Pancreas and hepatobiliary disorders
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Transcript of Pancreas and hepatobiliary disorders
Pancreas and Pancreas and hepatobiliary disordershepatobiliary disorders
Feb 12 2004Feb 12 2004
Andrea WilsonAndrea Wilson
Case 1 Case 1 (emedhome.com)(emedhome.com)
28 yo male28 yo male ““ulcer pain acting up”. Has a known peptic ulcer pain acting up”. Has a known peptic
ulcer. ulcer. Epigastric tenderness intermittent x 2 days not Epigastric tenderness intermittent x 2 days not
relieved with antacidsrelieved with antacids No rebound or guarding. Normal rectal.No rebound or guarding. Normal rectal. Busy shiftBusy shift Pt felt better after demerol and wanted to go Pt felt better after demerol and wanted to go
home.home.
Grey-Turner’s signGrey-Turner’s sign
associated with hemorrhagic pancreatitis. associated with hemorrhagic pancreatitis. However, this sign develops in <3% of patients with However, this sign develops in <3% of patients with
acute pancreatitis acute pancreatitis retroperitoneal hemorrhage, splenic rupture, ruptured retroperitoneal hemorrhage, splenic rupture, ruptured
aortic aneurysm, and ectopic pregnancy. aortic aneurysm, and ectopic pregnancy. blood along fascial planes and cause ecchymoses blood along fascial planes and cause ecchymoses
over the flanks. over the flanks. (lateral edge of the quadratus lumbrum muscle)(lateral edge of the quadratus lumbrum muscle)
Acute PancreatitisAcute Pancreatitis
Up to 80% of pts will have uneventful Up to 80% of pts will have uneventful recoveryrecovery
Ranson’s criteria correlate with risk of major Ranson’s criteria correlate with risk of major complications and deathcomplications and death
Overall mortality ranges from 7-20%Overall mortality ranges from 7-20%
Ranson’s criteriaRanson’s criteria
At admission or diagnosisAt admission or diagnosis Age > 55 yearsAge > 55 years WBC > 16,000/mm3WBC > 16,000/mm3 Blood glucose > 200mg/dlBlood glucose > 200mg/dl Serum LDH > 350 IU/mlSerum LDH > 350 IU/ml SGOT > 250 Sigma-Frankel SGOT > 250 Sigma-Frankel
units/dlunits/dl
During initial 48 hoursDuring initial 48 hours Hematocrit fall > 10%Hematocrit fall > 10% BUN rise > 5 mg/dlBUN rise > 5 mg/dl Serum calcium level < 8.0Serum calcium level < 8.0
Arterial oxygen pressure < Arterial oxygen pressure < 60 mm Hg60 mm Hg
Base deficit > 4 mEq/LBase deficit > 4 mEq/L Estimated fluid Estimated fluid
sequestration > 6,000 mlsequestration > 6,000 ml
So…So…
Hypotension, Hypotension, tachycardia >130, tachycardia >130, PO2 <60, PO2 <60, oliguria, oliguria, increasing BUN/Cr increasing BUN/Cr and hypocalcemia and hypocalcemia
= BAD= BAD
PancreatitisPancreatitis
Obstruction of ampulla with reflux of bile into Obstruction of ampulla with reflux of bile into pancreatic duct then activation of digestive pancreatic duct then activation of digestive enzymes and autodigestion of the pancreasenzymes and autodigestion of the pancreas
Gallstones + Etoh = >70%Gallstones + Etoh = >70%
Other causesOther causes
GET SMASHEDGET SMASHED Gallstones, ethanol, tumors, scorpion bite?, Gallstones, ethanol, tumors, scorpion bite?,
microbiology (bacteria, virus, parasites), microbiology (bacteria, virus, parasites), autoimmune (SLE, PAN, Crohn’s), autoimmune (SLE, PAN, Crohn’s), surgery/trauma, hyperlipidemia/ surgery/trauma, hyperlipidemia/ hypercalcemia, emboli/ischemia, drugshypercalcemia, emboli/ischemia, drugs
Also: pregnancy, liver disease, DKAAlso: pregnancy, liver disease, DKA
Acute pancreatitisAcute pancreatitis
SymptomsSymptoms Sharp epigastric painSharp epigastric pain Radiates to backRadiates to back Improves leaning frwdImproves leaning frwd N&VN&V Pain referred to RUQ or Pain referred to RUQ or
LUQLUQ Aggravated by eatingAggravated by eating
SignsSigns JaundiceJaundice Tachycardia (pain or Tachycardia (pain or
volume depletion)volume depletion) FeverFever Grey Turner’s -flankGrey Turner’s -flank Cullen’s – umbil Cullen’s – umbil
(neither specific)(neither specific)
Diagnostic evaluationDiagnostic evaluation
Amylase –Amylase – If 3x N then 80-90%sens , If 3x N then 80-90%sens ,
75% spec75% spec may return to normal within may return to normal within
24 hrs of pain onset24 hrs of pain onset Fallopian tubes, ovaries, Fallopian tubes, ovaries,
testes, adipose tissue, small testes, adipose tissue, small bowel, lung, thyroid, sk bowel, lung, thyroid, sk muscle, neoplasmsmuscle, neoplasms
LipaseLipase 90% sens and specific90% sens and specific Remain elevated for several Remain elevated for several
days after pain onset (7-14 )days after pain onset (7-14 )
What else would you order?What else would you order?
