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PATHOPHYSIOLOGY OF PANCREAS (Acute Pancreatitis (Pain:
noncrampy,…
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BILIARY TRACT
GALLSTONE DISEASE
Hallmark: biliary colic: pain
- u steady
- fairly severe
- in RUQ or, less commonly, epigastr sometimes going through to the back at the same level
- visceral (often described as dull or aching and may last from 1 to 4 hrs),
- tends to occur postprandial (may be after a large or fatty meal) but may have no relation to meals and awaken px at night,
- intolerance to fatty foods, flatulence, belching, and indigestion (collective term: dyspepsia)
- seldom relieved by anything but time and potent analgesics
- px most commonly well before onset of pain and then again within minutes to a few hours after the pain subsides.
P/E
- general appearance
- biliary colic: uncomfortable and restless
- acute cholecystitis: tends to be still
- V/S
- pulse rate may be high secondary to pain, infl, or infection.
- Fever often accompanies acute cholecystitis but not biliary colic, and high fever may be present with gangrene of gallbladder or if px has cholangitis.
- Low BP: severe dehydration or septic shock.
- abdomen
- biliary colic: soft, but some tenderness may be found in RUQ. Once pain subsides, abdomen nontender & normal betw episodes of colic.
- acute cholecystitis:
- positive Murphy’s sign (cessation of inspiration because of pain on deep palpitation of RUQ when visceral peritoneum overlying gallbladder inflamed);
- Once infl spreads to adj parietal peritoneum: localized guarding and may demonstrate rebound tenderness;
- tender mass representing infl gallbladder palpable in RUQ in 20%
- Rarely, generalized peritonitis w/ rebound tenderness if free perforation.
- Choledocholithiasis: unremarkable; cholangitis: tenderness in RUQ, Rebound not u found
- nontender, palpable gallbladder w/ jaundice suggests underlying malignant disease, such as carcinoma of pancreas (Courvoisier’s sign)
- malignant obstruction of common bile duct--> gallbladder passively distended as a result of back pressure & palpable in RUQ. If a stone causes distal ductal obstruction, site of origin of stone generally a diseased thick-walled gallbladder, which is incapable of passive distension
Acute cholecystitis
- more localizing tenderness
- steady or crescendo in nature
- localized in RUQ or in the epigastrium
- may radiate to back
- pain lasts longer than 3 to 4 hours and may continue for several days.
- somatic since parietal peritoneum u irritated.
- may be accompanied by nausea, vomiting, and systemic manifestations of an infl process including fever, tachycardia, and, in more severe cases, hemodynamic instability.
- If stone--> obstruction--> jaundice accompanied by light-colored stools and dark, tea-colored urine. (jaundice may fluctuate in intensity compared w/ progressive jaundice caused by malignant)
- malignancies (e.g., carcinoma of the pancreas) generally have dull, vague, or insignificant upper abdominal pain. Hx of marked weight loss often present
- Pruritus often present in pxs w/ obstructive jaundice.
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LIVER
HEPATIC TUMORS, CYSTS, AND ABSCESSES
Benign Tumors
Hemangioma
- Most asymptomatic at presentation & in follow-up.
- Occasionally, very large hemangiomas have pain
- lesions may undergo spontaneous thrombosis--> transient pain
Focal nodular hyperplasia (FNH)
- Pain, when present, likely caused by some other process
Hepatic adenomas
- expand and bleed in 20% to 40%, higher rates seen in women w/ long-term contraceptive use, pregnancy, and tumors larger than 5 cm
Malignant Tumors
Hepatocellular Carcinoma
- suspected in any known cirrhosis and sudden clinical decompensation, including worsening jaundice, encephalopathy, or increasing ascites
Cholangiocarcinoma
- Peripheral tumors may be asymptomatic
- central or hilar tumors (Klatskin Tumor) may cause obstructive jaundice and a bile duct stricture on ERCP
Hepatic Cysts
Simple Cysts
- Simple cysts occasionally may become quite large--> pain, early satiety, or segmental biliary obstruction
- Intracystic bleeding may occur w/ larger cysts
Polycystic Liver Disease
- cysts numerous, progressive enlargement the norm.
- often have polycystic kidney disease that may progress to ESRD
Hepatic Abscesses
Pyogenic Abscess
- bacterial liver abscess: u RUQ pain, fever, and leukocytosis
Portal HTN
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Ascites
- more than 1500 mL--> detected w/ physical findings (dependent dullness to percussion and presence of a fluid wave)
- Morbidity from ascites due to portal HTN: - umbilical, groin, and other abdominal wall hernias can enlarge dramatically - skin overlying hernias can become thinned and ulcerated; rupture of skin may occur & a. w/ a high mortality rate
- ARF in ascites rarely occurs spontaneously but may be precipitated by overzealous use of diuretics. more typical scenario: development of hepatorenal syndrome (HRS)
Hepatic Encephalopathy
- confusion, obtundation, tremor, asterixis, and fetor hepaticus, a sweet, slightly feculent smell of breath noted in advanced liver disease.
- Four stages:
- Stage I, mild confusion or lack of awareness
- Stage II, lethargy
- Stage III, somnolent but arousable
- Stage IV, coma.
- Even w/ normal consciousness, advanced liver disease: impaired psychomotor testing