22. Acute pancreatitis, Stool incontinence and its surgical treatment & Pneumothorax – types and therapy

What is the definition of ACUTE PANCREATITIS?

Acute pancreatitis is the inflammation of the pancreas caused by prematurely activated pancreatic digestive enzymes that invoke pancreatic tissue autodigestion.

What is the etiology of ACUTE PANCREATITIS?

The etiology of acute pancreatitis is associated with biliary stones (gallstones) or ethanol abuse, and 10-15% of cases are idiopathic. Other causes include hypertriglyceridemia, hypercalcemia, post-ERCP procedures, certain toxic drugs, and scorpion stings.

What are the risk factors of ACUTE PANCREATITIS?

Risk factors include biliary stones or gallstones, ethanol abuse, hypertriglyceridemia, and hypercalcemia. Post-ERCP procedures, certain toxic drugs, and scorpion stings can also be risk factors.

What is the pathophysiology of ACUTE PANCREATITIS?

The pathophysiology involves prematurely activated pancreatic digestive enzymes which then invoke pancreatic tissue autodigestion.

What is the clinical presentation of ACUTE PANCREATITIS?

Clinical presentation includes constant, severe epigastric pain classically radiating to the back, which worsens after meals or when supine and improves on leaning forward. Patients may also experience nausea, vomiting, low-grade fever, abdominal tenderness, guarding, distention, or ascites. Signs of shock like tachycardia, hypotension, and oliguria may be present, and rarely, skin changes such as Cullen's sign, Grey Turner's sign, or Fox's sign can be observed.

What are the signs of ACUTE PANCREATITIS?

Signs include abdominal tenderness, guarding, distention, and ascites. Signs of shock such as tachycardia, hypotension, and oliguria/anuria may also be present, and rarely, jaundice or skin changes like Cullen’s, Grey Turner’s, or Fox’s signs can be observed.

What are the symptoms of ACUTE PANCREATITIS?

Symptoms include constant, severe epigastric pain radiating to the back, which is worse after meals or when supine and improves by leaning forward. Nausea, vomiting, and low-grade fever are also common symptoms.

What are the diagnostic methods of ACUTE PANCREATITIS?

Diagnostic methods include blood tests showing serum amylase/lipase levels elevated three or more times the normal value, and assessment of WBC count, BUN, haematocrit, CRP, procalcitonin, and ALT. Imaging studies like ultrasound detect gallstones or pancreatic inflammation, while contrast-enhanced CT is the gold standard for diagnosing pancreatic necrosis. MRI, MRCP, and ERCP can also assess ductal or pancreatic abnormalities.

What is the pharmacological treatment of ACUTE PANCREATITIS?

Pharmacological treatment involves aggressive intravenous (IV) fluid resuscitation with crystalloids and analgesics like IV opioids (fentanyl or hydromorphone) for pain. Antibiotics, specifically carbapenems, are used if infected necrosis is present, limited to 14 days, and fenofibrates are given for hyperlipidaemia-induced pancreatitis.

What is the surgical treatment of ACUTE PANCREATITIS?

Surgical treatment for patients with infected pancreatic necrosis is necrosectomy, which is the gold standard for removing necrotic tissue and pancreatic ascites. For biliary pancreatitis, urgent ERCP and sphincterotomy within 24 hours are performed if choledocholithiasis or cholangitis is present, followed by cholecystectomy in all patients with biliary pancreatitis.

What are the complications of ACUTE PANCREATITIS?

Complications include localized issues such as pancreatic necrosis, bacterial superinfection of necrotic tissue, pancreatic pseudocysts, pancreatic abscess, and bleeding. Systemic complications involve SIRS/shock, sepsis, DIC, prerenal failure, hypocalcaemia, and paralytic ileus.

What is the definition of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Fecal incontinence is the involuntary loss of gas, liquid stool (minor incontinence), or solid stool (major incontinence). This condition can also lead to reduced self-confidence, anxiety, and social isolation.

What is the classification of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Fecal incontinence is classified as minor incontinence, which involves the involuntary loss of gas or liquid stool, or major incontinence, which involves the involuntary loss of solid stool.

What are the types of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Minor fecal incontinence affects males and females equally, whereas major incontinence is more common in women.

What is the epidemiology of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Fecal incontinence is more common in older adults. Minor fecal incontinence affects males and females equally, while major incontinence is more common in women.

What is the etiology of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Etiology can be unknown (idiopathic), but it is associated with damage to the anal sphincters, neurologic causes, decreased distensibility of the rectum, fecal impaction, or diarrhea.

What are the risk factors of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Risk factors include being elderly, having dementia, or experiencing physical disability such as pudendal nerve injury. Damage to anal sphincters, often from vaginal childbirth or anal surgery, and neurological conditions like diabetes, multiple sclerosis, or spinal cord injury are also risk factors. Fecal impaction, especially in older adults with mental health conditions, immobility, or loss of rectal sensation, and conditions causing diarrhea are further risk factors.

What is the pathophysiology of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Fecal incontinence results from various issues including damage to anal sphincters, impaired sensation and control over the lower digestive tract due to neurological causes, or decreased rectal distensibility. It can also occur when hardened feces relax anal sphincters, allowing liquid stool to escape around a blockage.

What is the clinical presentation of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

The clinical presentation is the involuntary loss of gas, liquid stool, or solid stool. It can also lead to emotional and social consequences such as reduced self-confidence, anxiety, and social isolation.

What are the symptoms of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

The primary symptom is the involuntary loss of gas, liquid stool, or solid stool. Patients may also experience reduced self-confidence, anxiety, and social isolation due to the incontinence.

What are the diagnostic methods of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Diagnosis involves medical history, physical examination, and tests like colonoscopy, sigmoidoscopy, or anoscopy. Anorectal manometry measures internal pressure, revealing anal sphincter tone and impaired rectal sensation or reflexes. Ultrasound (USG) or MRI of the rectum can identify abnormalities in anal sphincters, the rectal wall, or pelvic muscles, and stool tests can detect infection underlying diarrhea.

What is the surgical treatment of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Surgical treatment includes repair of anal sphincter injuries, particularly those from childbirth or surgery. If damage is irreparable, muscle transfer from other body areas like the leg or buttock can be used. A synthetic anal cuff can be implanted to be inflated for continence and deflated for bowel movements. As a last resort, colostomy involves surgically attaching the colon to the abdominal wall to collect stool in a bag, preventing leakage from the rectum.

What are the complications of STOOL INCONTINENCE AND ITS SURGICAL TREATMENT?

Complications can include a reduction in self-confidence, anxiety, and social isolation.

What is the definition of PNEUMOTHORAX?

A pneumothorax is the presence of air in the pleural space, between the lung and the chest wall, which can lead to partial or complete pulmonary collapse.

What is the classification of PNEUMOTHORAX?

Pneumothorax can be divided into spontaneous or acquired (traumatic), with spontaneous further classified into primary and secondary. Tension pneumothorax is also a classification where gas can enter the pleural space but cannot leave, causing a mediastinal shift.

What are the types of PNEUMOTHORAX?

Types include spontaneous (primary and secondary), acquired (traumatic), iatrogenic, and tension pneumothorax. Primary spontaneous occurs in patients without apparent underlying lung disease, while secondary occurs as a complication of existing lung disease.

What is the epidemiology of PNEUMOTHORAX?

Primary spontaneous pneumothorax is commonly seen in young, tall, male smokers and is more common on the right side.

What is the etiology of PNEUMOTHORAX?

Primary spontaneous pneumothorax is often caused by ruptured subpleural blebs or bullae. Secondary spontaneous pneumothorax is associated with underlying lung diseases like cystic fibrosis, COPD, asthma, interstitial lung disease, various infections (e.g., AIDS, mycobacterial, Pneumocystis carinii), malignancies, and collagen diseases. Traumatic pneumothorax results from blunt or penetrating injury, while iatrogenic pneumothorax can occur from mechanical ventilation, thoracocentesis, central venous catheter placement, or bronchoscopy.

What are the risk factors of PNEUMOTHORAX?

Risk factors for primary spontaneous pneumothorax include being young, tall, male, smoking, a family history, and asthenic body habitus, such as seen in Marfan syndrome or homocystinuria. Smoking significantly increases the risk, up to 20-fold.

What is the pathophysiology of PNEUMOTHORAX?

The pathophysiology involves increased intrapleural pressure, which leads to alveolar collapse. This results in a decreased ventilation/perfusion (V/Q) ratio and increased right-to-left shunting.

What is the clinical presentation of PNEUMOTHORAX?

