1. Paul James, MD MSc Wael Shabana, MD
Clinical Radiological Conference: Non-Neoplastic Biliary and Pancreatic Diseases
Paul James, MD MSc
Wael Shabana, MD
September 22rd, 2015

2. Objectives Etiology, risk factors and clinical presentation for:
1. Gallstone disease
Cholecystitis
Choledocholithiasis
Cholangitis
2. Acute pancreatitis
3. Chronic pancreatitis

3. Case 1
A 46 year old female presents to 2 am with several hours of severe upper abdominal pain, nausea, vomiting, chills and chills. Her pain and nausea gets worse with meals.
On examination: She is unwell and in pain. BMI 29.
Vitals: HR 112, Bpm, BP 150/86, T 38.2, O2 96%
Abdo: 8/10, sharp, epigastric and right upper quadrant tenderness on palpation.

4. Clinical case—contd. Hb 132 WBC 16 Plts 425 Cr 115
INR 1.1 Electrolytes normal.
Q: What is your differential diagnosis?
Q: What other information do you require to help you with a diagnosis?

5. Clinical case—contd. Bilirubin 35 (Nr <20) AST 60 (Nr <30)
ALT 55 (Nr <30)
ALP 190 (Nr <120)
Lipase 25 (Nr <30)

6. Radiology In a patient with RUQ pain and clinical findings indicating possible gallstone disease, what is the best first imaging test to confirm the diagnosis?
Computed tomography (CT) scan of the abdomen
Magnetic Resonance Cholangiopancreatography (MRCP)
Abdominal Ultrasound (US)
Hepatobiliary scintigraphy with 99mTcIDA (HIDA scan)
Endoscopic Retrograde Cholangiopancreatography (ERCP)

7. Answer: Abdominal Ultrasound
Ultrasound uses sound waves (no radiation) and is a excellent test for acute cholecystitis. High specificity for CBD stones as well.
It is inexpensive and broadly available.
US permits the diagnosis of other causes of RUQ and appropriate triage of patients to investigations or management in many cases.
Limitations:
a. Operator-dependent
b. < 75% sensitivity for CBD stones = can miss a CBD stone in 1 in 4 cases.

8. 2 common bile duct stones
Case 1
Ultrasound shows…
2 common bile duct stones
Radiology

9. Ultrasound: cholecystitis

10. Points for consideration
Plain abdominal radiography has no place in suspected acute cholecystitis
Ultrasound is highly accurate in the diagnosis of acute cholecystitis, particularly if the signs of gallbladder wall thickening/oedema, pericholecystic fluid, gallstones and positive ultrasonic Murphy's sign are all present
Negative or technically unsatisfactory ultrasound with continuing high clinical suspicion of acute cholecystitis should be followed by Tc-HIDA nuclear medicine scan
Radiology

11. Points for consideration
Ultrasound is the first imaging modality used in the algorithm for the investigation of cholestatic jaundice.
Further imaging depends on whether the bile ducts are dilated.
If the bile ducts are dilated and an ultrasound fails to demonstrate a cause, further imaging depends on a provisional clinical diagnosis. Investigations may the include CT scan of the abdomen, CT cholangiogram, Magnetic Resonance Cholangiopancreatography (MRCP) and Endoscopic US (EUS).
If the bile ducts are not dilated, hepatocellular causes of jaundice should be excluded prior to further imaging.
Endoscopic Retrograde Cholangiopancreatography (ERCP) is reserved for therapeutic indications or if there remains ongoing clinical doubt with non-diagnostic imaging studies.
Radiology

12. MRCP: CBD Stone

13. MRCP: CBD Stone

14. MRCP: CBD Stone

15. HIDA scan

16. Radiology

17. Case presentation (contd)
Impression:
Obstructing CBD stones, fever and elevated WBCs = Acute cholangitis ± cholecystitis.
Plan:
ABCs, IV fluid resuscitation.
Admit to hospital.
Blood cultures and repeat labs daily.
IV antibiotics to cover gram – organism.
5. Arrange from non-invasive stone extraction = ERCP.

18. A What? ERCP

19. Common bile duct stones

23. Summary: Acute cholangitis
Prompt clinical recognition
Labwork and imaging for diagnosis
Confirm presence of CBD stones
Stabilise and start antibiotics
Definitive therapy is therapeutic ERCP

24. Case 2
56 year old male presents to ER with acute sharp epigastric pain radiating to his back. Nausea and vomiting. Also notes dark urine and pale stools. No chills.
Q: What is your initial clinical impression?

26. Case presentation Hb 160 WBC 18 Plts 450 Bilirubin 93 (Nr <20)
AST 300 (Nr <30)
ALT 282 (Nr <30)
ALP 310 (Nr <120)
Lipase 1,600 (Nr <30)
Q: Now what do you think?
Q: What is the next step in diagnosis?

