Medication Overuse (Analgesic Rebound) Headache


-Medication Overuse headache occurs when long-term use of analgesics is interrupted for a few hours. 

-The prevalence is higher in women than in men 

– Most common primary headache associated is migraine 

-the risk is high with butalbital, tylenol, aspirin, triptans,opioids, ergotamines, NSAIDS 

Symptoms & Signs 

-Patient experiences headaches when he or she goes a certain period of time without taking analgesics


-a history of analgesic use averaging more than two to three days per week (15 or more days per month) in association with chronic daily headache


-Discontinuation of the offending medication 

-Patient education 

Chronic Pancreatitis

Chronic pancreatitis 


-Chronic pancreatitis is a syndrome involving inflammation, fibrosis, and loss of acinar and islet cells in the pancreas. 

-Causes: Alcoholism (70%), smoking, duct obstruction, hyperparathyroidism, cystic fibrosis, hyperlipidemia

-the most common cause of clinically apparent chronic pancreatitis in adults is alcoholism; in children is cystic fibrosis 

-Smoking is an independent, dose-dependent risk factor for chronic pancreatitis

Symptoms & Signs 

Abdominal pain: epigastric, often radiating to the back, may be relieved by sitting upright or leaning forward, often worse 15 to 30 minutes after eating;  nausea, vomiting, fat malabsorption (poorly formed greasy, malodorous stools); Diabetes 


Diagnosis relies on a combination of clinical findings, laboratory findingsimaging tests, and pancreatic function testing.

Labs: Secretin pancreatic function test

Amylase and lipase: elevated in the early disease; normal or low in later stages. Thus, unlike in acute pancreatitis, they are neither diagnostic nor prognostic in chronic pancreatitis 

Fecal Pancreatic Elastase-1 (FPE-1): A level >200 μg/g of stool is considered normal, and FPE-1 levels <100 μg/g of stool correlate with severe exocrine pancreatic insufficiency. 

Imaging: Transabdominal ultrasound, Contrast-enhanced CT and MRI

The diagnosis is confirmed if there are calcifications within the pancreas on CT Scan. 

Pancreatogram: beading of the pancreatic ducts 

Steatorrhea: A 72-hour quantitative fecal fat determination is the gold standard. 


Life style modifications: Cessation of alcohol and of smoking; 

Pain control: Analgesics

Supplements: Pancreatic enzymes, lipase, vitamins 

Ductal stone obstruction: Endoscopic clearance, surgical therapy, ESWL

Check for IBS: Pancreatic exocrine insufficiency is also seen in Diarrhea-predominant irritable bowel syndrome (D-IBS). So, check for PEI in D-IBS. 


Complications: Pseudocyst, biliary ductal obstruction, fistula, pseudoaneurysms, pancreatic cancer 

Pancreatic Pseudocyst


-Pancreatic pseudocysts are encapsulated collections of pancreatic fluid with high enzyme concentrations that arise from the pancreas.

-They are surrounded by nonepitheliazed wall of granulation tissue and fibrosis. 

-They are usually located either within or adjacent to the pancreas in the lesser sac.

-Many occur as complications of severe acute pancreatitis

-Pseudocysts develop in about 10% of cases of acute pancreatitis, 30% of patients with chronic pancreatitis  

Symptoms and Signs 

-Failure to recover from acute pancreatitis 

-a palpable tender mass in the epigastrium 

-Abdominal pain, fever, weight loss, tenderness, jaundice 

-they may become secondarily infected and become abscesses 

-they can erode into visceral arteries and cause pseudoaneurysms 


Labs: Persistent serum amylase elevation, leukocytosis 

Imaging: Transabdominal ultrasound, Contrat-enhanced CT Scan, MRI

-Rule out Cystic neoplasms 

Asymptomatic pseudocysts: expectant management, Spontaneous resolution occurs in 50% of cases; Supportive care includes nasogastric feeding, proton pump inhibitors, somatostatin receptor agonists 

Symptomatic pseudocysts: 

Excision: Most definitive treatment 

External Drainage: Percutaneous catheter drainage 

Internal Drainage: Cystojejunostomy, Cystogastrostomy, Cystoduodenostomy 


-The recurrence rate for pancreatic pseudocyst is 10% 

-Complications: Infection, Rupture, Hemorrhage

Acute pancreatitis


-Acute pancreatitis is an acute inflammatory disorder of the pancreas that involves the pancreas and peripancreatic tissues. 

