enteral nutrition Preferred over prolonged fasting. Epigastric pain to the back with a lipase five times normal and an alcohol history, no gallstones makes it modern.

The point: Acute pancreatitis is acute inflammation of the pancreas, most often caused by gallstones or alcohol in the UK (the mnemonic captures the rarer causes, including drugs, hypercalcaemia, hypertriglyceridaemia and ERCP). It presents with severe epigastric pain radiating to the back, vomiting and tenderness, and the diagnosis needs two of three: characteristic pain, a serum amylase or lipase more than three times the upper limit, and cross-sectional imaging findings, with lipase being more specific. Severity is scored (for example with the Glasgow or APACHE II score) and drives the level of care. Management is supportive: aggressive fluid resuscitation, analgesia, oxygen and careful monitoring, with early enteral nutrition and treatment of the cause. Antibiotics are not given routinely and are reserved for proven infection, such as infected pancreatic necrosis. A CT at 48 to 72 hours assesses for necrosis in severe disease. Gallstone pancreatitis is followed by cholecystectomy, and an obstructing stone with cholangitis needs urgent ERCP. Complications include necrosis, pseudocyst, systemic inflammatory response with organ failure, and in chronic disease, diabetes and malabsorption.

Source: British Society of Gastroenterology — acute pancreatitis guidelines British Society of Gastroenterology · tier 2, specialty society or college