Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

TCD 9 - RUQ Abdominal Pain MBChB, BSc (Hons)r FY1 - London@scrubbedup_HISTORIES !?!?!?! NEXTWEEK AGAIN NOTTHIS WEEK LOL @manchesterisoc MEDOLOGYX ISOCMedEd MOCK MMIs Saturday 10th December Volunteer Interviewers Wanted Sign-up Form next slide *Disclaimer* The content of this presentation was created by med students for med students. This session isn’t intended to replace any formal education provided by the uni of mani, so make sure to review all the cases on 1Med and read your ILOs and attend at least 40 hours/week of clinical experience ;)Admin Stuff - Checkyourjunkmail - Checktheemailaddressthatyouregisteredwithtoday - Pleasedon’tDMme/robyn/maria-wedon’thavephonesxxx - YouwilleventuallygettheslidesIpromise(ifyoufilledout feedbackformsthatislol) - BEPATIENTWITHUS(PLEASEEEEEvbizzyrn5thyrispeak) - Don’tworryaboutthenittygrittystuff,justtryandabsorbas muchasyoucan - ZAKrecommendation-don’ttakelotsofnotesitsvsillyimobut - STOPbeingsomeaninyourfeedbackas🥺f-wevalueitbutweare hoomansattheendofthedaytryingourbestxxxSo what is this teaching exactly? Covers the main pathologies mentioned in each week’s TCD Progress Test, CCA/OSCE, DDx, top notch medics basically NOT HERE TO HOLD YOUR HAND THROUGH THE 1MED CASES SUCCINCT, HIGH YIELD, SHARP and ACCO KEYWORD IS نﺎﺳﺣإA brotherly advice :)How to benefit from this session Contribute & Input (LEGIT most important thing) Ask questions Ask more questions If i don’t know something (most likely so, i will find out for u) Don’t be afraid to get something wrong ! Don’t be mean ! I WILL PICK ON PPL (but nicely I promise dw) SMILE, HAVE FUN, (cry), GET INVOLVED Offer me food (not compulsory but highly encouraged) Contents 1. Cholecystitis 2. Gallstones and Biliary Colic 3. Acute/Ascending Cholangitis 4. Acute Pancreatitis 5. Hiatus Hernia Standard case icl no complaints just gotta get jiggy wid it ygmLiver Function Tests (rapid review)LFTs (why and what?) WhydowedoLFTs?Discuss ➔ Clotting(prothrombintime,INR) ➔ Albumin ◆ Liverdisease=↓albuminproduction ◆ Inflammation=↓albuminproduction(notusefulinacute..why?) ◆ EnteropathiesorNephroticSyndr↑↑loss=↓albumin ➔ Enzymes(3xUL) ◆ AST,ALT,ALP ● ALT,AST>>ALP=HEPATOCELLULAR ● ALT,AST<<ALP=BILIARY/OBSTRUCTIVE ◆ Gamma-GT=biliarytreeirritation,risesafteralcohol ➔ Bilirubinaround50µM/L=jaundice ↑ALP+↑GGT-thinkbiliarydisease ↑ALP+normalGGT-thinkbonedisease LFT interp - detail tings ➔ ALT/ALP ◆ ↑↑10xALT:ALP-->hepatocellularinjury ◆ ↑↑3xALP:ALT-->cholestasis ◆ Both-->mixedpicture LFT interp - detail tings ➔ ALP/GGT ◆ ↑↑ ALP + ↑↑ GGT --> cholestasis ◆ ↑↑ ALP alone --> bone disease (bone cancer/↑↑ PTH/osteomalacia/Paget's) ◆ ↑↑ GGT alone → alcohol/enzyme-inducing drugs LFT interp - detail tings ➔ ALT/AST ◆ ALT>AST-->non-alcoholicliverdisease(mainly viral) ◆ AST>ALT-->alcoholicliverdisease/cirrhosis ● ASTaghfirullah→alcohol ◆ AST:ALT>2-->alcoholicliverdisease ◆ ALT>500-->notALD(evenif...) ◆ ALT>1000-->viralhepatitis ◆ ALT>10,000-->paracetamolOD LFT interp - detail tings ➔ Syntheticfunction ◆ ↓↓Albumin→ ● Hepatocellularinjury(chronic-half-life=20days) ● Nephroticsyndrome/protein-losingenteropathy ● Inflammation(negativeacute-phasereactant). ◆ ↑↑PT→ ● Hepatocellularinjury(acute/chronic) ● ↓↓VitaminKJaundice RJaundice (icterus) ➔ Yellowpigmentationoftheskincausedby ↑bilirubininblood ➔ UnconjugatedHyperbilirubinemia - ○ Notfromliverorbiliarytree ➔ ConjugatedHyperbilirubinemia - ○ Causedbyliver&biliarydisorders Bilirubin LFTs summary ➔ Bilirubin ◆ ↑↑UBr→ ● Pre-hepatic(haemolysis) ● Intra-hepatic(↓↓uptake/conjugation) ◆ ↑↑CBr→ ● Intra-hepatic(hepatocellularinjury/↓↓excretion ● Post-hepatic(cholestasis)PreHepatic NormalUrine NormalStools IntraHepatic VariableUrine VariableStools PostHepatic DarkUrine PaleStoolsPre-Hepatic Jaundice ➔ UnconjugatedBilirubin(UCB) hasnoeffectonurinebecauseUCBiswater insoluble ➔ Overproduction- Haemolysis(Malaria+Others),IneffectiveErythropoiesis (haemolyticanemia,G6PD..case11),RBCabnormalities(sicklecell,hypersplenism) ➔ ImpairedHepaticUptake-Drugs(egparacetamol,rifampicin),Ischaemic Hepatitis ➔ ImpairedConjugation-GilbertsSyndrome,Crigler-NajjarSyndrome ➔ Yellowingofskin+eyesinnewbornbabies ➔ NeonatalJaundice-Combinationofabove ➔ Newbornshavehighconc.ofRBCandnotafullydevelopedliver--->↑UBinblood ➔ UBcancrossBBBandcauseneurologicaldysfunction(encephalopathy/kernicterus DANGER) ➔ Treatedwithphototherapy(breaksUBdownsoconjugatesitwithoutliverandthen excreted)Intra-Hepatic Jaundice (Hepatocellular) Whataresomeintra-hepatic causesofjaundice?Discuss ➔ Causedbydysfunctionofhepatocytes (cancausemixedpictureof ↑UCB+↑CB) ➔ DamagetothehepatocytesreleaseALT(reasonfor↑ALTinLFTs) ➔ Causes ➔ Haemochromatosis-↑ironinblood ➔ Leadstomanydifferentsymptoms ◆ AlcoholicHepatitis (tiredness,bronzeskin, ◆ Cirrhosis ➔ Liverbiopsyshows“perl’sstains”(iron ◆ ViralHepatitis deposits) ◆ NAFLD ◆ DrugInduced(paracetamol,statins,TBdrugs) ➔ Wilson’sDisease -↑copperinblood ◆ AutoimmuneLiverDisease depositsonliverandinCNS ◆ Haemochromatosis ➔ Causesliver/neuro/psychiatricproblems ◆ Wilson'sDisease ➔ Kayser-Fleischerringsincornea ➔ Treatwithcopperchelation(penicillamine) PainlessJaundicein<40y/o…thinkGilbert'sSyndrome “-chol-”prefixmeanstodowithbile/gallbladder Post-Hepatic Jaundice (Cholestatic or Obstructive) ➔ Causedbyblockageofbileflow→DamagetobileductreleaseALPandGGT (therefore↑↑ALPseeninLFTs) ➔ ConjugatedHyperbilirubinemiaismorecommoninclinicalpractiseand presentswithDARKURINE+/-PALESTOOLSandinseverecasesPRURITUS (fancywordforitching) symptomsseenin intra-hepaticjaundicetoo ➔ Causes (slidebefore) ◆ HeadofPancreasCancer(REDFLAG--->PAINLESSJAUNDICE!)ngcholangitis) ◆ CompressionofBileDucts(portahepatislymphnodeenlargement) ◆ PrimarySclerosingCholangitis ◆ Cholangiocarcinoma(REDFLAG--->PAINLESSJAUNDICE!+/-UCPMHx)CholelithiasisDefinitely Defining the Definitions Definitively ➔ Cholelithiasis: ◆ referstogallstones ➔ Choledocholithiasis: ◆ referstogallstoneswithinthebiliarytree(CBD). ➔ Biliarycolic: ◆ referstoaself-limitingpainintheRUQ/epigastriumassociatedwith gallstones. ➔ Acutecholecystitis: ◆ referstotheacuteinflammationofthegallbladder,mostcommonly causedbygallstones. ➔ Acutecholangitis: ◆ referstoinfectionofthebiliarytree,commonlyduetoan obstructingstoneintheCBDTime to get (Bile) Stoned ➔ 20%ofpopaffected-80%oftheasympto ➔ Fat,Female,Forty,Fertile,Fair ➔ Types: ◆ Cholesterol85% ● Westerndietlol ◆ Blackpigment/calciumbilirubinate10% ● ↑bilirubin-haemolyticanaemiasicl ◆ Brownpigment/Calciumbilirubinate+calciumsalts5% ● Postcholecystectomy/infxrelatedidklolThese Gallstone mofos cause A LOT stuff:Biliary ColicBiliary Colthiccc ➔ Biliarycolic→ ◆ Colic→constantpainfor>30mins-6hrs ◆ Duetogallbladdercontractingagainstagallstone (cholelithiasis)lodgedinthecysticduct. ◆ ColickyRUQpain→ ~rightshoulder/interscapular region+/-N/V ● ↑↑aftereating,especiallyfattyfood. ● Lasts<6hours ● Nofever/↑↑WCC/-veMurphy's. ◆ SameRFsasbefore5Fs ◆ THISISNOTCHOLECYSTITISUSCHMEEKSIx + Rx ➔ LFTsandUSS1stlinemofos ◆ UsuallynormalLFTs-maybesomeWCCslol ◆ USS ● StonesinGB/AcousticShadowing ➔ Rx- ◆ AnalgesiaandDietchange(ripcouldneverbeme) ◆ Likelytobecomeinfected→considerandelective cholecystectomy ◆ NeedtoruleoutaCBDstonewithUSS(p.s.cholecystectomy wouldbeuselesshere)-alsoUSSisbadatlookingatCBDjs ● MRCPtovisualiseitall ● ERCPtophysicallyyeetoutalodgedstoneygmAcute CholecystitisWho dis bih? ➔ InflammationofGB,mostcommonlybutnotalwayscaused bygallstones ➔ SameRFsasbefore-5Fs ➔ Calculous-inflamduetoimpactedGSincysticduct ➔ Acalculous-vrare-duetosurgicalcomps,infx,ischaemia, cancer,trauma,immunosuppresionetcetc(ignore/allowit ahlie)S/S ➔ RUQ/epigastricpain ➔ N/V ➔ Pyrexia ➔ RUQ/epigastrictenderness-MURPHYYY(?tfdisdonny?) ➔ RUQ/epigastricguarding ➔ Pyrexia ➔ Tachycardia ➔ Hypotension(severecases) Ix ➔ LFTs/FBC/Preggo/Amylase ◆ Probsnormal-WCCs+CRP ➔ USS ◆ ThickenedGBwall +pericholecysticfluid ➔ Maybeanothercausenon-GSrelated? ◆ CTAP ➔ Can’tseeGSandmaybesomewhereelse ◆ MRCP ➔ GSinbiliarytreeandneedsremovalafterMRCP ◆ ERCP ➔ ZAKTOPTIP: ◆ Remember,evenifinflamedGB,ifthereisaGSinBTacholecystectomywon’thelp,onlyERCPwillRx ➔ IVAbxSTAT ◆ Probsaugmentin(coamoxi) ➔ Fluids+Analgesia ➔ ElectiveLapCholecystectomywithin72hrs ◆ Ifnotthenwithintheweek SIMPLESHHEHEHEHEHAcute/Ascending CholangitisWho dis bih? ➔ Infectionofthebiliarytree(Sometimescausedby choledocholithiasis,2ndtoE.Coli)Howisthisdifferent fromacutechole?