CPD II: stool appearance and pancreatitis

the first part of this lecture focused on the diagnosis of different GI disorders based on stool appearance. ribbon shape might indicate spasm/IBS, uterus malposition or enlargement, compression from a mass. pencil shaped: spasm/IBS and stricture. floating stools: malabsorption, cystic fibrosis. small and hard: dehydration, low fiber, delayed tract time, hypochlorhydria. large and hard: dehydration, hypotonic bowel. difficult to pass: hemorrhoids, anal fissure, dehydration, hypotonic bowel. loose but not watery: mild intestinal irritation and malabsorption. alternating constipation and diarrhea: poor diet, parasites, IBS. offensive stool odor: dysbiosis or food decay. very dark stool: melena, upper GI bleeding. light brown, clay, green, or bright yellow colors: gallbladder issues (obstruction, excess secretion).

the next section in the GI lecture covered pancreatic disorders: acute and chronic pancreatitis. acute pancreatitis causes severe abdominal pain which can feel like a knife stuck in the LUQ and cause extreme limitation of movement and even breathing. it is most commonly caused by heavy alcoholism (pain develops over a few weeks) in men and by biliary tract disease or obstruction (pain develops suddenly) in women. other etiologies might include NSAID use or hypertriglyceridism.

the diagnosis of acute pancreatitis is made through the history/physical and a few useful lab tests. besides the knife like LUQ pain, patients might present with fever, hypoactive bowel sounds, jaundice, dyspnea (because any movement will worsen the pain). additionally, cullens and grey-turner signs might be positive, which indicate retroperitoneal hemorrhage from pancreatic autodigestion. the lab tests most helpful are amylase, lipase, CBC and a chem screen; serum amylase levels are elevated soon after the onset of pain and return back to normal 2-3 days afterwards whereas urine amylase elevates 7-10 afterwards. CBC might show elevated hematocrit and leukocytosis, while a chem screen might show hyperglycemia, hypocalcemia, and elevated bilirubin/AST/ALT. treatment of acute pancreatitis generally involves 100% pancreatic rest and pain management, although 10% of patients will die regardless of treatment. the remaining 90% might recover within 2-3 weeks.

chronic pancreatitis is also caused mainly by long term alcoholism, and can also be idiopathic, or hereditary, or due to hyperlipidemia, protein malnutrition, cystic fibrosis, or biliary obstruction. patients with chronic pancreatitis might remain asymptomatic for 62 months (81 months for alcoholics), then develop severe epigastric/LUQ pain that may radiate to the back in a band like fashion and come in 2-3 hour episodes. the pain might be relieved slightly by lying in the fetal position on the left side, in contrast to acute pancreatitis, the pain of which is generally not relieved by anything.

in contrast to acute pancreatitis, the physical might not be very useful for diagnosis, although fundoscopy might reveal milky white retinal blood vessels from hyperlipidemia, and an abdominal exam might reveal pseuodocysts, which are inflammatory masses. amylase and lipase levels are only slightly elevated- the more useful tests are serum trypsin, calcium, and TG levels, as well as the bentiromide test, which measures the excretion of PABA in the urine (decreased in pancreatic insufficiency). ultrasound, chest xray, and CT all show calcification in 30% of patients. pancreatic function can also be measured via direct tests, or stimulating the pancreas with a secretogogue and measuring pancreatic output in the duodenum or directly via cannulation.

questions
stool diagnosis...
1. what might a ribbon shaped stool indicate?
2. what might a pencil shape stool indicate?
3. what might floating stools indicate?
4. what might stools that are small and hard indicate?
5. what might stools that are large and hard indicate?
6. what might stools that are difficult to pass indicate?
7. what might stools that are loose but not watery indicate?
8. what might be indicated from alternating constipation and diarrhea?
9. what might an offensive stool odor indicate?
10. what might a very dark stool color indicate?
11. what might a light brown or clay stool color indicate?
12. what might a greenish or bright yellow stool color indicate?

acute pancreatitis...
13. what is post prandial exocrine secretion stimulated by?
14. what is acute pancreatitis and what are its hallmark characteristics?
15. what are the common causes of acute pancreatitis in men and women?
16. what is the severity of alcoholism usually associated with acute pancreatitis?
17. what is the relationship between the size of gallstones and the risk of getting acute pancreatitis?
18. besides alcoholism and gallstones, what are some other etiologies for acute pancreatitis?
19. what are the signs and symptoms of acute pancreatitis?
20. what is the difference in the onset of pain for acute pancreatitis caused by alcoholism vs. gallstones?
21. what are the two typical pain patterns presented by patients with acute pancreatitis?
22. what might the pain from acute pancreatitis be alleviated by?
23. what might the pain from acute pancreatitis be worsened by?

acute pancreatitis diagnosis...
24. what are some PE findings that might be found from a patient with acute pancreatitis?
25. what do the cullen's and grey turner signs indicate?
26. what is a potential skin manifestation of acute pancreatitis?
27. which labs would be useful in the diagnosis of acute pancreatitis?
28. what might be found in the serum amylase test?
29. what might be found in the urine amylase test?
30. which amylase test would be ordered if the patient came in immediately after onset of pain vs. a few days after?
31. what is the advantage of the lipase test compared to the amylase test?
32. what does a lipase:amylase ratio of greater than 2 indicate?
33. what might be seen in a CBC of a patient with acute pancreatitis?
34. what might be seen in the chem screen of a patient with acute pancreatitis?
35. what is the imaging technique of choice in diagnosing acute pancreatitis?
36. what is the prognosis for patients with acute pancreatitis?
37. what are the treatment goals for patients recovering from acute pancreatitis?

