1. Biliary disease + pancreatitis for finals (and beyond) …the story of Mrs Harvey-Henry Dr Julian Dickmann General Surgery

2. By the end of this session… You will be able -To recognise the common complications of gallstone disease -Understand the underlying pathophysiology -Start initial management and investigations -To initiate treatment.

3. First doctor You are the F2 in general practice – Mrs Harvey- Henry, a 44 year old restaurant critic comes to you with her private ultrasound report after a visit to the well woman clinic which showed “numerous gallstones”. She does not complain of any symptoms. She is very worried – what do you advise?

4. Gallstones The commonest cause of emergency hospital admission with abdominal pain 1 1- Kettunen et al. Emergency abdominal surgery in the elderly. Hepatogastroenterology. 1995;42:106–8. Pictures from BMJ Review (Gallstones) = common in exams

5. “Pathological” effects of gallstones Silent 90% asymptomatic WITHIN THE GALLBLADDER

6. Second doctor You are the F1 in A+E – Mrs Harvey-Henry, presents to the emergency department with a 1h history of RUQ pain after dining at the Fat Duck. The pain has now subsided and she is very worried. What do you advise (examination unremarkable)?

7. “Pathological” effects of gallstones Biliary colic WITHIN THE GALLBLADDER  INTERMITTENT PAIN  NOT SYSTEMICALLY UNWELL

8. Clinical management & investigations Do not admit. Ultrasound as an outpatient. Conservative – Analgesia – Anti-emetics Medical – Ursodesoxycholic acid (not effective) Surgical – Cholecystectomy (laparoscopic) Biliary colic

9. Third doctor You are the F1 in A+E – Mrs Harvey-Henry, now complains of a 2 day history of RUQ pain, vomiting and feeling unwell.

10. “Pathological” effects of gallstones Acute cholecystitis WITHIN THE GALLBLADDER

11. Acute cholecystitis – pathogenesis obstruction of the cystic duct (gallstones / sludge) ↑ Intraluminal pressure supersaturation of cholesterol Inflammatory response (PG-I 2 /E 2 ) ± secondary bacterial infection (E Coli, Klebsiella) in 20%

12. Acute cholecystitis – diagnosis Murphy’s sign positive: inspiratory arrest by pain on palpation AND the absence of left sided arrest of inspiration

13. Acute cholecystitis – investigations Ultrasound Distended “thick walled” gallbladder Gallstones / Sludge Murphy’s sign – elicited with probe Preparation for ultrasound abdomen: Fasting for 6h. Clear fluids until 2h. (+ full bladder for renal/gynae) Blood tests CT (CXR) Δ RLL Pneumonia

14. Conservative – Analgesia – Anti-emetics Medical – IV Antibiotics (Tazocin ± Gentamicin) Surgical – definite treatment – Laparoscopic / open cholecystectomy – High surgical risk + sepsis: percutaneous cholecystostomy Acute cholecystitis – management Acute cholecystitis – management II

15. Timing of surgery? 28.5% readmission rate (gallstone-related complications) on NHS waiting list (1) Either: Early urgent (<72h) or delayed-interval LC – Introduction of an “urgent cholecystectomy service”  of readmission rate 19% to 3.6% (2) – Optimal time: 6-12 weeks after initial admission (3) Acute cholecystitis – management Acute cholecystitis – management I (1) Cheruvu et al. Ann R Coll Surg Engl 2002 (2) Mercer et al. Br J Surg 2004 (3) Gurusamy et al. Br J Surg. 2010

16. Complications Anaesthetic risk (PE, Pneunomia, MI) Procedure-specific risks: – Conversion to open – Injury to CBD – Biliary leak causing biliary peritonitis – Post-op haemorrhage – Intra-abdominal abscess

17. 4 th doctor Mrs Harvey-Henry responds well to analgesia and antibiotics but a day you as the F1 notice that she is appears jaundiced (obviously you noticed this without looking at the bilirubin…).

18. “Pathological” effects of gallstones Obstructive jaundice Choledocolithiasis =stone in CBD Oedema around the biliary tract Mirizzi’s syndrome (stone in Hartmann’s pouch compressing common hepatic duct)

19. Choledocolithiasis Suspect if: JAUNDICE ± deranged liver function ± dilated CBD Management 1 st – MRCP 2 nd – Endoscopic retrograde cholangiopancreatography (ERCP) NB: no diagnostic test, treatment only (>90% success rate) (operative CBD exploration during cholecystecomy)

20. Normal CBD diameter < 50 years – 6mm > 50 years – 8mm post-cholecystectomy >10mm Senturk et al. Eur J Radiol. 2012 Jan;81(1):39-42.

21. 5 th doctor On your on-call night shift, the a nurse on Willoughby ward bleeps you: Mrs Harvey- Henry’s MEWS is 8 (systolic BP of 85, HR 120, RR 24, T 39.2). They are apologetic, but as she was in a side-room, they only noticed this at midnight. So you make your way up to the ward…

22. Ascending cholangitis Bacterial infection (E. Coli) of the biliary tree Management: IV Fluids, Abx + urgent removal of obstruction (ERCP)

23. 6 th doctor Mrs Harvey-Henry is successfully resuscitated by yourself (ABC!) and there was a slot for an ERCP available first thing in the morning. Anything to consider?

25. 7 th doctor You get bleeped at 11pm. The nurses tell you that Mrs Harvey Henry needs more pain relief. Her pain is not adequately controlled on paracetamol, tramadol and hourly oramorph. Could you come and assess her?

26. post-ERCP Pancreatis (PEP) 5% risk esp. multiple injections of contrast into pancreatic duct

27. Acute Pancreatitis Aetiology Gallstones (50%) Alcohol (35%) Post-ERCP (5%) (the rest = 5%) Pain severe epigastric central abdominal radiation to the back Vomiting

28. 8 th doctor Your SHO and registrar are busy in theatres. You are on your own. Start initial investigations and management.

29. Management Nil by mouth IV Access (green cannula) Bloods – FBC/U+Es/Amylase/CRP/G+S/Clotting Aggressive fluid replacement – 1000ml Hartmann’s stat – 1000ml Hartmann’s 2h / 4h / 6h Catheterise – strict fluid balance Hourly observations Analgesia ABG For ANY surgical admission

30. ABGs…

31. Investigations LOOK FOR SIGNS OF (MULTI-) ORGAN FAILURE Modified Glasgow criteria – prognostic criteria Predicts severity of severe pancreatitis: ≥3 factors are over the first 48h indicate severe pancreatitis  ITU involvement P a O 2 <8kPA[ARDS] Age>55y NeutrophilsWBC>15 Calcium <2mmol/l [lipid saponification] Renal functionUrea >16[hypovoloaemia] EnzymesLDH >600, AST>200[autolysis] Albumin<32g SugarBM >10mmol/l[endocrine disturbance]

32. Questions? Covered in the handout: – Biliary malignancies (cholangiocarcinoma) – Chronic pancreatitis