Computer generated transcript

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

OSCEAZY X GEEKY MEDICS The Gastroenterology Station - Examination Joseph BeeneyExamination introduction and general tips The abdominal examination Spot diagnosis and cases Role FY1 Setting Emergency department Patient Jamie Penn, a 20-year-old man, presents to the emergency department with acute onset abdominal pain. STUDENT Student task Perform a focused INSTRUCTIONS abdominal examination on this patient. After 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. General examination tips! 1 Examine from the right-hand side of the bed Be systematic 2 Inspect → Palpate → Percuss → Auscultate 3 Call the patient by their name throughout so you don’t forget it 4 Ask for patient’s age rather than DoB 5 Say “there is no evidence of” rather than I am looking for 6 Be confident and show off! The Introduction Use WIPE! W Wash hands and don PPE I Introduce your name and role Patient’s name and DoB P E Explain examination and gain consent Adjust bed to 45 degrees, ask patient to lie on bed Adequately expose patient’s chest, abdomen and lower legs Check if patient is in any pain before startingExamination – the processAbdominal Examination General Inspection Patient • Comfortable at rest/in pain • Obvious scars, jaundice, cachexia, hernias, abdo distension Objects/Equipment • Stomas • Mobility aids • Feeding tubes • Catheters • IV access • Surgical drains GENERAL INSPECTION Patient Comfortable at Jaundice rest/in pain? Scars Abdomen Hernias Cachexia Pallor distention Hyperpigmentation GENERAL INSPECTION Objects and equipment Catheter Mobility aids IV access Stoma bag Surgical Parenteral Medications drain nutrition Feeding tube Arms General Inspection Hands Inspection Inspection Patient • Pallor • Comfortable at rest/in pain • Palmar erythema • Bruising • Koilonychia, • Obvious scars, jaundice, leukonychia • Excoriations cachexia, hernias, abdo distension • Clubbing • Needle track Objects/Equipment • Asterixis marks Palpation • Stomas • Mobility aids • Temperature • Acanthosis • Radial pulse nigricans • Feeding tubes • Catheters • Dupuytren’s • IV access • Surgical drains • Hair loss contracture HANDS AND ARMS - inspection Palms Pallor Palmar erythema Redness of heel of palm Could suggest anaemia Could suggest • GI bleed – haemorrhoids, chronic liver disease bowel cancer, peptic ulcer • Liver cirrhosis • Malabsorption - Crohn’s • Wilson’s disease • Haemochromatosis disease, coeliac disease • Can also be a normal finding, • Malnutrition common in pregnancy HANDS AND ARMS - inspection Fingernails Leukonychia Koilonychia Whitening of nail bed Spoon-shaped nails Associated with Associated with hypoalbuminaemia iron deficiency anaemia • End-stage liver disease • Malabsorption - Crohn’s disease, coeliac disease • Protein-losing enteropathy • GI bleed – haemorrhoids, bowel cancer, peptic ulcer HANDS AND ARMS - inspection Fingernails Ask patient to put index fingernails Clubbing back-to-back Observe Schamroth’s window Normal – Schamroth’s Lost when there is uniform swelling of window the soft tissue of the terminal phalanx Associated conditions • Inflammatory bowel • Coeliac disease • Liver cirrhosis • Lymphoma of GIT • Also seen in various cardiovascular and respirClubbing – loss of Schamroth’s window HANDS AND ARMS - inspection Asterixis Ask patient to outstretch their arms Ask patient to cock their wrists back and hold them there for 30 secs Observe for a flapping tremor Hepatic encephalopathy also: CO2 retention in type 2 resp failure https://youtu.be/h5T8rWqLM-U?si=mrEVv1yfZe9GHjOY HANDS AND ARMS - palpation Temperature Radial pulse Use DORSUM of hands to assess Palpate radial pulse with tips of temperature fingers to assess rate and rhythm Assess both sides to compare RATE Count no. pulsations