-It can vary in presentation from mild to severe.

-It is the most common inpatient gastrointestinal diagnosis in the United States. 

-The most common causes of acute pancreatitis in the United States are gallstones and alcohol abuse. 

-Other causes: infections, ischemia, hypercalcemia, hypertriglyceridemia, neoplasms, toxins, drugs, trauma 

Symptoms & Signs 

Abdominal pain: Acute onset of a severe constant epigastric pain that radiates through to the mid back; often made worse by walking and lying supine and better by sitting and leaning forward; nausea, vomiting, fever, tachycardia, tachypnea, Cullen sign (periumbilical ecchymoses), Grey Turner sign (flank ecchymoses), tetany as a result of hypocalcemia 

Memory Aid: CUllen Sing: PeriUmbilical 


Labs: Elevated serum amylase and lipase; leukocytosis, elevated serum creatinine, BUN, elevated C-reactive protein; Elevated immunoreactive trypsinogen more sensitive in infants; In hypertriglyceridemia-induced pancreatitis, serum amylase is spuriously normal


Plain radiographs:  may show a “sentinel loop” (a segment of air-filled small intestine most commonly in the left upper quadrant), the “colon cutoff sign” (a gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation); calcified gallstones 

Contrast-enhanced CT is the most common currently available imaging technique for staging the severity of pancreatitis


-The most important first step in the evaluation is to identify risk of progression to severe pancreatitis 

-All patients with suspected acute pancreatitis should be admitted to hospital. 

-The severity is assessed using scoring systems: Ranson criteria, SOFA score, APACHE II score, BISAP score 

-Treatment depends on the severity of symptoms 

Mild disease: Fluid resuscitation, pain control,  resume intake of fluid and foods when the patient is pain free; clear liquids, low-fat diet; mild disease subsides spontaneously within several days. 

Severe disease: Admission to ICU; IV fluids; Bowel and pancreatic rest;  calcium gluconate if there is hypocalcemia with tetany; treat coagulopathy; Enteral nutrition; antibiotics for infected pancreatitis; Surgical consultation 


Mortality rate 25% with infected necrosis; 30% with multiorgan failure 

Complications: acute tubular necrosis, ARDS, pancreatic abscess, pseudocyst, chronic pancreatitis, pericardial effusion, peptic ulcer disease, hyperglycemia, psychosis 

Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is a progressive disease characterized by inflammatory strictures involving the intrahepatic and extrahepatic biliary tree. 

-It eventually results in secondary biliary cirrhosis

-Men are more commonly affected than women (70:30 ratio), with a mean age at onset near 40 years.

A vast majority of patients (prevalence rates range from 70% to 90%) have underling inflammatory bowel disease, especially ulcerative colitis. 

-Smoking is associated with a decreased risk of primary sclerosing cholangitis in patients who also have inflammatory bowel disease. 

-Coffee consumption is also associated with a decreased risk of primary sclerosing cholangitis. 

Symptoms & Signs 

Fatigue, right upper quadrant abdominal pain, pruritus, jaundice, and acute cholangitis 


Labs: Disproportionate elevation of serum alkaline phosphatase; hypergammaglobulinemia, increased serum IgM levels, p-ANCA 

Imaging: MRCP is the diagnostic study of choice with  “beads on a string” apperance 

Liver biopsy: The most characteristic histologic finding is ‘onion skin pattern due to fibrous obliteration of small bile ducts with concentric replacement by connective tissue 


-There is no specific proven treatment for PSC

-Medical management is largely supportive 

-Pruritis: Cholestyramine, naltrexone, rifampin, doxepin 

-surveillance colonoscopy with biopsies should be carried out at 1–2-year intervals.

-screen for osteopenia at 2–3-year intervals after an initial evaluation.

-Liver transplantation is best choice for patients with advanced PSC


-Complications: Fat-soluble vitamin deficiencies (A,D,E and K), Metabolic bone disease, cholangitis, cholelithiasis, gallbladder cancer, cholangiocarcinoma, liver cancer, colon cancer 

-Patients with PSC have an 8–15% lifetime risk of developing cholangiocarcinoma. 

-With liver transplantation, 5-year survival is up to 85%