0071643192.pdf

Pseudomonas) are commonly identified pathogens. Risk factors include bile
duct stricture, ampullary carcinoma, and pancreatic pseudocyst.

SYMPTOMS/EXAM

■ Charcot’s triad—RUQ pain, jaundice, and fevers/chills – is classic.
■ Reynold’s pentad, Charcot’s triad plus shock and altered mental status,
may be present in acute suppurative cholangitis and suggests sepsis.

DIAGNOSIS

■ Leukocystosis, increased bilirubin, and increased alkaline phosphatase
■ Obtain blood cultures to rule out early sepsis.
■ Ultrasound or CT may be a useful adjunct, but diagnosis is often clinical.
■ ERCP is both diagnostic and therapeutic (biliary drainage).

TREATMENT

■ Broad spectrum IV antibiotic treatment: Penicillin/antipenicillinase, ceftriax-
one + metronidazole, imipenum, or ampicillin + gentamycin + metron-
idazole.
■ Patients often require ICU admission for monitoring, hydration, and BP support.
■ Acute suppurative cholangitis requires emergent bile duct decompression
via ERCP sphincterotomy, percutaneous transhepatic drainage, or open
decompression.

PANC REAS

Pancreatitis

In the United States, >80% of acute pancreatitis cases result from binge drink-
ing or biliary stones; only 5% of heavy drinkers develop pancreatitis. Twenty
percent of cases are complicated by necrotizing pancreatitis. Pancreatitis can
be classified as either acute or chronic (see Table 11.14).

ETIOLOGY

■ EtOHandgallstonesand, to a much lesser extent, trauma, account for
about 90% cases of pancreatitis.
■ Drugs:Azathioprine, pentamidine, sulfonamides, thiazide diuretics, 6MP,
valproic acid, dideoxyinosine
■ Metabolic: Hyperlipidemia or hypercalcemia
■ Mechanical: Pancreas divisum, sphincter of Oddi dysfunction, mass
■ Infectious:Viruses (eg, mumps, coxsackievirus B) and, to a lesser extent,
bacteria and parasites (eg, Ascaris lumbricoides)
■ Other:Scorpion bites, hereditary pancreatitis (an autosomal-dominant
mutation of the trypsinogen gene), cystic fibrosis, pregnancy

SYMPTOMS

■ Sudden onset, persistent, deep epigastric pain, often radiating to the back,
thatworsens when patients are supine and improves when they sit or
lean forward
■ Severe nausea, vomiting, and fever are also seen.

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

Charcot’s triad is fever,

jaundice, and RUQ pain.

Raynaud’s pentad also

includes decreased mental

status and sepsis.

Gallstones and alcohol are the

main causes of pancreatitis in

the United States.