Count no. pulsations Palpate up to the elbows in 15 secs, multORly by 30 secs, multiply by 4 to get bpm 2 to get bpm Normal = 60-100bpm Symmetrically warm = adequate perfusion Is there brady or tachycardia? Cold = poor peripheral perfusion RHYTHM Is it regular or irregular? HANDS AND ARMS - palpation Dupuytren’s contracture Cord Inspect and palpate patient’s hands for Dupuytren’s contracture Thickening of connective tissue in the palms = thickened palmar skin, formation Unable to of nodules and cords straighten finger Associated with… Leads to flexion contracture of the • High alcohol consumption fingers • Diabetes • Increasing age and male sex • Family history HANDS AND ARMS Arms Bruising Excoriations Needle track marks Could suggest Bruising, clotting Scratch scarring marks abnormality and scabs from Patient could be trying to relieve repeated IV pruritis due to cholestasis drug use • Liver cirrhosis • Primary biliary cholangitis • Also bleeding disorders, • Primary sclerosing cholangitisIncreased risk of blood- haematological borne virus transmission • Intrahepatic cholestasis of pregnancy malignancies • Gallstones • Hepatitis B and C • Malignancy • HIV HANDS AND ARMS Axillae - acanthosis nigricans Hold patient’s arm and raise it to inspect BOTH axillae • Commonly occurs in axillae, but can occur anywhere Hyper- keratosis • Can occur in healthy people, esp. in people with black/brown skin Associated conditions Type 2 diabetes Hyperpigmentation Polycystic ovary syndrome GI malignancy – esp. stomach cancer General Inspection Hands Arms Neck and Face Inspection Inspection Patient • Pallor Neck Mouth • Palmar erythema • Bruising • Lymphadenopathy • Oral candidiasis • Comfortable at rest/in pain • Koilonychia, • Glossitis • Obvious scars, jaundice, leukonychia • Excoriations Eyes cachexia, hernias, abdo distension • Clubbing • Aphthous ulcers • Asterixis • Needle track • Conjunctival pallor • Angular Objects/Equipment marks • Jaundice stomatitis • Stomas • Mobility aids Palpation • Acanthosis • Xanthelasma • Temperature nigricans • Corneal arcus • Hyperpigmented • Feeding tubes • Catheters • Radial pulse • Kayser-Fleischer rings macules • Dupuytren’s • Hair loss • IV access • Surgical drains contracture • Ciliary flush NECK AND FACE Neck Palpate both supraclavicular fossae Feel for evidence of lymphadenopathy Left supraclavicular lymph node is called Virchow’s node Virchow’s node is a common site of Virchow’s metastasis for an intraabdominal suprafossacular node malignancy (esp. gastric cancer) NECK AND FACE Eyes Xanthelasma Corneal arcus Soft, yellow macules/ White/grey opaque Due to lipid deposition Due to lipid deposition papules/plaques ring around the iris In older patients (>60 years old), normal sign of Associated with ageing In younger patients, associated hypercholesterolaemia with hypercholesterolaemia Kayser-Fleischer rings Ciliary flush Dark brown-yellow Sign of anterior uveitis Associated with Wilson’s disease Red eye, blood vessels around• Inflammation of the uveal tract ring around the iris the cornea are injected (iris + ciliary body + choroid) Autosomal recessive condition where • Other features include there is copper accumulation and photophobia, pain, decreased deposition in liver, brain and other organs visual acuity, irregular pupil → liver cirrhosis → associated with IBD NECK AND FACE Eyes cont. Jaundice Conjunctival pallor Ask patient to lift upper eyelids and look Ask patient to pull down lower eyelids to downwards (best viewed on superior inspect the conjunctiva aspect of the sclera) Suggests anaemia → GI bleed – haemorrhoids, bowel cancer, Suggests high bilirubin levels → Hepatitis peptic ulcer → Liver cirrhosis → Malabsorption - Crohn’s disease, coeliac → Gallstones – acute cholecystitis, acute cholangitis disease → Pancreatic