- ◆ CausedbiliaryobstructionofCBD+/-CBDstricture→ bacterialinfection ➔ Biliary Colic (stone stuck in neck of gallbladder) - RUQ Pain ➔ Acute Cholecystitis (cystic duct ➔ Ascending Cholangitis (CBD sepsis) - RUQ Pain + Fever/↑WCC + Jaundice Ix ➔ LFTs/FBC/Preggo/Amylase-Why? ◆ ElevatedWCCs+CRP ◆ ElevatedALP+CBr ➔ USS ◆ StoneinCBD+ductdilation ➔ Can’tseeGSandmaybesomewhereelse ◆ MRCP ➔ GSinbiliarytreeandneedsremovalafterMRCP ◆ ERCPRx ➔ IVAbxSTAT ◆ Probsaugmentin(coamoxi)orTazocin(whoshe?) ➔ Fluids+Analgesia ➔ ERCP-Stent NB:ifGBisfilledwithpus,drainitviaCholecystostomyPSC & PBC TheyreaccdiffthingswthhhhhPSC- Primary Sclerosing Cholangitis ● Intrahepatic&extrahepaticductsare strictured/fibrotic ● Bileobstructs ● Ductsstiffening(sclerose) ● Stronglyassociatedwith ulcerative colitis(70%) ● Usuallyasymptomaticinearlydays(50%) ○ RUQpain,fatigue,pruritus,jaundice,fever ● Increasestheriskofcholangiocarcinoma ● Riskofcirrhosis ● Ifudonttransplanttheliver→avg survivalrateis12years ● Cholestaticpicture-ALPmost deranged ● Antibodies: ○ p-ANCA ● Goldstandardfordx→ERCPor MRCP ○ Multiplebeadedstrictures Mx: ● Livertransplant ● ERCP-dilateandstentstrictures ● CholestyramineforitchingPBC- Primary Biliary Cirrhosis ● Theimmunesystemviolatesthesmallbileductsintheliver-INTRAHEPATIC ● Obstructstheoutflowofbile-sotheybuildupintheblood ● Middleagedwomen→S/S→itch,jaundice,dryeyes/skin,fatigue ● Autoimmuneconditions-thyroid,coeliac,Sjogren’s→incriskofHCC ● LFTs-ALPfirst,thenbilirubinandtherest ○ ↑ESR↑IgM The4Ms - Middleagedwoman ● Autoantibodies - Antibodyochondrial ○ AMA-mostspecifictoPBCandformspartofthediagnosticcrite-iAnti-SmoothMuscle ○ ANAantibodies-inabout35%ofpatients antibody - IgMraised ● Biopsy+USS→granulomasonintralobularbileducts ● ↑bileacids=itching ● Ursodeoxycholicacid-Slows progression ● ↑bilirubin=jaundice ● Cholestyramine ● ↑cholesterol=xanthelasma ● LivertransplantAcute PancreatitisAcute pancreatitis intro ● Lotsofpancreaticenzymesreleasedwithinpancreas→autodigestion ○ Vesselautodigestion→bleeding→retroperitonealhaemorrhage ● BecomingmoreandmorecommonandisbasicallyMRI/Wythgastrolol ● Morecommoninthemalespecies ● S/S: ○ SuddenonsetSevereepigastricpain-->back. ○ ↓↓bysittingforwards. ○ N/V ○ Ileus ○ GreyTurners ○ CullensEponymous ( when someone creatively names something that they discovered