AXR – calcification of the pancreas or AXR – calcification of the pancreas or gallstones if calcified, free air, ileus, colon gallstones if calcified, free air, ileus, colon “cut-off” if transverse colon involved“cut-off” if transverse colon involved
CXR – atelectasis, effusionCXR – atelectasis, effusion U/S and CT if further evaluation needed – U/S and CT if further evaluation needed –
diffusely enlarged pancreas, dilated CBDdiffusely enlarged pancreas, dilated CBD CT negative in 30% of mild pancreatitisCT negative in 30% of mild pancreatitis
ComplicationsComplications
Phlegmon 18% - Phlegmon 18% - Pancreatic abscess 3%Pancreatic abscess 3% Pancreatic pseudocyst 10%Pancreatic pseudocyst 10% AscitesAscites Thrombosis of the central portal systemThrombosis of the central portal system Shock, ARDS and MSOFShock, ARDS and MSOF Profound metabolic disturbances including Profound metabolic disturbances including
hyperglycemia and hypocalcemiahyperglycemia and hypocalcemia
ManagementManagement
1) hemodyanmic stabilization1) hemodyanmic stabilization 2) allevation of pain2) allevation of pain 3) stop progression of damage3) stop progression of damage 4) tx of local and systemic complications4) tx of local and systemic complications
AdmitAdmit NPO, IV analgesics, NG if emesis/ileusNPO, IV analgesics, NG if emesis/ileus Aminoglycoside or cephalosporin if deterioration Aminoglycoside or cephalosporin if deterioration
suggests abscesssuggests abscess
Chronic PancreatitisChronic Pancreatitis
Fibrosis, ductal abnormality, calcification and Fibrosis, ductal abnormality, calcification and cellular atrophycellular atrophy
Leads to chronic pancreatic insufficiency and Leads to chronic pancreatic insufficiency and chronic pain.chronic pain.
Autodigestion from pancreatic digestive Autodigestion from pancreatic digestive enzymes + other vasoactive substances enzymes + other vasoactive substances causing chemical irritation ->edema – causing chemical irritation ->edema – hemorrhage/necrosishemorrhage/necrosis
Chronic pancreatitisChronic pancreatitis
ALCOHOLALCOHOL DM, protein-calorie malnutrition, hereditary DM, protein-calorie malnutrition, hereditary
pancreatitis, cystic fibrosis, hyperparathyroidism, pancreatitis, cystic fibrosis, hyperparathyroidism, pancreas divisumpancreas divisum
Pseudocyst, ascites, CBD stricturePseudocyst, ascites, CBD stricture If>90% exocrine function lost then trouble!If>90% exocrine function lost then trouble!
Steatorrhea (fat), azotorrhea (protein), progressive Steatorrhea (fat), azotorrhea (protein), progressive weight loss.weight loss.