cancer, pancreatitis → Malnutrition NECK AND FACE Mouth Ask patient to open their mouth Inspect the mouth and mucous membranes for… Aphthous ulcers Angular stomatitis Hyperpigmented macules Painful, round/oval shallow ulcers Inflammation at the corners of the Dark hyperpigmented macules inside the mouth mouth, causing painful cracks and found on mucous membranes fissures Associated with Associated with… Peutz-Jeghers syndrome → Mechanical trauma, tiredness Associated with… → B12/folate/iron deficiency → Dry lips • Autosomal dominant condition → Crohn’s disease → B12/folate/iron deficiency • Many GIT polyps → IBD • Very high risk of intestinal and extra-intestinal cancers NECK AND FACE Mouth cont. Ask patient to stick their tongue out Then lift their tongue to the roof of their mouth Inspect their tongue for… Oral candidiasis Glossitis Fungal infection of Candida Inflammation of the tongue that causes pain, swelling and Patients have a white plaques that erythema can be wiped off to show Tongue appears smooth erythematous mucosa underneath Associated with… → B12/folate/iron deficiency Associated with immunosuppression → Infection General Inspection Hands Arms Neck and Face Inspection Inspection Neck Patient • Pallor Mouth • Comfortable at rest/in pain • Palmar erythema • Bruising • Lymphadenopathy • Oral candidiasis • Koilonychia, • Glossitis • Obvious scars, jaundice, leukonychia • Excoriations Eyes • Aphthous ulcers cachexia, hernias, abdo distension • Clubbing • Needle track • Conjunctival pallor Objects/Equipment • Asterixis marks • Angular Palpation • Jaundice stomatitis • Stomas • Mobility aids • Temperature • Acanthosis • Xanthelasma • Radial pulse nigricans • Corneal arcus • Hyperpigmented • Feeding tubes • Catheters • Dupuytren’s • Kayser-Fleischer rings macules • IV access • Surgical drains • Hair loss • Ciliary flush contracture Chest Inspect for… • Hair loss • Spider naevi • Gynaecomastia CHEST Inspect for… Gynaecomastia Spider naevi Hair loss Proliferation of benign Central red papule with Due to increased male fine red lines oestrogen levels glandular expanding breast tissue • Liver cirrhosis out Due to increased oestrogen levels Due to increased oestrogen levels Can be also due to • Liver cirrhosis • Obesity • Liver cirrhosis malnutrition • Also seen in pregnancy Can be also due to drugs like spironolactone and digoxin and those taking COCP = Charcot’s triad A 70-year-old woman presents to A&E with a fever, jaundice and right upper quadrant pain. She has a history of gallstones. Acute cholangitis A 40-year-old man visits his GP with jaundice, pruritis Primary sclerosing cholangitis and RUQ pain. He has a PMHx of ulcerative colitis. Strong association An 80-year-old man is brought to A&E by his son with severe, acute onset abdominal pain. Earlier today he had 1 episode of Bowel perforation faecal vomiting. He now also is confused and has a fever. He regularly takes codeine for chronic back pain. A 20-year-old woman presents to her GP with a 1-year history of Crohn’s disease bloody diarrhoea and RLQ pain. On examination, there are aphthous ulcers in the mouth and erythema nodosum on her shins.It’s time for a break! General Inspection Hands Arms Neck and Face Inspection Inspection Neck Patient • Pallor Mouth • Comfortable at rest/in pain • Palmar erythema • Bruising • Lymphadenopathy • Oral candidiasis • Koilonychia, • Glossitis • Obvious scars, jaundice, leukonychia • Excoriations Eyes • Aphthous ulcers cachexia, hernias, abdo distension • Clubbing • Needle track • Conjunctival pallor Objects/Equipment • Asterixis marks • Angular Palpation • Jaundice stomatitis • Stomas • Mobility aids • Temperature • Acanthosis • Xanthelasma • Radial pulse nigricans • Corneal arcus • Hyperpigmented • Feeding tubes • Catheters • Dupuytren’s • Kayser-Fleischer rings macules • IV