GALLSTONES AND PANCREATITISalex knight

Topics Case Presentation Bile and LFT’s Gallstones Risk Factors Complications +

Presentations

Clinical Scenario A 45 year old female presents to A&E

with an hour long history of severe RUQ pain, and associated vomiting. She has had this in the past few weeks but now its got worse

She has no significant past medical history, is on no regular medication, and has no allergies. She does not smoke, drinks 14 units of alcohol per week and works as a market analyst.

On examination she is febrile at 38.5, tachycardic at 110bpm and her BP is 135/65. On palpation, her abdomen is soft but tender in the RUQ. Murphy’s sign positive

Investigations Bedside tests

Observations Blood tests

LFTs Serum bilirubin ALP

FBCs High WCC

Inflammatory markers CRP

Imaging Abdominal Ultrasound scan

Management Conservative

NBM IVI fluids Analagesia

Medical Antibiotics?

Surgical Laparascopic +/- open cholecystectomy

Liver Functions Digestion

processing digested food breaking down food and turning it into energy

Homeostasis controlling levels of fats, amino acids and glucose

in the blood storing iron, vitamins and other essential chemicals manufacturing, breaking down and regulating numerous

hormones including sex hormones Immune

combating infections in the body clearing the blood of particles and infections including

bacteria neutralising and destroying drugs and toxins

Blood manufacturing bile Enzymes and proteins - those involved in blood clotting

and tissue repair.

Bile Water, Electrolytes, Bile acids, Cholesterol, Phospholipids Conjugated Bilirubin

Bile Metabolism

Liver Function Tests and Bile Albumin

General synthetic function + severity of Liver disease Clotting

Also synthetic - Prothrombin time (INR) Total Bilirubin

Processing function Aminotransferases (AST+ALT)

Mitochondrial and cytosolic enzymes – ALT more specific ALP

Enzyme in the cells lining the biliary ducts of the liver γGlutamyl-transpeptidase (GGT)

A rough marker of alcohol consumption if ALP is normal

Gallstones 80% - “Cholesterol” Stones

Cholesterol supersaturation of bile Proportion to bile salts and phospholipids

Crystallisation-promoting factors Bile salt loss in terminal Ileum in Crohn’s Disease

Motility of gall bladder 20% - “Pigment” Stones

Calcium Bilirubinate Haemolytic Diseases Cause of recurrent stones post cholecystectomy

Risk Factors

Increasing age Rapid weight loss Drugs – OCP Ileal disease or resection Diabetes

Presentations/Complications Asymptomatic – Incidental finding In the Gall bladder

Chronic Cholecystitis Biliary Colic Acute Cholecystitis

Empyema of the gallbladder Biliary peritonitis Abcess

Mucocoele Carcinoma of the gallbladder

In the common bile duct Obstructive jaundice Cholangitis Pancreatitis

Chronic Cholecystitis Abdominal Pain Indigestion Bloating Burping Nausea

Important differentials – peptic ulcer and hiatus hernia

Biliary Colic Spasm pain when the gallbladder contracts

against a stone in the Hartmann’s Pouch Epigastrium or RUQ Constant, not in waves Extremely severe – sweaty, writhe around

Important Differentials: Perforated peptic ulcer, pancreatitis, ruptured aneurysm

Acute Cholcystitis Usually progression of biliary colic Increased glandular secretion Distension – possible impeding vascular supply Chemical Inflammation Bacterial Infection Murphy’s sign Patients lie still

Local Peritonitis Important Differentials: Basal Pneumonia,

Intrahepatic Abcess, Perforated peptic ulcer, pancreatitis, ruptured aneurysm

Investigations Bedside tests

Observations Blood tests

LFTs Serum bilirubin ALP

FBCs High WCC

Inflammatory markers CRP

Imaging Abdominal Ultrasound scan

Management Conservative

NBM IVI fluids Analagesia

Medical Antibiotics?

Surgical Laparascopic +/- open cholecystectomy

Cholecystectomy Complications

General Bleeding Infection Pneumoperitoneum – vagus nerve – decereased

cardiac output Specific

Bleeding from cystic artery is more difficult to stop haemodynamically

Common Bile Duct Injury or stone movement. Bowel Perforation

Common Bile Duct

RUQ Pain

Fever/Rigors

Jaundice

Triad only present in minority Pain is the most common In comparison to jaundice from

malignancy the Jaundice fluctuates Fever indicates biliary sepsis

Investigations Bedside tests

Observations Blood tests

LFTs Serum bilirubin ALP

FBCs High WCC

Inflammatory markers CRP

Imaging Abdominal Ultrasound scan CT

Special Tests ERCP MRCP

Management Conservative

NBM IVI fluids Analagesia

Medical Antibiotics

Surgical ERCP

Pancreatitis

Pancreatitis Mild:

Enzymatic spillage Inflammatory cascade activation and Localized oedema. Local exudate may also lead to increased serum levels

of pancreatic enzymes. Moderate:

Increasing local inflammation bleeding, fluid collections and spreading local oedema involving the mesentery and retroperitoneum other organs.

Severe: Necrosis Profound localized bleeding and fluid collections Spread to local structures mesenteric infarction, peritonitis and intra-

abdominal fat ‘saponification’. A persisting accumulation of inflammatory fluid, usually in the lesser

sac, is a pseudocyst, i.e. does not have an epithelial lining.

At admission: Age in years > 55 years White blood cell count > 16x10/l Blood glucose > 11 Serum AST > 200 Serum LDH > 500

Within 48 hours: Calcium < 2 Hematocrit fall > 10% Oxygen PO2 < 8kPa BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV

fluid hydration Base deficit (negative base excess) > 4 Sequestration of fluids > 6 L

Ranson Number ITU admission Death1 (0-2points) 2% 2%2 (3-4 points) 20% 20%3 (5-6 points) 50% 40%4 (7-8 points) 100% 90%

ERCP Endoscopic Retrograde Cholangio

Pancreatography Diagnostic +/- Therapeutic Stone extraction

Fogarty balloon Basket catheters

Sphincterotomy

ERCP Risks Bleeding – especially if Sphincterotomy is concerned Infection – cholangitis in the bile duct. Pancreatitis – 5%

Younger patients, Previous post-ERCP pancreatitis Females Procedures that involve cannulation or injection of the pancreatic duct Patients with sphincter of Oddi dysfunction

Gut perforation Additional risk if a sphincterotomy is performed. D2 is anatomically retroperitoneal, perforations due to

sphincterotomies are also retroperitoneal. Oversedation can result in dangerously low blood pressure,

respiratory depression, nausea, and vomiting. There is also a risk associated with the contrast dye in patients

who are allergic to compounds containing iodine.

MRCP

Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique that uses magnetic resonance imaging to visualise the biliary and pancreatic ducts in a non-invasive manner

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Complications/Presentations

Investigations

Ranson’s Criteria