Case 2Case 2
56 yo male56 yo male new onset diabetesnew onset diabetes Dull epigastric pain worse at hsDull epigastric pain worse at hs 10 lb weight loss in past 6 months10 lb weight loss in past 6 months Mildly jaundicedMildly jaundiced ?palpable gallbladder?palpable gallbladder No Murphy’sNo Murphy’s
Pancreatic cancerPancreatic cancer
Males: females 2:1Males: females 2:1 6 month survival6 month survival Usually ductal cell adenocarcinoma and Usually ductal cell adenocarcinoma and
usually in the head of the pancreasusually in the head of the pancreas Smoking, high fat/protein diet, DM, DDT Smoking, high fat/protein diet, DM, DDT
exposureexposure Courvoisier’s lawCourvoisier’s law
4 main gallstone problems4 main gallstone problems
Symptomatic cholelithiasis (biliary colic)Symptomatic cholelithiasis (biliary colic) CholecystitisCholecystitis CholangitisCholangitis PancreatitisPancreatitis
Back to med school…Back to med school…
Bile needed for absorption of fats and fat Bile needed for absorption of fats and fat soluble nutrients from small intestinesoluble nutrients from small intestine
Imbalance of chol + solubilizing agentsImbalance of chol + solubilizing agents 70% of gallstones are >70% cholesterol 70% of gallstones are >70% cholesterol
(radiolucent)(radiolucent) 20% are pigment stones bc of abnormal 20% are pigment stones bc of abnormal
solubility of unconjugated bilirubin with the solubility of unconjugated bilirubin with the precipitation of calcium saltsprecipitation of calcium salts
10% mixed10% mixed
Gallstone risk factorsGallstone risk factors
Cholesterol – female, 20-40, pregnant/OCP, parity, Cholesterol – female, 20-40, pregnant/OCP, parity, obsesity/ profound weight loss, TPN, fam hx, C.F., obsesity/ profound weight loss, TPN, fam hx, C.F., Crohn’s, clofibrate, ceftriaxone, Pima indiansCrohn’s, clofibrate, ceftriaxone, Pima indians
(fat, female, forty, fertile, ethnic, estrogen, diet, (fat, female, forty, fertile, ethnic, estrogen, diet, drugs)drugs)
Pigment stones – Asian, chronic biliary tract Pigment stones – Asian, chronic biliary tract infection, chronic liver disease, intravasc hemolysis infection, chronic liver disease, intravasc hemolysis (sickle cell or spherocytosis)(sickle cell or spherocytosis)
Protective factorsProtective factors
ascorbic acid (?increased cholesterol catabolism) ascorbic acid (?increased cholesterol catabolism) coffee (3-4 cups/day 40% less likely to develop coffee (3-4 cups/day 40% less likely to develop
gallstones) Yeah!gallstones) Yeah!
Biliary colicBiliary colic
Stone lodged in cystic or CBD -> inc in Stone lodged in cystic or CBD -> inc in intraluminal pressure/ distention -> N&V& intraluminal pressure/ distention -> N&V& pain (15%)pain (15%)
Usually constant (not colic) but <6 hrsUsually constant (not colic) but <6 hrs Epig or RUQ dull/visceral pain with radiation Epig or RUQ dull/visceral pain with radiation
to R post shoulder + N&Vto R post shoulder + N&V Eating after fasting or fatty mealEating after fasting or fatty meal May have post-attack soreness for 1-2 daysMay have post-attack soreness for 1-2 days
CholecystitisCholecystitis
If obstruction persists – inflammation +/- If obstruction persists – inflammation +/- infection of gallbladder wallinfection of gallbladder wall
May develop gangrene +/- perf -> more May develop gangrene +/- perf -> more localized pain/ peritonitislocalized pain/ peritonitis
More parietal painMore parietal pain Murphy’s sign (97% sens, only 48% in Murphy’s sign (97% sens, only 48% in
elderly)elderly) May have fever/chillsMay have fever/chills
Acalculous cholecystitisAcalculous cholecystitis
5-10% of cholecystitis5-10% of cholecystitis Elderly + DM + immunosuppressed ( trauma, Elderly + DM + immunosuppressed ( trauma,
burn, labor, surgery, vasculitis, gallbladder burn, labor, surgery, vasculitis, gallbladder torsion, parasitic or bacterial infections of the torsion, parasitic or bacterial infections of the biliary tract.)biliary tract.)
