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 abdominal pain with fever. Here, upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones points elsewhere.
2. Acute pancreatitis correct Correct. Pain in the upper abdomen spreading to the back with a lipase over three times normal is acute pancreatitis, here caused by alcohol.
3. Perforated peptic ulcer Sudden pain with a rigid, guarded abdomen and free air on scan. But upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones does not point to it.
4. Ruptured abdominal aortic aneurysm Back and abdominal pain with shock. That does not match upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones.
5. Mesenteric ischaemia Pain worse than the examination suggests, with a raised lactate. It does not fit upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones.

The point: Acute pancreatitis is sudden inflammation of the pancreas, most often caused by gallstones or alcohol in the UK (a memory aid covers the rarer causes, including drugs, high blood calcium, high blood fats and after an ERCP procedure). It shows up as severe pain in the upper mid-abdomen (epigastric pain) spreading through to the back, with vomiting and tenderness. The diagnosis needs two out of three: the typical pain, a blood test called amylase or lipase more than three times the normal upper limit, and scan findings, with lipase being the more specific test. How severe it is gets a score (for example the Glasgow or APACHE II score), which decides the level of care needed. Treatment is supportive: plenty of fluid into a vein, pain relief, oxygen and close monitoring, along with feeding through the gut early rather than leaving the patient fasting, and treating whatever caused it. Antibiotics are not given as routine and are kept for proven infection, such as infected dead pancreas tissue (infected pancreatic necrosis). A CT scan at 48 to 72 hours checks for dead tissue in severe disease. Gallstone pancreatitis is followed by removing the gallbladder (cholecystectomy), and a blocked bile duct stone with infection of the bile ducts (cholangitis) needs an urgent ERCP procedure. Complications include dead pancreas tissue, a fluid-filled sac called a pseudocyst, a body-wide inflammatory response with organ failure, and, in disease that keeps coming back, diabetes and poor absorption of food.

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 dead pancreas tissue. But upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones does not point to it.
2. Urgent ERCP for an obstructing stone with cholangitis For a blocked bile duct. Here, upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones points elsewhere.
3. Aggressive intravenous fluid resuscitation correct Correct. The main early treatment is plenty of fluid into a vein along with supportive care.
4. Analgesia and oxygen with close monitoring Supportive care. That does not match upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones.
5. Early enteral nutrition Feeding through the gut early is better than leaving the patient fasting for a long time. It does not fit upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones.

The point: Acute pancreatitis is sudden inflammation of the pancreas, most often caused by gallstones or alcohol in the UK (a memory aid covers the rarer causes, including drugs, high blood calcium, high blood fats and after an ERCP procedure). It shows up as severe pain in the upper mid-abdomen (epigastric pain) spreading through to the back, with vomiting and tenderness. The diagnosis needs two out of three: the typical pain, a blood test called amylase or lipase more than three times the normal upper limit, and scan findings, with lipase being the more specific test. How severe it is gets a score (for example the Glasgow or APACHE II score), which decides the level of care needed. Treatment is supportive: plenty of fluid into a vein, pain relief, oxygen and close monitoring, along with feeding through the gut early rather than leaving the patient fasting, and treating whatever caused it. Antibiotics are not given as routine and are kept for proven infection, such as infected dead pancreas tissue (infected pancreatic necrosis). A CT scan at 48 to 72 hours checks for dead tissue in severe disease. Gallstone pancreatitis is followed by removing the gallbladder (cholecystectomy), and a blocked bile duct stone with infection of the bile ducts (cholangitis) needs an urgent ERCP procedure. Complications include dead pancreas tissue, a fluid-filled sac called a pseudocyst, a body-wide inflammatory response with organ failure, and, in disease that keeps coming back, diabetes and poor absorption of food.

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 definitive treatment?

1. Analgesia and oxygen with close monitoring Supportive care. Here, upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones points elsewhere.
2. Antibiotics only for proven infection Such as infected dead pancreas tissue. It does not fit upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones.
3. Early enteral nutrition Feeding through the gut early is better than leaving the patient fasting for a long time. That does not match upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones.
4. Urgent ERCP for an obstructing stone with cholangitis For a blocked bile duct. But upper abdominal pain spreading to the back with a lipase five times normal and an alcohol history, no gallstones does not point to it.
5. Treat the cause correct Correct. Treating the cause, here stopping alcohol, prevents it coming back.

The point: Acute pancreatitis is sudden inflammation of the pancreas, most often caused by gallstones or alcohol in the UK (a memory aid covers the rarer causes, including drugs, high blood calcium, high blood fats and after an ERCP procedure). It shows up as severe pain in the upper mid-abdomen (epigastric pain) spreading through to the back, with vomiting and tenderness. The diagnosis needs two out of three: the typical pain, a blood test called amylase or lipase more than three times the normal upper limit, and scan findings, with lipase being the more specific test. How severe it is gets a score (for example the Glasgow or APACHE II score), which decides the level of care needed. Treatment is supportive: plenty of fluid into a vein, pain relief, oxygen and close monitoring, along with feeding through the gut early rather than leaving the patient fasting, and treating whatever caused it. Antibiotics are not given as routine and are kept for proven infection, such as infected dead pancreas tissue (infected pancreatic necrosis). A CT scan at 48 to 72 hours checks for dead tissue in severe disease. Gallstone pancreatitis is followed by removing the gallbladder (cholecystectomy), and a blocked bile duct stone with infection of the bile ducts (cholangitis) needs an urgent ERCP procedure. Complications include dead pancreas tissue, a fluid-filled sac called a pseudocyst, a body-wide inflammatory response with organ failure, and, in disease that keeps coming back, diabetes and poor absorption of food.

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