Clinical presentation varies from asymptomatic to cardiopulmonary compromise, often including sudden dyspnea, sudden, severe, and/or stabbing ipsilateral pleuritic chest pain, cough, and tachypnea. On the affected side, there is decreased chest wall movement, hyperresonant percussion, and reduced or absent breath sounds. Subcutaneous emphysema may also be present.

What are the signs of PNEUMOTHORAX?

Signs on the affected side include decreased chest wall movement, hyperresonant hemithorax on percussion, and reduced or absent breath sounds on auscultation. A pleural rub and subcutaneous emphysema may also be observed.

What are the symptoms of PNEUMOTHORAX?

Symptoms include sudden dyspnea, sudden, severe, and/or stabbing ipsilateral pleuritic chest pain, and cough. Tachypnea is also a common symptom.

What are the diagnostic methods of PNEUMOTHORAX?

Diagnostic methods include chest x-ray, which is a confirmatory test showing an ipsilateral pleural line with reduced or absent lung markings, and CT scans, which accurately estimate size and assess lung parenchyma. Arterial blood gas analysis can detect respiratory acidosis, and ECG may show changes in QRS amplitude or ST segments.

What is the pharmacological treatment of PNEUMOTHORAX?

Pharmacological treatment primarily involves supplemental oxygen (4-6 L/min) via nasal cannula or mask with a reservoir. Symptomatic treatment is also provided to manage the patient's discomfort.

What is the surgical treatment of PNEUMOTHORAX?

Surgical treatment for a first episode may involve tube thoracostomy, especially for large or symptomatic pneumothorax. For recurrent pneumothorax, surgery aims to resect blebs/bullae and obliterate the pleural space via chemical/abrasion pleurodesis or parietal pleurectomy, performed through a minithoracotomy or thoracoscopically.

What are the complications of PNEUMOTHORAX?

Complications include complete pulmonary collapse leading to respiratory failure, tension pneumothorax causing cardiac failure, and hemothorax, especially in cases of trauma. Other complications are pneumomediastinum, pneumoperitoneum, recurrence, and post-surgical issues such as persistent fistula with continuous air leak or infection.

What are the contraindications of PNEUMOTHORAX?

Full parietal pleurectomy is a contraindication for lung transplantation in patients with cystic fibrosis. There is no information in the sources regarding general contraindications for pneumothorax or its overall treatment.

What is the definition of SPONTANEOUS PNEUMOTHORAX?

Spontaneous pneumothorax occurs without an identifiable external event and is divided into primary (without underlying lung disease) and secondary (as a complication of underlying lung disease).

What is the classification of SPONTANEOUS PNEUMOTHORAX?

Spontaneous pneumothorax is classified into primary spontaneous pneumothorax and secondary spontaneous pneumothorax. Primary occurs in patients without clinically apparent lung disease, while secondary occurs as a complication of underlying lung disease.

What are the types of SPONTANEOUS PNEUMOTHORAX?

The types of spontaneous pneumothorax are primary spontaneous pneumothorax and secondary spontaneous pneumothorax.

What is the epidemiology of SPONTANEOUS PNEUMOTHORAX?

Primary spontaneous pneumothorax is commonly observed in young, tall, male smokers and is more frequently unilateral on the right side.

What is the etiology of SPONTANEOUS PNEUMOTHORAX?

Primary spontaneous pneumothorax is usually caused by the rupture of small subpleural blebs or bullae. Secondary spontaneous pneumothorax results from underlying lung diseases such as cystic fibrosis, COPD, asthma, interstitial lung disease, various infections (e.g., AIDS, mycobacterial, Pneumocystis carinii), malignancies, and certain collagen diseases.

What are the risk factors of SPONTANEOUS PNEUMOTHORAX?

Risk factors for primary spontaneous pneumothorax include being young, tall, male, smoking, a family history, and asthenic body habitus, such as seen in Marfan syndrome or homocystinuria. Smoking significantly increases the risk.

What is the pathophysiology of SPONTANEOUS PNEUMOTHORAX?

The pathophysiology involves increased intrapleural pressure, leading to alveolar collapse. This results in a decreased ventilation/perfusion (V/Q) ratio and increased right-to-left shunting.

What is the clinical presentation of SPONTANEOUS PNEUMOTHORAX?