Do worseDo worse
InvestigationsInvestigations
CBC (but WBC may be Normal) ? Low HbCBC (but WBC may be Normal) ? Low Hb Lipase +/- liver function tests (may be normal)Lipase +/- liver function tests (may be normal) U/S sensitivity >95% for stones > 2mm, spec 78%U/S sensitivity >95% for stones > 2mm, spec 78% False neg and pos rates 2-4% may miss cholecystitisFalse neg and pos rates 2-4% may miss cholecystitis Emergency physician U/SEmergency physician U/S HIDA/DISIDA best for cholecystitis sensitivity HIDA/DISIDA best for cholecystitis sensitivity
almost 100%, spec 90% but start with U/Salmost 100%, spec 90% but start with U/S 12 lead ECG, U/A, preg test, AXR, CXR12 lead ECG, U/A, preg test, AXR, CXR
DDxDDx
Gastritis, PUD, hepatitis, hepatic abscess, Gastritis, PUD, hepatitis, hepatic abscess, intraabd abscess, ischemic gut, Fitz-Hugh-intraabd abscess, ischemic gut, Fitz-Hugh-Curtis syndrome (GC or Chlamydial Curtis syndrome (GC or Chlamydial perihepatitis), pancreatitis, GERD, perihepatitis), pancreatitis, GERD, AppendicitisAppendicitis
Renal colic, pyelonephritisRenal colic, pyelonephritis Pneumonia, acute MI, Pneumonia, acute MI, PID +/- TOA, ectopic pregnancyPID +/- TOA, ectopic pregnancy
BactobiliaBactobilia
35-65% of pts with cholecystitis 35-65% of pts with cholecystitis E. coli or Klebsiella in 70%E. coli or Klebsiella in 70% Also Enterococcus, Bacteroides, Clostridium, Also Enterococcus, Bacteroides, Clostridium,
GDS, StaphGDS, Staph For non-septic: third generation cephalosporinFor non-septic: third generation cephalosporin Septic: amp, gent and clindaSeptic: amp, gent and clinda
CholangitisCholangitis
Complete obstruction + bacteria = cholangitisComplete obstruction + bacteria = cholangitis Backup into lymphatic vessels and hepatic Backup into lymphatic vessels and hepatic
veinsveins High mortality rateHigh mortality rate Stone, stricture, Ca Stone, stricture, Ca Increased ALP, GGT, bili (late) +/- AST, ALTIncreased ALP, GGT, bili (late) +/- AST, ALT E. coli, Klebsiella, PseudomonasE. coli, Klebsiella, Pseudomonas
Triads and pentadsTriads and pentads
25% Charcot’s triad25% Charcot’s triad Fever jaundice, RUQ painFever jaundice, RUQ pain Reynold’s pentadReynold’s pentad Altered LOC, distributive shock Altered LOC, distributive shock
Cholangitis management Cholangitis management EMR Aug 12 , 2002EMR Aug 12 , 2002
Volume resuscitation +/- vasopressorsVolume resuscitation +/- vasopressors Broad-spectrum antibioticsBroad-spectrum antibiotics Surgery or endoscopic decompressionSurgery or endoscopic decompression
Weird and wonderfulWeird and wonderful
Gallbladder empyemaGallbladder empyema Emphysematous (gangrenous) cholecystitis (1% of Emphysematous (gangrenous) cholecystitis (1% of
cholecystitis)cholecystitis) Hydrops= mucous accumulation in gallbladder due to Hydrops= mucous accumulation in gallbladder due to
cystic duct obstructioncystic duct obstruction Gangrene perforationGangrene perforation Cholecystoenteric fistula (repeated attacks)Cholecystoenteric fistula (repeated attacks) Gallstone ileus – cholecystoenteric connection with Gallstone ileus – cholecystoenteric connection with
impacted stone at ileocecal valve, pneumobiliaimpacted stone at ileocecal valve, pneumobilia
ManagementManagement
Urgent biliary decompression for pts in Urgent biliary decompression for pts in extremis or with clinical deteriorationextremis or with clinical deterioration
Consider operating if porcelain gallbladder Consider operating if porcelain gallbladder (15-20% assoc Ca) , DM, hx of biliary (15-20% assoc Ca) , DM, hx of biliary pancreatitispancreatitis
Demerol vs morphine, antiemeticsDemerol vs morphine, antiemetics Admit, hydrate, antibiotics (even though Admit, hydrate, antibiotics (even though
questionable in cholecystitis)questionable in cholecystitis)
What about ERCP?What about ERCP?
Severe pancreatitis, continuing biliary colic, Severe pancreatitis, continuing biliary colic, cholangitis, obstructive jaundice, stones in cholangitis, obstructive jaundice, stones in CBD or CBD dilationCBD or CBD dilation
Ultimately endoscopic sphincterotomy and Ultimately endoscopic sphincterotomy and stone extraction followed by laparoscopic stone extraction followed by laparoscopic cholecystectomy is preferred tx for cholecystectomy is preferred tx for choledocholithiasis.choledocholithiasis.
