-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
-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 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
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 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 (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%