uPPER GASTROINTESTINAL
CASE 21: right upper QuaDrant pain
history
A 44-year-old woman presented to the emergency department with a 1-day history of constant abdominal pain and vomiting. The pain came on suddenly, shortly after eating her evening meal. This was followed by intermittent bouts of bilious vomiting. She has diabetes and is concerned about her blood sugars as she has not been able to eat a normal diet since the pain started. Her bowels have opened normally and she has no urinary symptoms.
examination
The patient is febrile with a temperature of 38°C and a pulse rate of 116/min. She is not clinically jaundiced. On examination of the abdomen, she is found to have tenderness in the right upper quadrant, which is worsened by placing two fingers beneath the tip of the ninth costal cartilage during inspiration. A tender mass is palpable in the right upper quadrant. The urine is clear and rectal examination is normal.
INVESTIGATIONS
|
|
Normal |
haemoglobin (hb) |
11.7 g/dl |
11.5–16.0 g/dl |
mean cell volume |
81 fl |
76–96 fl |
White cell count |
18 × 109/l |
4.0–11.0 × 109/l |
platelets |
312 × 109/l |
150–400 × 109/l |
Sodium |
135 mmol/l |
135–145 mmol/l |
potassium |
4.4 mmol/l |
3.5–5.0 mmol/l |
urea |
4 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
69 μmol/l |
44–80 μmol/l |
amylase |
69 iu/dl |
0–100 iu/dl |
aspartate transaminase (aSt) |
67 iu/dl |
5–35 iu/l |
alkaline phosphatase (alp) |
76 iu/dl |
35–110 iu/l |
gamma-glutamyl transferase (ggt) |
50 iu/dl |
11–51 iu/l |
albumin |
42 g/l |
35–50 g/l |
bilirubin |
25 mmol/l |
3–17 mmol/l |
blood glucose |
27 mmol/l |
3.5–5.5 mmol/l |
Questions
•Whose sign is elicited on examination of the abdomen?
•What is the most likely diagnosis?
•What is your first-line treatment?
•What would you prescribe to treat the high blood glucose?
•What specific complication is this patient at risk of?
43
100 Cases in Surgery
ANSWER 21
Murphy’s sign has been demonstrated, which is described as tenderness under the tip of the ninth costal cartilage, which catches on inspiration. A palpable mass, caused by inflammation and adherent omentum, is present in up to 40 per cent of patients with cholecystitis. An abdominal ultrasound should be requested, which should confirm a thickened gallbladder wall with surrounding free fluid, supporting the diagnosis.
The majority of episodes of acute cholecystitis settle with analgesia and antibiotics. This patient’s diabetes should be controlled with an insulin infusion, until she restarts a normal diet. Many centres are now performing early cholecystectomy, especially for patients with recurrent episodes, or if the symptoms fail to settle despite conservative treatment. If this is not appropriate, then elective cholecystectomy can be carried out at an interval of approximately 6 weeks, after the inflammation has settled.
Acute cholecystitis can lead to a build-up of infected bile within the gallbladder lumen, resulting in an empyema. The gallbladder can also become gangrenous, leading to perforation. Patients are at increased risk if they are diabetic, immunosuppressed, obese or have a haemoglobinopathy.
If patients are elderly or have significant comorbidities, initial decompression may be accomplished under radiographic guidance (percutaneous cholecystostomy). These patients should be managed aggressively with antibiotics and early decompression, as the resulting sepsis can be life-threatening.
KEY POINT
•early cholecystectomy is now routinely practised in the management of acute cholecystitis.
44
Upper Gastrointestinal
CASE 22: epigaStriC pain anD vomiting
history
A 50-year-old man presents to the emergency department with vomiting and severe epigastric pain, which radiates through to the back. The pain was of gradual onset, coming on over the past 2 days. He denies any previous episodes. He is not on any regular medication, but admits to drinking in excess of eight cans of lager a day. He is a heavy smoker, but denies any recreational drug use. He is homeless and relates his heavy drinking to depression.