access • Surgical drains • Hair loss • Ciliary flush contracture Abdomen Chest Inspection – scars, hernias, distension etc. Inspect for… Palpation – 9 regions, liver, spleen etc. • Hair loss • Spider naevi Percussion – liver, spleen, shifting dullness etc. • Gynaecomastia Auscultation – bowel sounds, aortic and renal bruits ABDOMEN What’s the first thing to do… Lower the bed so patient is lying flat! Extra things: Ask if patient has any abdominal pain before you start Tell patient they can ask you to stop at any pointABDOMEN Inspect Palpate Percuss Auscultate ABDOMEN - inspection Scars Stomas Hernias Striae Caput medusae CulTurner’s signs- distention Abdomen Scars Kocher Midline laparotomy • Gallbladder and biliary tree operations Paramedian Mercedes Benz • Spleen, kidney, adrenal gland operations modification • Same as Rooftop • Classically liver transplant Rooftop modification Laparoscopic • Oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resections, liver transplant Transverse Loin • Nephrectomy Pfannenstiel • Caesarean section, Gridiron/Lanz hysterectomy Rutherford-Morrison • At McBurney’s point • Colon, implantation of • Appendicectomy kidney transplant Abdominal distension – the 6 Fs Fat Indicates obesity Flatus Gas in the bowel Foetus Faeces Constipation, faecal impaction Fluid Ascites – liver cirrhosis, congestive heart failure, malignancy, pancreatitis, hypoalbuminaemia, peritoneal tuberculosis Fulminant mass Stomas Ileostomy Colostomy Urostomy Made using small bowel Made using large bowel Made using ileal conduit to drain ureters Located in right iliac fossa Located in left iliac fossa Located in right iliac fossa Spout for faeces to drain No spout, flush to the skin Spout for urine to drain without touching and irritating skin Contents = liquid/mushy Contents = solid/semi-solid Contents = urine 2 types – end and loop 2 types – end and loop ileostomies colostomiesSigns of haemorrhagic pancreatitis Cullen’s sign Grey-Turner’s sign Bruising around the umbilicus Bruising in the flanks Other Caput medusae Striae Hernias Head of Medusa Stretch marks due to skin Ask patient to cough to tearing from rapid Engorged paraumbilical veins observe any hernias growth/over-stretching of skin Umbilical hernia • Obesity Incisional Due to portal hypertension • Pregnancy hernia • Common in adolescents • Ascites • Intra-abdominal malignancy Liver cirrhosis • Cushing’s syndrome ABDOMEN - palpation Light palpation Lightly palpate all 9 abdominal regions Right Epigastrium hypochondrium If patient mentions pain, palpate furthest away from the pain hypochondrium first, to try and find the centre of the pain - Tenderness - Rebound tenderness – releasing compressed abdominal wall causes Right flank Umbilical Left flank sharp pain (indicates peritonitis) region - Guarding – abdominal muscle contraction in response to pain - Rovsing’s sign – palpation of LIF causes pain in RIF (indicates peritonitis) - Masses Right iliac Suprapubic Left iliac fossa region fossa Deep palpation Palpate all 9 abdominal regions, but more deeply Palpate using one hand on top of the other for support Feel for any masses, note the… - Location – which region? - Size and shape – approx. - Consistency – soft/hard, smooth/irregular? Watch the patient’s face as you palpate, - Mobility – is it mobile or attached? they may not tell you they are in pain - Pulsatility – is it vascular? ABDOMEN - palpation Liver 1 Use flat edge of your right hand (index finger side) to palpate 2 Start in right iliac fossa Ask patient to take a deep breath and palpate abdomen, keeping 3 your hand there as the patient expires to feel for the liver edge 4 Repeat and move up the abdomen 1 inch at a time until you get to the right costal margin 5 Liver edge may or may not be palpable Some causes of hepatomegaly below the costal