chronic pancreatitis...
38. what is the mean age of diagnosis for chronic pancreatitis?
39. what is the bimodal age distribution for idiopathic chronic pancreatitis?
40. what are the etiologies for chronic pancreatitis?
41. what is the quality of the pain experienced in chronic pancreatitis?
42. how long do episodes of pain generally last?
43. how long on average might a patient with chronic pancreatitis remain asymptomatic? how does this vary if the patient is an alcoholic?
44. besides the abdominal pain, what are some other symptoms that a patient with chronic pancreatitis might present with?
45. what is the characteristic position that a patient with chronic pancreatitis assumes when undergoing a severe episode?
46. chronic pancreatitis may eventually lead to...

chronic pancreatitis diagnosis...
47. how useful is the PE in the diagnosis of chronic pancreatitis?
48. what might fundoscopy reveal?
49. what might be a finding in the abdomen of a chronic pancreatitis patient?
50. what signs might be present in an advanced case of chronic pancreatitis?
51. what are some lab tests that may aid in the diagnosis of chronic pancreatitis?
52. what is the bentiromide test?
53. at what extent of disease progression of chronic pancreatitis does steatorrhea occur?
54. what are two stool tests that might be helpful in the diagnosis of chronic pancreatitis?
55. what are some pancreatic function tests that can aid in the diagnosis of chronic pancreatitis?
56. what would be shown on an xray and ultrasound of a patient with chronic pancreatitis?
57. what would be shown on a CT scan of a patient with chronic pancreatitis?

answers
1. spasm / IBS, uterus malposition or enlargement, compression from a mass. [ribbon, spasm, IBS, uterus] [the uterus had a ribbon in it that caused it to spasm irritably]
2. spasm / IBS, stricture of colon. [pencil spasm stricture]
3. malabsorption, cystic fibrosis.
4. dehydration, low fiber diet, delayed tract time, hypochlorhydria.
5. dehydration, hypotonic bowel.
6. hemorrhoids, anal fissure, dehydration, hypotonic bowel.
7. mild intestinal irritation and malabsorption.
8. poor dietary habits / food allergies, parasites, IBS, liver/gallbladder irritation / dysfunction. [diet, parasites, IBS]
9. dysbiosis or food decay.
10. melena; upper GI bleeding.
11. lack of bile pigments, liver / gallbladder obstruction.
12. gallbladder problem; excess bile secretions/bile salt.

13. CCK, cephalic stimuli, intestinal stimulation.
14. an acute inflammation of the pancreas associated with edema, swelling, autodigestion, necrosis, hemorrhage.
15. alcohol for men, biliary tract disease for women.
16. greater than 200mL a day for 5-15 years.
17. risk is inversely proportional to size.
18. hypertriglyceridemia, NSAID use, post ERCP.
19. severe LUQ pain that may radiate straight through back.
20. pain from gallstones develops suddenly, whereas pain from alcoholism develops over a few weeks.
21. the feeling of a knife stuck in the left ribcage, and pain in the left scapula that radiates from the front around the side.
22. supine position often alleviates pain.
23. coughing, deep breathing, movement.

24. fever
abdominal tenderness / guarding
hypoactive bowel sounds
jaundice
dyspnea
cullen's sign
grey-turner sign
25. hemorrhage: pancreas is autodigesting and leaking blood into skin.
26. erythematous nodules on extensor surfaces from focal subcutaneous fat necrosis.
27. lipase, amylase, CBC, chem screen.
28. 75% of acute pancreatitis cases have high serum amylase levels which may rise 2-12 hours after onset and remain elevated for 2-3 days.
29. elevated levels 7-10 days after serum amylase returns to normal levels.
30. serum amylase for immediately after onset, urine amylase for a few days afterwards.
31. more specific to the pancreas, and has a longer half life than amylase.
32. alcoholism or gall bladder dysfunction.
33. leukocytosis and elevated hematocrit.
34. hyperglycemia from decreased insulin
hypocalcemia from saponification of peritoneal fat
elevated bilirubin, ALT, AST.
35. abdominal ultrasound.
36. 10% die regardless of treatment, 90% recover within 2 weeks.
37. 100% pancreatic rest and pain management.

38. ~46yo.
39. one peak at 19.2yo, another at 56.2yo.
40. long term alcoholism
idiopathic
hereditary
cystic fibrosis
hyperlipidemia
protein malnutrition
pancreatic obstruction
[that idiot heretic hyped up pancreatic malnutrition]
41. severe, persistent pain often in the mid or LUQ which may radiate in a band to the back.
42. several hours.
43. 62 months, 81 months for alcoholics.
44. diarrhea, weight loss, steatorrhea.
45. lying on left side in the fetal position.
46. type II diabetes.

47. not very useful at all.
48. milky white hue in retinal blood vessels due to hyperlipidemia.
49. pseudocyst- inflammatory mass in abdomen.
50. signs of malnutrition: decreased subcutaneous fat, muscle wasting, sunken supraclavicular fossa.
51. serum amylase and lipase (slightly elevated), serum trypsin, calcium, and TG levels.
52. a test that measures the urinary excretion of PABA, which can indicate pancreatic insufficiency if lowered.
53. when 90% of the pancreas is destroyed.
54. fecal chymotrypsin and elastase.
55. direct tests (sensitive but invasive)
duodenal aspirate tests
pancreatic output tests
56. calcifications found in 30%.
57. calcifications and pseudocysts.