examination
The patient is sweaty and agitated. He says he is unable to lie flat for the examination and vomits persistently. His blood pressure is 150/80 mmHg and he has a pulse rate of 120/min. Palpation of his abdomen reveals tenderness in the epigastrium. The abdomen is not distended and he has normal bowel sounds. Rectal examination is unremarkable.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
12 g/dl |
11.5–16.0 g/dl |
mean cell volume |
102 fl |
76–96 fl |
White cell count |
13.3 × 109/l |
4.0–11.0 × 109/l |
platelets |
310 × 109/l |
150–400 × 109/l |
Sodium |
132 mmol/l |
135–145 mmol/l |
potassium |
4.2 mmol/l |
3.5–5.0 mmol/l |
urea |
5 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
72 μmol/l |
44–80 μmol/l |
amylase |
4672 iu/dl |
0–100 iu/dl |
aSt |
30 iu/l |
5–35 iu/l |
ggt |
212 iu/l |
11–51 iu/l |
albumin |
25 g/l |
35–50 g/l |
bilirubin |
12 mmol/l |
3–17 mmol/l |
glucose |
5 mmol/l |
3.5–5.5 mmol/l |
lactate dehydrogenase (lDh) |
84 iu/l |
70–250 iu/l |
total serum calcium |
2.35 mmol/l |
2.12–2.65 mmol/l |
Questions
•What is the most likely diagnosis?
•Which important differential diagnosis should be excluded?
•How will you grade the severity of the condition?
•What are its causes?
•What are the other causes of the elevated serum marker of this condition?
•How will you manage the condition?
•Give four potential complications.
45
100 Cases in Surgery
ANSWER 22
The most obvious abnormal result is the raised amylase, giving a diagnosis of acute pancreatitis. The history and macrocytosis would suggest this is of alcoholic aetiology, but it is important to ultrasound the abdomen to exclude gallstones as the cause. The pain is typically severe and radiates through to the back, due to the retroperitoneal position of the pancreas. Vomiting is also a common feature, as a result of gastric stasis caused by the local inflammation. The severity of the attack has no relation to the rise in serum amylase. Twenty per cent of cases of pancreatitis have a normal serum amylase, particularly when there is an alcoholic aetiology.
It is important to exclude a perforated peptic ulcer in this patient by requesting an erect chest x-ray, which would show free subphrenic air in 90 per cent of cases. The serum amylase can be elevated in a patient with gastric perforation due to the systemic absorption of pancreatic enzymes from the abdominal cavity. An amylase rise of over 1000IU/dL, however, is usually diagnostic of acute pancreatitis.
Ranson’s criteria are used to grade the severity of alcoholic pancreatitis, but it takes 48 h before the score can be used. Each fulfilled criterion scores a point and the total indicates the severity.
•On admission:
•Age >55 years
•White cell count >16 × 109/L
•LDH >600 IU/L
•AST >120 IU/L
•Glucose >10 mmol/L
•Fluid sequestration >6 L
•Within 48 h:
•Haematocrit fall >10 per cent
•Urea rise >0.9 mmol/L
•Calcium <2 mmol/L
•Partial pressure of oxygen (pO2) <60 mmHg
•Base deficit >4
Estimates on mortality are based on the number of points scored: 0–2 = 2 per cent; 3–4 = 15 per cent; 5–6 = 40 per cent; >7 = 100 per cent.
!Causes of acute pancreatitis
•Common (80 per cent): gallstones, alcohol
•Rare (20 per cent): idiopathic, infection (mumps, coxsackie b virus), iatrogenic (endoscopic retrograde cholangiopancreatography [erCp]), trauma, ampullary or pancreatic tumours, drugs (salicylates, azathioprine, cimetidine), pancreatic structural anomalies (pancreatic divisum), metabolic (hypertriglyceridaemia, raised Ca2+), hypothermia
46
Upper Gastrointestinal
!Causes of hyperamylasaemia
•perforated peptic ulcer
•mesenteric infarction
•Cholecystitis
•generalized peritonitis
•intestinal obstruction
•ruptured ectopic pregnancy
•Diabetic ketoacidosis
•liver failure
•bowel perforation
•renal failure
•ruptured abdominal aortic aneurysm
The aim of treatment is to halt the progression of local inflammation into systemic inflammation, which can result in multi-organ failure. Patients will often require nursing in a highdependency or intensive care unit. They require prompt fluid resuscitation, a urinary catheter and central venous pressure monitoring. Early enteral feeding is advocated by some specialists. If there is evidence of sepsis, the patient should receive broad-spectrum antibiotics. An ultrasound may demonstrate the presence of gallstones, biliary obstruction or a pseudocyst. Computerized tomography (CT) is used to confirm the diagnosis a few days after the onset of the symptoms, and can be used to assess for pancreatic necrosis.
!Complications of pancreatitis
Local |
Systemic |
pancreatic pseudocyst |
renal failure |
abscess formation |
respiratory failure |
biliary obstruction |
Septic shock |
Fistula formation |
electrolyte disturbance |
thrombosis |
multi-organ failure and death |
KEY POINTS
•ranson’s criteria are used to grade the severity of acute alcoholic pancreatitis.
•patients should be managed aggressively and may require treatment in a highdependency or in intensive care unit.
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