margin in healthy people Hepatitis Leukaemia Liver edge Hepatocellular carcinoma Myeloma • >2cm below costal marhepatomegaly Hepatic metastases Glandular fever • Nodular consistenliver cirrhosis Primary biliary cholangitis Wilson’s disease Tricuspid regurgitation • Tender hepatitis, cholecystitis • Pulsatiltricuspid regurgitation Haemochromatosis Haemolytic anaemia ABDOMEN - palpation Gallbladder 1 Position fingers at right costal margin in mid-clavicular line 2 In healthy people, gallbladder should not be palpable If palpable, suggests gallbladder enlargement due to biliary flow 3 obstruction and/or infection Murphy’s sign Position fingers at right costal margin in mid-clavicular line Ask patient to take a deep breath Positive result = patient suddenly stops mid-breath due to pain → Suggests cholecystitis ABDOMEN - palpation Spleen 1 Use flat edge of your right hand (index finger side) to palpate Start in right iliac fossa 2 3 your hand there as the patient expires to feel for the splenic edge Repeat and in a diagonal line towards the left 4 costal margin 1 inch at a time until you get toome causes of splenomegaly the left costal margin Portal hypertension (secondary to liver cirrhosis) Splenic edge should not be palpable at the 5 left costal margin – suggests splenomegaly Congestive heart failure Glandular fever Splenic metastases Haemolytic anaemia ABDOMEN - palpation Kidneys 1 Place left hand underneath patient’s right flank just below the right costal margin, and place right hand on patient’s right flank just below the right costal margin 2 Push fingers on each hand together to ballot the right kidney 3 kidneytient to take a deep breath and feel for lower pole of the right 4 Kidneys not usually palpable in healthy people, unless they have a low BMI Repeat for left kidney 5 Bilaterally enlarged Unilaterally enlarged • Polycystic kidney disease • Renal tumour • Amyloidosis ABDOMEN - palpation Abdominal aorta Use BOTH hands to deeply palpate area superior 1 to umbilicus in the midline Healthy people → hands move superiorly with each 2 pulsation 3 Hands diverge with each pulsation, suggests abdominal aortic aneurysm ABDOMEN - palpation Bladder 1 Tell the patient that this part of the examination might be uncomfortable and make them need to urinate 2 Palpate downwards from the umbilicus to the pubic bone 3 In healthy people, the bladder should not be palpable 4 If palpable in the suprapubic area, it suggests urinary obstruction/retention ABDOMEN - percussion Technique 1. Place flat of middle finger on patient 2. You can also place the index finger down too (less chance of missing and hitting the patient) 3. Use the tip of your middle finger on your free hand to strike the distal IP joint of the finger on the patient 4. Use your wrist to strike rather than using your whole arm 5. Don’t try and strike your finger too hard 6. Press firmly with the finger on the patient – you will get a much louder sound ABDOMEN - percussion Liver Percuss starting in right iliac fossa, and move up 1 inch 1 at a time towards the right costal margin Note the position where the note changes from 2 resonant to dull, → LOWER liver border Continue percussing moving upwards 1 inch at a time until 3 the note changes from dull to resonant, → UPPER liver border Use the approx. positions of the upper and lower liver borders to estimate 4 the size of the liver ABDOMEN - percussion Spleen 1 Percuss starting in right iliac fossa, and move up 1 inch at a time in a diagonal line towards the left costal margin 2 If there is splenomegaly, note the position where the note changes from resonant to dull If there is no splenomegaly, you won’t be able to locate the spleen with 3 percussion ABDOMEN - percussion Bladder 1 Percuss starting at the umbilical region, and move down 1 inch at a time towards the pubic