The clinical presentation includes sudden dyspnea, chest pain, cough, and tachypnea. On the affected side, there is decreased chest wall movement, hyperresonant percussion, and absent breath sounds; a pleural rub may also be present.

What are the signs of SPONTANEOUS PNEUMOTHORAX?

Signs on the affected side include decreased chest wall movement, hyperresonant hemithorax on percussion, and absent breath sounds on auscultation. A pleural rub may also be observed.

What are the symptoms of SPONTANEOUS PNEUMOTHORAX?

Symptoms include sudden dyspnea, chest pain, cough, and tachypnea.

What are the diagnostic methods of SPONTANEOUS PNEUMOTHORAX?

Diagnostic methods include chest x-ray, and CT scans to accurately estimate the size of the pneumothorax and assess remaining lung parenchyma.

What is the pharmacological treatment of SPONTANEOUS PNEUMOTHORAX?

Pharmacological treatment includes supplemental oxygen (4-6 L/min) via nasal cannula or mask with a reservoir. Symptomatic treatment is also provided.

What is the surgical treatment of SPONTANEOUS PNEUMOTHORAX?

For a first episode, surgery may be indicated for prolonged air leak, tension pneumothorax, or residual lung collapse after conservative treatment. For recurrent spontaneous pneumothorax, surgical aims include resecting blebs/bullae and obliterating the pleural space via chemical/abrasion pleurodesis or parietal pleurectomy, performed via minithoracotomy or thoracoscopy. For secondary spontaneous pneumothorax in COPD patients, tube thoracostomy and chemical pleurodesis or long-term tube thoracostomy are options.

What are the complications of SPONTANEOUS PNEUMOTHORAX?

Complications include tension pneumothorax, pneumomediastinum, hemopneumothorax, and recurrence. Other complications can be complete pulmonary collapse leading to respiratory failure, and post-surgical issues like persistent air leak or infection .

What are the contraindications of SPONTANEOUS PNEUMOTHORAX?

Full parietal pleurectomy is a contraindication for lung transplantation in patients with cystic fibrosis. There is no information in the sources regarding general contraindications for spontaneous pneumothorax or its overall treatment.

What is the definition of TENSION PNEUMOTHORAX?

Tension pneumothorax occurs when a large amount of intrapleural air accumulates, entering the pleural space but unable to leave. The increasing pressure leads to complete lung collapse on the affected side and pushes the mediastinum to the contralateral side.

What is the etiology of TENSION PNEUMOTHORAX?

Tension pneumothorax is a complication of pneumothorax, occurring when air enters the pleural space but is unable to exit. This leads to increasing pressure within the pleural cavity.

What is the pathophysiology of TENSION PNEUMOTHORAX?

Pathophysiology involves gas entering the pleural space but being unable to exit, causing increasing intrapleural pressure. This pressure leads to complete lung collapse on the affected side and pushes the mediastinum to the contralateral side.

What is the clinical presentation of TENSION PNEUMOTHORAX?

In addition to general pneumothorax symptoms, clinical presentation includes severe acute respiratory distress, cyanosis, restlessness, diaphoresis, and reduced chest expansion on the ipsilateral side. Patients may also present with distended neck veins and hemodynamic instability, such as tachycardia, hypotension, and pulsus paradoxus.

What are the signs of TENSION PNEUMOTHORAX?

Signs include reduced chest expansion on the ipsilateral side, distended neck veins, and hemodynamic instability, manifesting as tachycardia, hypotension, and pulsus paradoxus.

What are the symptoms of TENSION PNEUMOTHORAX?

Symptoms include severe acute respiratory distress, cyanosis, restlessness, and diaphoresis.

What are the diagnostic methods of TENSION PNEUMOTHORAX?

Diagnosis is primarily clinical, but a chest x-ray may show tracheal deviation towards the contralateral side.

What is the surgical treatment of TENSION PNEUMOTHORAX?

Emergency surgical treatment involves immediate chest decompression via chest tube placement or, if unavailable, emergency needle thoracostomy, which should be followed by chest tube placement. Needle thoracostomy is performed by inserting a large-bore needle into the 2nd intercostal space along the midclavicular line.

What are the complications of TENSION PNEUMOTHORAX?

Complications include complete lung collapse on the affected side and the pushing of the mediastinum to the contralateral side. This can ultimately lead to cardiac failure .