Gallstones, Acute Cholecystitis, Gastritis, GORD PDF

 **[Gallstones:]** Gallbladder- Stores bile - Gallstones are small stones that form within the gallbladder (cholelithiasis). Most stones are made of cholesterol Risk Factors: - 5 F's": Fat, Female, Fertile, Forty, and Family history - pregnancy and oral contracep...

 **[Gallstones:]** Gallbladder- Stores bile - Gallstones are small stones that form within the gallbladder (cholelithiasis). Most stones are made of cholesterol Risk Factors: - 5 F's": Fat, Female, Fertile, Forty, and Family history - pregnancy and oral contraceptives\* - haemolytic anaemia - malabsorption (such as previous ileal resection or Crohn's disease). Presentation: - Biliary colic (pain in upper abdomen, spasmodic, cramping): - Severe, colicky epigastric or RUQ pain - Often triggered by meals (high fat meals) - Lasting 30min-8hrs - May be associated with nausea and vomiting - Fat free diet advised to reduce gallbladder contraction and therefore less colic pain. - **[Acute cholecystitis]** - Acute cholecystitis is **acute gallbladder inflammation** - Complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall. Presentation: - Severe constant RUQ or epigastric associated with signs of inflammation, **such as fever and lethargy** - Tender in the RUQ - **Positive Murphy's sign** - Most people with gallstones asymptomatic, only when they have symptoms/complications [Investigations for Gallstones] Laboratory Tests: - **FBC and CRP**- ↑WBC and CRP in acute cholecystitis, but not raised in biliary colic. - **LFTs-** often normal with biliary colic, possible mildly **raised in ALT acute cholecystitis.** \* - \*if ALP and bilirubin are both raised consider obstruction such as CBD stone \*\* Only used if obstructive picture/CBD stone Ultrasound findings/questions (first-line investigation): - Gallstones ? - Acute cholecystitis (thickened gallbladder wall)? - CBD stone (Common bile duct)? - Dilated CBD? **MRCP** (Magnetic resonance cholangio-pancreatography) - MRI scan that gives a detailed image of the biliary system. - Identifying biliary strictures and malignancy. - Used if ultrasound scan does not show stones in the duct but there is CBD duct dilatation or raised bilirubin or deranged LFTs. Most gallstones not radio opaque so will not show up on Xray or CT Management: - Asymptomatic gallstones= no need for treatment- reassurance - Acute cholecystitis- may need emergency admission if systemically unwell - Nil by mouth - IV fluids - Antibiotics (as per local guidelines) - NG tube if vomiting **ERCP** (Endoscopic Retrograde Cholangio-Pancreatography) \*\* - Endoscope involves inserting an endoscope down to through to CBD opening to clear the stones in the CBD or put in stents to improve drainage. **Laparoscopic cholecystectomy:** (surgical removal of gallbladder) indicated where patients are symptomatic, or the gallstones are leading to complications (e.g acute cholecystitis) P**ercutaneous cholecystostomy:** to manage gallbladder empyema when: - Surgery is contraindicated at presentation and - Conservative management is unsuccessful. [Laparoscopic Cholecystectomy Complications] - Wound infection - Bleeding - Bile leaking into the tummy due to perforation of gall bladder - Damage to one of the openings (ducts) carrying bile out of the liver - Blood clots - Anaesthetic risks - Retained stones - Sepsis - Post-cholecystectomy syndrome: bloating and diarrhoea for few weeks- improves with time due to change in bile flow **Gastritis** Gastritis is the histological presence of gastric mucosal inflammation. Causes - Helicobacter pylori infection - Non-steroidal anti-inflammatory drugs (NSAIDs) - Alcohol Symptoms - Dyspepsia - Epigastric discomfort - Nausea, vomiting, and loss of appetite Atypical symptoms- concerning for upper GI malignancy: - Unintentional weight loss - Progressive dysphagia - ALARM symptoms - **Consider a 2WW for stomach cancer in patient with an upper abdominal mass** Offer urgent 2WW upper GI endoscopy in people: - with dysphagia - ≥ 55 yrs with weight loss and any of the following: - Upper abdominal pain - Reflux - Dyspepsia. -  Investigations - **Clinical diagnosis-** no further tests if mild and self-limiting - Ask about the alarm symptoms - **Assess lifestyle** factors - **Review medication**- excessive use OTC medication such as Rennie's, Ibuprofen, naproxen (NSAIDS predisposed/ causing for inflammation of the mucosa, peptic ulcers, Gi bleeds. As well as corticosteroids - **Blood test-** Consider arranging a full blood count, to check for anaemia and/or a raised platelet count. - **Investigations for H.Pylori** if reoccurring dyspepsia Endoscopy - Carbon-13 urea breath test - Stool antigen test- wait at least 2 weeks after treatment of PPI as could give false negative (Prescription of PPI could be due to use of NSAIDS) - Laboratory serology test (if other 2 not available) - Management Lifestyle advice - Lose weight - Avoid any trigger foods, such as coffee, chocolate, tomatoes, faty or spicy foods. - Eat smaller meals - Stop smoking, if appropriate. - Reduce alcohol consumption Medical Management: - Prescribe a full-dose proton pump inhibitor (PPI) for 1 month -  - **H. Pylori eradication** → 1-week **triple therapy:** - PPI twice daily - Amoxicillin 1g twice daily - If allergies: Clarithromycin 500mg twice daily or Metronidazole 400mg twice daily - Advice pt not to ake with alcohol - Caused by NSAIDs → stop NSAID & give PPI **GORD:** Gastro-oesophageal reflux disease (GORD) is a condition whereby gastric acid from the **stomach leaks up into the oesophagus.