after themselves ) signs (they’renotaccthatrelevantclinicallybutitsOSCEandprogresstestbait.It’s basicallyinternalbleedingandisalatesignofhaemorrhagicpancreatitis) Cullens-periumbilicalbruising GreyTurners-flankbruisingAcute pancreatitis corzes ● Idiopathic ● Gallstones(35%) ● Ethanol(30%) ● Trauma ● Steroids/Steds/Juice/Roids/GymGuice/Sustenance/TrenbalonySandwich/DBol ● MUMPS(orchitis/parotitis/pancreatitis) ● Autoimmune(PAN) ● ScorpionKing/Venom(shush) ● Hyper/Hypo:↑Ca2+,↑Lipids,↓Temp ● ERCP(lol) ● Dwugsss ○ Steroids,Sulfasalazine/Mesalazine,Diuretics,SodiumvalproateWEHAVEBETTERTIKTOKSNOWIPROMISE PLEASESTILLFOLLOWUSTY@SCRUBBEDUP_ Ix ➔ Bloods: ◆ FBC,LFTs,UE,CRP ● Mayberaisedinflamstuff,maybepost-hepaticALPpicture ◆ Amylase ◆ Lipase(morespecific+longerhalflife) ◆ Calcium ➔ USS→GALLSTONES ➔ CT ◆ Ifnotgettingbetterfrom5-7days ● DoCTtovisualisefullextentofnecroticchangesGlasgow Imrie Score (again, eponymous) -P-PaO 28. -<2 = mild. -A-Age(>55). -N-Neutrophilia(>15). -2 = moderate -C-Calcium(<2). (consider ICU -R-Renalfunction(urea>16). -E-Enzymes(AST>200)/ELEVATEDLDH. intervention). -A-Albumin(<32). -S-Sugar(>10). ->2 = severe.Rx ➔ Verysupportive ◆ AggressiveandearlyIVFluidresus ◆ Stronganalgesiaandantiemetics ◆ ?abxxxxx???? ➔ Treatanyunderlyingcauses(GS→ERCPlol) ➔ CTifnotimprovingComplications of an upset pancweas :( ➔ Local ◆ Necrosis→riskofinfx ◆ Pseudocyst ● 4weekspost-peripancreaticfluidcollection ● Painfulandneedssurgical/endoscopicdrainage ◆ Pseudoaneurysm/VTE→haemorrhage ➔ Systemic ◆ ARDS→mostcommoncauseofdeathinAP ◆ ShockHiatus HerniaSliding RollingHiatus hernia ● Vvcommonanatomicalabnormality ● Herniationofpartofthestomachthroughtheesophagealhiatus(anopeningin thediaphragm) ● Majorityoftheseareasymptomatic,incidentalfindingsduringendoscopyor imagingsuchasCTorbariumswallow ● TwoTypes:(actually5typesbuttheycansub-categorisedasthis) ○ Sliding-80% ○ Rolling-20%Risk factors ● Obesity ● Pregnancy ● Trauma Widentheoesophagealhiatus,shortened ● Previousgastrooesophageal oesophagus→pullthestomachupwards surgery ● Age ● Congenitaldefects ● >50%ofpatientswithGORDhavea typeIhiatusherniaSigns and symptoms ● Asymptomatic ● Heartburn ● Regurgitation ● Dysphagia ● Epigastricpain ● Postprandialfullness(excessivelyfullafterameal) ● Nausea ● RetchingManagement ● Mostofthetimedon’trequireintervention Sliding GOJslidesthrough→LOSincompetent Complications:Refulx Rx:weightloss,PPI+/-surgery? Rolling Cardiaslidesthrough→LOScompetent Complications:volvulus/strangulation Rx:SurgeryevenifasymptoFeedback form!!I know u guys like questions but i got bare stuffs to do so pls forgiving me i g2g lol i promise insha’Allah i will have proggy qs back on next time !