symphysis 2 If the bladder is distended, note where the note changes from resonant to dull 3 Use this to estimate location of the bladder’s upper border ABDOMEN - percussion Shifting dullness 1 time towards left flankilical region, move 1 inch at a 2 Dull note suggests ascites Keep your fingers over the dull note area, ask the patient 3 to roll towards you (onto their right side) 4 Wait for 30 secs, percuss again 5 If ascites is present, this dull note area will now be resonant (fluid has now shifted) Malignancy Pancreatitis Liver cirrhosis Ascites Hypoalbuminaemia Congestive heart Peritoneal failure tuberculosis ABDOMEN - auscultation Bowel sounds Use diaphragm of stethoscope to listen to bowel sounds Do this is 2 different places on the abdomen, for 10 seconds Bowel sounds should be present and sound like gurgling Tinkling bowel sounds → indicates obstruction Absent bowel sounds → indicates ileus ABDOMEN - auscultation Bruits Use diaphragm of stethoscope to listen to bruits (suggests turbulent blood flow) Aortic bruits Auscultation 1-2cm superior to location: umbilicus, midline Associations: AAA Renal bruits Auscultation 1-2cm superior to location: umbilicus, lateral to midline on each side Associations: Renal artery stenosis Hands Arms General Inspection Neck and Face Inspection Inspection Neck Mouth Patient • Pallor • Comfortable at rest/in pain • Palmar erythema • Bruising • Lymphadenopathy • Oral candidiasis • Koilonychia, • Excoriations • Glossitis • Obvious scars, jaundice, leukonychia Eyes • Aphthous ulcers cachexia, hernias, abdo distension • Clubbing • Needle track • Conjunctival pallor Objects/Equipment • Asterixis marks • Jaundice • Angular Palpation • Xanthelasma stomatitis • Stomas • Mobility aids • Temperature • Acanthosis • Hyperpigmented • Feeding tubes • Catheters • Radial pulse nigricans • Corneal arcus macules • Dupuytren’s • Hair loss • Kayser-Fleischer rings • IV access • Surgical drains contracture • Ciliary flush Legs Abdomen Chest Check for… Inspection – scars, hernias, distension etc. Inspect for… • Pitting oedema • Hair loss Palpation – 9 regions, liver, spleen etc. • Spider naevi • Erythema nodosum Percussion – liver, spleen, shifting dullness etc. • Gynaecomastia • Pyoderma gangrenosum Auscultation – bowel sounds, aortic and renal bruits LEGS Pitting oedema Press one finger on patient’s lower legs and ankles Swollen tissue will not spring back and leave an indentation Associated with hypoalbuminaemia → Liver cirrhosis LEGS Erythema nodosum Pyoderma gangrenosum Inflammation of subcutaneous fat First appears as a small, erythematous pustule Tender, erythematous, nodular lesions Then rapidly develops in a very painful ulcer Typically found on the shins Ulcer has a characteristic purple edge Both are extra-intestinal manifestations of IBD Completing the exam Explain to Thank patient Dispose of PPE patient that the and wash hands exam is over Framework for summarizing Today, I performed an abdominal examination on _____, a __ year-old male/female with _______. On general inspection, the patient seemed comfortable at rest, and there was no relevant medical equipment by the bed On examination of the hands, arms and face there was no peripheral stigmata of gastrointestinal disease. The radial pulse was strong and regular, with a rate of ___bpm. On examination of the neck there was no evidence of lymphadenopathy On palpation of the abdomen, all regions were soft and non-tender and there was no evidence of organomegaly On percussion, there was a resonant note in all regions On auscultation, there were normal bowel sounds present and no bruits were noted In summary, this was a normal abdominal examination To complete the examination, I would check the hernial orifices, perform a digital rectal examination and examine the external genitaliaSpot