** Risk factors: - Lifestyle factors, such as obesity, trigger foods, smoking, alcohol, coffee, and stress. - Drugs that decrease the lower oesophageal sphincter pressure, such as calcium-channel blockers, anticholinergics, theophylline, benzodiazepines, and nitrates. - Pregnancy Symptoms - Chest pain- burning retrosternal sensation, worse after meals, lying down, bending over, or straining - Dyspepsia - Excessive belching - Odynophagia - Chronic cough - Nocturnal cough - 10% of patient with GORD will have develop Barrett's Oesophagus by the time they seek medical attention - Sour taste in mouth Pathophysiology: - Metaplastic Columnar epithelium replaces stratifies squamous epithelium that normally lined distal oesophagus. Investigations - **Clinical diagnosi**s- good history and resolution of symptoms after a trial of a proton-pump inhibitor. - **Upper GI endoscopy** (If red fag symptoms, new onset in older or worsening or continued symptoms despite PPI) Specialist investigations - 24hr pH monitoring combined with oesophageal manometry- diagnose oesophageal dysmotility - Barium swallow or meal Management - Lifestyle management - Lose weight - Avoid any trigger foods, such as coffee, chocolate, tomatoes, fatty or spicy foods. - Eat smaller meals - Stop smoking, if appropriate. - Reduce alcohol consumption - Sleep with the head of the bed - Offering a full-dose PPI for 4 weeks for proven GORD, to aid healing. - Offering a full-dose PPI for 8 weeks for proven severe oesophagitis, to aid healing. Surgical Management Three main indications for surgery: - Failure to respond to medical therapy - Patient preference to avoid life-long medication - Patients with complications of GORD\* (in particular respiratory complications, such as recurrent pneumonia) **Laparoscopic fundoplication is the gold standard for anti-refux surgery** **Acute Pancreatitis** - Pancreatitis = Inflammation of the pancreas - Categorized into acute or chronic pancreatitis - **Acute pancreatitis**- rapid onset of inflammation and symptoms. After an episode of acute pancreatitis normal function usually returns - **Chronic pancreatitis-** long-term inflammation and symptoms with a progressive or permanent deterioration in pancreatic function Three main causes: - Gallstones - Alcohol - post-ERCP -  Presentation: - Severe epigastric pain - Radiating through to the back - Associated with vomiting - Abdominal tenderness - Systemically unwell (low grade fever and tachycardia)  Investigations: - Amylase -- is raised 3X the upper limit in acute pancreatitis - FBC (for WBC) - U&E (for urea) - LFTS (for albumin and AST/ALT) - Calcium - LDH - ABG (for PaO2 and blood glucose) **Ultrasound** is the initial investigation of choice in assessing for gallstones **CTAP-** can assess for complication of pancreatitis (such as necrosis, abscess and fuid collections. It is not usually required unless complications are suspected **Glasglow Scoring:** Severity of Pancreatitis Management: - Initial resuscitation (ABCDE approach) - IV fluids: & fuid balance chart (catheter often required to accurately monitor urine output- Aim for a urine output of at least \>0.5ml/kg/hr) - NG tube if profusely vomiting - Nutrition- Mild cases- low fat diet introduced as tolerated, Severe- enteral (NG/NJ) or Parenteral (TPN) - Nil by mouth - Analgesia: - paracetamol + opioid analgesia - Careful monitoring - Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy) - Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area) - Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections) Complications **Pancreatic necrosis:** - Ischaemic infarction of pancreatic tissue due to ongoing inflammation, should be suspected if persistent systemic inflammation \>7 days. - Should be confirmed by CT imaging. - Necrotic area is prone to infection - Broad spectrum antibiotics should be given for prophylaxis in confirmed cases of necrosis. - Treatment with pancreatic necrosectomy- to remove all area of infection and necrosis **Pancreatic pseudocyst:** - Collection of fluid containing pancreatic enzymes, blood, and necrotic tissue Occur anywhere within or adjacent to the pancreas - Lack an epithelial lining - Incidentally on imaging or can present with symptoms of mass effect, such as biliary obstruction or gastric outlet obstruction - Prone to haemorrhage or rupture and can become infected. - 50% spontaneously resolve - If present \>6wks then unlikely to resolve without intervention- surgical debridement or endoscopic drainage