No Fever, No Jaundice
2-3hrs after eating
May radiate to inferior
angle right scapula
– Bloods, USS
– Rarely empyema
– Bloods, USS
– Cholecystectomy or
– If duct dilated on USS will need
on table cholangiogram or preop MRCP
– Ascending cholangitis
– Vit A,D,E, K malabsorption
– Bloods, USS, MRCP or ERCP
– ERCP 5-20% of cases rise in
AMY after procedure
– 0.5-5% risk of causing
ERCP + sphincterotomy
Epigastric or RUQ pain
Radiates through to the back
Other signs & sx:
Grey Turner & Cullens sign (blood stained peritoneal exudate)
Diagnosis – Amylase 3x upper limit of normal
Severe pancreatitis can lead to multi-system organ failure
(cytokines, toxic enzymes, haemolysis, DIC, fat necrosis)
When to call ITU?
• Scoring – Modified Glasgow score
Renal urea >16
Enzymes LDH>600 AST>200
Score greater or equal to 3 d/w ITU
Supportive: ABC approach
2 Access – central line if v. Severe, fluids
3 catheter – monitor urine output
4 Baseline ABG
6 NG – prevents vomiting and gastric dilation
9 Consider nutrition NG/NJ/TPN
10 Abx if severe or assoc. with gallstones
11 PPI – prevent gastric erosions
12 CT scan >day 5 to assess for complications
• Courvoisiers Law – Jaundice in the presence of an enlarged
non tender gallbladder is unlikely to be gallstone related.
Therefore likely to be pancreatic or GB cancer.
• Other features
New onset diabetes
• Most are palliative -5yr survival ~3%
Abx for cholangitis
• 10-15% are surgical candidates – Whipples procedure
1. 30yo female 2day hx constant pain RUQ associated with
vomiting. Murphys positive. Febrile.
2. 56yo male 1week severe abdominal pain. Febrile. O/E:
RUQ peritonism with a palpable lump. Bloods show
3. 60yo man 6hour hx of constant generalised abdo pain.
O/E signs of shock. Abdomen is distended, generalised
guarding and tenderness.
4. 38yo female 6hour hx of colicky RUQ pain radiating to
back and shoulder. Afebrile, abdomen is soft &
5. 40yo female treated for acute cholecystitis with
palpable non tender gallbladder. Afebrile and
6. 78yo female known gallstones central colicky abdo
pain and vomiting. Constipated for a few days. O/E
increased bowel sounds and abdominal distension.
7. 42yo male sudden onset severe epigastric pain
radiating through to the back. Vomiting and rething.
O/E in shock, upper abdo tenderness, some guarding.
8. 60yo male presents with episodic RUQ
pain, jaudice, fever and chills.
• A 56 year old lady presents with pancreatitis. She
is saturating 98% on air, BP is 80/50, HR 105, RR
16. BM 6, Calcium is within normal limits, WCC
20.2, albumin 36, Lfts derranged ALT 700, LDH
650. U&Es normal.
What is her score?
What should you do?
• Which of these can cause a raised amylase?
• Which of the following is diagnostic of
a) a serum amylase >3x upper limit of normal
b) a serum amylase >1000
c) a serum amylase >2x upper limit of normal
d) jaundice with obx lfts
e) RUQ pain and jaundice