diagnosis and casesA 60-year-old man presents to the GP with jaundice, gynaecomastia and ascites. He reports having drank half a bottle of vodka a day for Liver cirrhosis the last 30 years. On examination, the liver border is hard and nodular. A 30-year-old woman presents to the GP with a 4-year history of diarrhoea, abdominal bloating and an intensely itchy, papular rash on Coeliac disease her buttocks, elbows and knees. There is a family history of type 1 diabetes and autoimmune thyroid disease. A 12-year-old boy presents to A&E with abdominal pain that began 4 hours ago. It started around the umbilicus and is now Appendicitis at the right iliac fossa. He has vomited 3 times. A 90-year-old man presents to his GP with a recent change to his Bowel cancer bowel habits. He frequently experiences bloody diarrhoea. He has lost 3 stone in weight over the last 3 months. He has a 40-year pack history. Data interpretation - bowel perforation on XR Subdiaphragmatic free Rigler sign on AXR Falciform ligament Football sign on AXR gas on erect CXR sign on AXR Both sides of the bowel Radiolucent oval contour Gas can be seen under wall can be visualised Falciform ligament is that suggests a massive outlined by free pneumoperitoneum the diaphragm abdominal gas Triangles of gas may Looks like an American You can see both the also be present (triangle upper and lower sides of Falciform ligament football the diaphragm sign) connects the liver to the Rare, usually seen in anterior abdominal wall neonates Examination findings Systemic symptoms Systemic symptoms – N+V, fever, tachycardia Abdo inspection Acute pancreatitis Abdo palpation Acute onset epigastric tenderness – radiates to back Abdo auscultation Reduced bowel sounds - ileus Risk factors Acronym = I GET SMASHED Idiopathic Gallstones - Most common cause Ethanol - 2ndmost common cause Trauma Acute pancreatitis Steroids Mumps, Malignancy Autoimmune disease - SLE, Sjogren’s syndrome Scorpion sting Hypertriglyceridaemia, hypercalcaemia ERCP Drugs - e.g., thiazide-like diuretics, azathioprine, tetracyclines Investigations Bedside ECG - for epigastric pain to prevent missing any MIs, aortic dissections Labs FBC, CRP, U&Es, LFTs, albumin, LDH, blood glucose Lipase – very specific, levels >=3 times normal Amylase – less specific, levels >=3 times normal ABG Acute pancreatitis Beta-hCG in women of childbearing age Imaging To assess the biliary tree for gallstones - Abdominal USS To exclude other differentials and asses for acute pancreatitis complications - CT-AP If patient not improving/cause unknown, consider additional imaging - MRCP and/or EUS Glasgow-Imrie score These criteria are used to assess the severity of acute pancreatitis Mnemonic = PANCREAS Acute pancreatitis P PaO2 <7.9kPa 1 point for each answer A Age >55 Score of 0-1:mild N Neutrophils WWC >15 Score of 2: moderate C Calcium <2mmol/L Score of >=3:severe R uRea >16mmol/L E Enzymes LDH >600 IU/L A Albumin <32g/L Blood glucose S Sugar >10mmol/L Immediate Surgical Lifestyle • Emergency admission, ABCDE approach • Gallstones • Smoking cessation services • IV fluids - ERCP +/- laparoscopic • IV analgesia cholecystectomy • Alcohol support services • Supplemental oxygen • IV antibiotics • Pancreatic necrosis • Low fat diet - If infected pancreatic necrosis - Surgical debridement • Antiemetics • Early nutritional support • Pancreatic pseudocyst/abscess - Associated with better patient outcomes - Percutaneous/endoscopic - Enteral nutrition, NG/NJ tube if drainage cannot tolerate oral intake - Parenteral nutrition if necessaryPLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK References • https://app.biorender.com/ • https://radiopaedia.org/ • https://geekymedics.com/ • https://teachmesurgery.com/ • https://www.osmosis.org/ • https://zerotofinals.com/ • https://dermnetnz.org/