CholecystectomyCholecystectomy
Best management for Best management for Frequent or severe attacksFrequent or severe attacks Hx of gallstone complicationsHx of gallstone complications Stones over 2 cmStones over 2 cm Congenitally abnormal hepatobiliary system, Congenitally abnormal hepatobiliary system, +/- DM+/- DM
Discharge home if:Discharge home if:
Resolution of symptoms (4-6 hrs)Resolution of symptoms (4-6 hrs) Correction of intravascular volume deficitsCorrection of intravascular volume deficits Restored ability to drinkRestored ability to drink Give them analgesicsGive them analgesics
Keep if high risk with CBD stones or if Keep if high risk with CBD stones or if pregnantpregnant
Then what?Then what?
Asymptomatic gallstones develop Asymptomatic gallstones develop complicationscomplications
10% at 5 yrs10% at 5 yrs 15% at 10 yrs15% at 10 yrs 18% at 15-20 yrs18% at 15-20 yrs Close observation even for most diabetic Close observation even for most diabetic
patientspatients
Primary biliary cirrhosisPrimary biliary cirrhosis
Autoimmune associations Autoimmune associations Antimitochondrial antibody in >90%Antimitochondrial antibody in >90% Not fully understood. Necrotizing inflammation Not fully understood. Necrotizing inflammation
leading to bile duct fibrosisleading to bile duct fibrosis Often detected by elevated ALP on routine screeningOften detected by elevated ALP on routine screening Women, age 35-60, pruritus, fatigue, jaundice, Women, age 35-60, pruritus, fatigue, jaundice,
hyperpigmentation, eventual cirrhosishyperpigmentation, eventual cirrhosis Biopsy, colchicine, methotrexate/cyclosporine, Biopsy, colchicine, methotrexate/cyclosporine,
ursodiol, transplantursodiol, transplant
Secondary biliary cirrhosisSecondary biliary cirrhosis Postop strictures/ gallstonesPostop strictures/ gallstones Usually with superimposed infectious cholangitisUsually with superimposed infectious cholangitis Congenital biliary atresia, CF, choledochal cystsCongenital biliary atresia, CF, choledochal cysts Signs and symptoms like PBC but also intermittent Signs and symptoms like PBC but also intermittent
bouts of colic/cholangitisbouts of colic/cholangitis AMA negativeAMA negative Suspect if bile flow obstruction, especially postopSuspect if bile flow obstruction, especially postop
Sclerosing cholangitisSclerosing cholangitis
Affects extrahepatic +/- intrahepaticAffects extrahepatic +/- intrahepatic On ERCP see thickened ducts with narrow, On ERCP see thickened ducts with narrow,
beaded luminabeaded lumina Often associated with IBD, fibrosing Often associated with IBD, fibrosing
conditions, AIDSconditions, AIDS Cholestyramine for pruritus, transplantCholestyramine for pruritus, transplant Age, bili, histologic stage and splenomegaly Age, bili, histologic stage and splenomegaly
predict survivalpredict survival
What should I rememberWhat should I remember
Pancreatitis – get Pancreatitis – get smashedsmashed
Biliary colic - <6 hrsBiliary colic - <6 hrs Cholecystitis – usually Cholecystitis – usually
antibiotics, consider antibiotics, consider acaculous cholecystitisacaculous cholecystitis
Weird and wonderful Weird and wonderful complicationscomplications
When to discharge colicWhen to discharge colic
ReferencesReferences Cholangiography and PancreatographyCholangiography and Pancreatography, by M. Ohta, et al., Eds. Igaku-, by M. Ohta, et al., Eds. Igaku-
Shoin Ltd., Tokyo, University Park Press, Baltimore, 1978 Shoin Ltd., Tokyo, University Park Press, Baltimore, 1978 Emergency MedicineEmergency Medicine. Tintinalli, Kelen, Stapczynski.. Tintinalli, Kelen, Stapczynski. Emergency Medicine Reports – Presentation and mangement of Acute Emergency Medicine Reports – Presentation and mangement of Acute
biliary Tract Disorders in the Emergency Department – optimizing biliary Tract Disorders in the Emergency Department – optimizing Assessment and Treatment of Cholelithiasis and cholecystitis Aug 12 Assessment and Treatment of Cholelithiasis and cholecystitis Aug 12 20022002
Harrison’s principles of Internal Medicine 14Harrison’s principles of Internal Medicine 14 thth edition 1984 edition 1984 http://http://www.bupa.co.uk/health_information/html/organ/liver.htmlwww.bupa.co.uk/health_information/html/organ/liver.html Presentation by Rob Hall 2002Presentation by Rob Hall 2002 Thomson, A.B.R., Shaffer E.A Thomson, A.B.R., Shaffer E.A First Principles of GastroenterologyFirst Principles of Gastroenterology. 1997. 1997 www.emedhome.comwww.emedhome.com