Gallstones and pancreatitis
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Transcript of Gallstones and pancreatitis
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