GALLSTONES AND PANCREATITIS alex 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  γ Glutamyl-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

 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 NumberITU admissionDeath 1 (0-2points)2% 2 (3-4 points)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

3 things I want you to take away  Complications/Presentations  Investigations  Ranson’s Criteria