27. Acute Pancreatitis

28. Diagnosis – Amylase
Elevates within HOURS and can remain elevated for 4-5 days
High specificity when using levels >3x normal
Many false positives
Most specific = pancreatic isoamylase (fractionated amylase)

29. Diagnosis – Amylase Elevation
Pancreatic Source
Biliary obstruction
Bowel obstruction
Perforated ulcer
Appendicitis
Mesenteric ischemia
Peritonitis
Salivary
Parotitis
DKA
Anorexia
Fallopian tube
Malignancies
Unknown Source
Renal failure
Head trauma
Burns
Postoperative

30. Diagnosis – Lipase The preferred test for diagnosis
Begins to increase 4-8H after onset of symptoms and peaks at 24H
Remains elevated for days
Sensitivity % and Specificity 60-99%
>3X normal S&S ~100%

31. Causes of Acute Pancreatitis
Etiologies
Idiopathic
Gallstones (or other obstructive lesions)
EtOH
Trauma
Steroids
Mumps (& other viruses: CMV, EBV)
Autoimmune (SLE, polyarteritis nodosa)
Scorpion sting
Hyper Ca, TG
ERCP
Drugs (thiazides, sulfonamides, ACE-I, NSAIDS, azathioprine)
EtOH and gallstones account for 60-70% of cases

32. Prognosis

33. Prognosis Many different scoring systems -Ranson (most popular)
-APACHE II
-CT severity Index
Limited clinical application

34. 5% with <2 signs
20% with 3-5 signs
60% with 6-8 signs
>75% with >8 signs

35. CT scan of the abdomen

36. CT scan of the abdomen

37. CT scan of the abdomen

38. Role of Imaging in acute pancreatitis
Exclude an underlying cause (eg gallstones)
Detect complications
Guide the management of complications
(eg fluid collection drainage)
Radiology

39. US and CT in pancreatitis
Ultrasound:
To help determine aetiology of pancreatitis
Assess for gallstone-induced pancreatitis
Assess bile duct if abnormal liver function
CT SCAN - Routine CT scan is NOT indicated
Indications for CT scan include:
Where diagnosis is in doubt
Clinically severe cases to assess degree of pancreatic necrosis
Failure to improve or sudden deterioration
Imaging complications of pancreatitis
Radiology

40. Radiology

41. Management Remove offending agent Supportive care
Monitor for complications

42. Supportive Care NPO to clear fluid diet as tolerated
IV fluid and electrolyte replacement
Analgesia
Nutritional support

43. When To Consider Antibiotics
Cholangitis
Infected necrosis
Abscess
Infected pseudocyst
Note:
In each of these cases, an intervention is required to address the infection source.
Slide 327
Antibiotic use in acute pancreatitis
In acute pancreatitis, antibiotics are used for two major indications. The prophylactic use of antibiotics may reduce the number of pancreatic and non-pancreatic infections, but are usually reserved for those with severe disease. Antibiotics are used therapeutically for the treatment of cholangitis or other infections.

44. Case 3
65 year old male with years of epigastric pain radiating through to the back—aggravated by food and relieved by tylenol with codeine. Antacids do not help.
Over the past 6 months:
Lost 8 Kg in weight over 2 years.
Feels bloated.
4-8 loose pale stools per day.
Smoking: 40 pack-years
Alcohol: Over 20 standard drinks/ week. Rye.
Physical examination: Thin, 135lbs. BMI 21.
No icterus. Epigastric tenderness. Otherwise normal.

45. Case 3. Q: What is your clinical impression?
Q: Where is the pain from?
Q: Why is there weight loss?
Q: Why is alcohol intake important ?
Q: How would you investigate this patient?

46. CT Scan of the Abdomen
Radiology

47. CT scan of the abdomen
Radiology

48. Points for consideration
In suspected chronic pancreatitis, CT is moderately accurate in diagnosis
Ultrasound may also be indicated to assess gallstone disease
In equivocal cases, MRCP or endoscopic ultrasound can be considered.
Endoscopic retrograde pancreatography (ERCP) should be reserved for intervention. ERCP is not a diagnostic procedure.
Radiology

49. Radiology

50. Chronic Pancreatitis

51. Pathophysiology of Chronic Pancreatitis
Irreversible parenchymal (acinar cell) destruction leading to pancreatic dysfunction Exocrine insufficiency – enzymes = weight loss and steatorrhea Endocrine insufficiency - islet cell = diabetes

53. Sources of Pain in Chronic Pancreatitis

54. Causes of Chronic Pancreatitis
Etoh (>80%)
Idiopathic
Other rare causes include:
Gallstones
Hyperparathyroidism
Autoimmune
Congenital malformation
Genetics: Cystic Fibrosis

57. Pancreatic Enzyme Therapy
Goal:
Replace needed enzymes lost due to exocrine insufficiency
Improves:
Pain
Diarrhea
Nutrient absorption

59. Assess for Reversible Causes/Complications
Pain Relief Algorithm
Confirm Diagnosis
History, Imaging, Pancreatic Function Testing
Assess for Reversible Causes/Complications
EtOH and smoking cessation
Biliary stones
Collections
Malignancy
Treat
Medical Therapy
Analgesics
Pancreatic enzymes
Psychiatry
Dilated Main Pancreatic Duct
ERCP
Endoscopic nerve block
Surgery
Normal Main Pancreatic Duct
Endoscopic nerve block
Pancreas Islet Cell Transplant

60. GI: pjames@toh.on.ca Radiology: wshabana@toh.on.ca
Thank you
GI:
Radiology: