Pancreatitis and Gallbladder Disease

1
Pancreatitis and Gallbladder Disease

• Stefan Da Silva
• Jan 18th 2006

2
Pancreatitis

• Case 1
• 47 yr old male with hx of chronic EtOH presenting
  with epigastric tenderness and vomiting
• Do you
• A) Ask him what his poison is and join in..
• B) Proceed by scolding him on drinking too
  much
• C) Chalk it up to EtOH induced gastritis, call
  the drunk tank and go for coffee
• D) Astutely consider multiple causes of his
  presentation and proceed to work him up

3
Pancreatitis

• Some backround
• Pathophysiology
• Poorly understood ? thought to be direct
  cellular toxicity or increased ductal pressure
• Release of inflammatory mediators may cause
  systemic immune response syndrome resulting in
  multi-organ failure

4
Pancreatitis

• Etiology
• 80 caused by gallstones (45) or alcohol (35)
• GET SMASHED
• Gallstones, ethanol, tumors, scorpion bite?,
  microbiology (bacteria, virus, parasites),
  autoimmune (SLE, PAN, Crohns), surgery/trauma,
  hyperlipidemia/ hypercalcemia, emboli/ischemia,
  drugs
• Also pregnancy, liver disease, DKA

5
Pancreatitis

• Etiology cont
• Gallstones
• Obstruction either directly (stone in pancreatic
  duct and CBD) or indirectly (stone in bile duct
  applies transmural pressure on pancreatic duct)
• Leads to activation of pancreatic enzymes ?
  resulting in pancreatitis

6
Pancreatitis

• Etiology cont
• Alcohol
• Mechanism unclear
• 5 to 10 yrs of chronic EtOH abuse before onset

7
Pancreatitis

• Etiology cont
• Drugs
• Tylenol
• Steroids
• Ranitidine
• Valproic Acid
• ASA
• Lasix
• etc

8
Pancreatitis

• Clinical Features
• Epigastric pain (but can be diffuse)
• Relatively rapid onset
• Can radiate to mid-back
• Degree of pain does not correlate with severity
  of disease
• Approx 50 of patients will have hx of similar
  abdo pain in past

9
Pancreatitis

• Physical Examination
• Hypotension
• Tachycardia
• Tachypnea
• Low-grade fever
• Jaundice
• Rales or diminshed breath sounds
• Cullens sign (blood around the umbilicus)
• Grey Turners sign (discoloration of flank)
• Rarely peritoneal findings since pancreas is
  retroperitoneal organ

10
Pancreatitis

• Case 2
• 60 yr old male complaining of epigastric pain
  radiating to back. Looks pale and diaphoretic.
  Diminished breath sounds. Denies any hx of EtOH
  abuse.
• Vitals 37.8, 110, 25RR, 100/50, 90 RA
• EDE shows no AAA
• Aside from initial ABCs and resusitation what lab
  values do you want??

11
Pancreatitis

• Lab Tests
• Lipase/Amylase
• CBC
• LDH
• LFTs
• CH6
• Ca
• Albumin

12
Pancreatitis

• AMYLASE
• Cleaves carbohydrate
• Pancreas, salivary glands, other organs
• Rises in 6hrs
• Peaks in 48hrs
• Falls over 1week

• LIPASE
• Hydrolyzes TG
• Occurs in pancreas and other tissues
• Rises in 6 hrs
• Peaks in 24 hrs
• Falls over 1 - 2 weeks

13
Pancreatitis

• AMYLASE
• Sensitivity 80 - 95
• Specificity 70
• If 3X normal then specificity approaches 100 but
  sensitivity decreases to 60
• Can be seen elevated in ectopic pregnancy,
  parotitis, renal failure, ischemic bowel,
  obstruction,

• LIPASE
• Sensitivity 80 - 95
• Specificity 90
• 5X normal gives 60 sensitivity and 100
  specificity. Generally regarded that 2X normal
  is gives adequate sensitivity and specificity to
  diminish possibility of missing pancreatitis

14

• Case 2 cont
• OK so youve ordered the labs are here are some
  of the magic numbers
• WBC 14.00
• AST 200 U/L
• LDH 400 IU/L
• Glucose 12
• You call up your friendly neighbourhood internist
  you states wow, we just admitted a pancreatitis
  2 days ago and has a Ransons Criteria of 6.
  You have a medical student with you today and
  decide to quiz him on the Ransons Criteria.
  What does he say?

15
Pancreatitis

• Ransons Criteria

• During initial 48 hours
• Hematocrit fall gt 10
• BUN rise gt 5 mg/dl
• Serum calcium level lt 8.0
• Arterial oxygen pressure lt 60 mm Hg
• Base deficit gt 4 mEq/L
• Estimated fluid sequestration gt 6,000 ml

• At admission or diagnosis
• Age gt 55 years
• WBC gt 16,000/mm3
• Blood glucose gt 200mg/dl
• Serum LDH gt 350 IU/ml
• AST gt 250 Sigma-Frankel units/dl

16
Pancreatitis

• What do we use it for???
• Add total number at 48hrs
• gt 7 then mortality is 100
• 5 6 40
• 3 4 15
• 0 3 1
• May not be as accurate in pts with AIDS due to
  HIV-induced lab changes
• Other scoring systems APACHE-II

17

• Case 3
• 65 yr old male with previous gallstone disease
  presenting with epigastric pain, diaphoresis and
  low grade fever. PMH for diabetes, GERD, CAD,
  COPD
• What would be a short differential diagnosis
• What, if any, imaging studies would you want to
  perform and why?

18
Pancreatitis

• Radiographic studies
• AXR
• May exclude other causes of abdo pain including
  bowel obstruction or perforation
• CXR
• May show pleural effusion or ARDS
• U/S
• Better visualization of biliary tract
• Recommended in 1st 24 hrs to determine if stones
  are the cause
• Insert studies!!!
• CT
• Best look at pancreas, pseudocysts, hemorrhage
• Useful in ED to exclude other diagnosis of
  abdominal pain
• Recommended when 1) uncertain dx 2) severe
  clinical pancreatitis, leukocytosis, elevated
  temp 3) Ransons score gt 3 4) APACHE score gt
  8 5) No improvement in 72 hrs 6) acute
  deterioration
• Contrast does not worsen pancreatitis

19
Pancreatitis

• DDX
• Perforated viscus
• PUD
• GB disease
• Gastro
• Ectopic Pregnancy
• AAA
• Bowel Obstruction
• Bowel Ischemia
• MI
• Pericarditis
• Pneumonia

20

• Case 4
• Youve got a 49 yr old female that youve
  diagnosed with pancreatitis, thinking pretty good
  about your self that youve made the diagnosis
  you strut around the department giving high
  fives. Suddenly you here a page overhead asking
  you to go to Bed 5. You arrive and see your
  pancreatitis patient in mild respiratory
  distress.
• What are the initial management options in
  pancreatitis?
• What are the complications of pancreatitis?

21
Pancreatitis

• Management
• Primarily supportive
• Volume replacement
• Monitor vitals and urine output and lytes
• Pain control
• Narcotic analgesia (most narcotics may affect the
  function of the sphincter of Oddi)
• Nutrition
• NPO in severe cases BUT recent studies have shown
  that pts with mild to moderate pancreatitis have
  shown no benefit from fasting or NG suction
• NG suction only in cases of intractable vomiting
  and some enteral feeding should begin early (if
  unable then parental nutrition should be
  initiated)
• Complications!!!!
• Hypotension
• Respiratory Failure
• Hyperglycemia (treat cautiously as will
  self-correct)
• Hypocalcemia
• Hypomagnesiumia

22
Pancreatitis

• ERCP???
• Recommended in severe obstruction pancreatitis
• Medications
• H2 blockers no evidence
• Antibiotics used in severe pancreatitis and
  resultant sepsis. Broad spectrum
• Surgery
• Indicated if necrotic, hemmorhagic, abscess
  drainage

23
Pancreatitis

• Disposition
• Admission for all
• ICU vs Medicine vs Hospitalist
• Unpredictable courseoverall mortality is 8

24
Pancreatitis

• Chronic Pancreatitis
• EtOH, EtOH, EtOH..
• Supportive care
• Pain control
• Usually lab values are not helpful, clinical
  diagnosis
• R/O other causes of abdominal pain
• Can be managed as outpt.

25
Gallbladder Disease

• Biliary Colic
• Cholecystitis
• Cholangitis
• Sclerosing Cholangitis

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Gallbladder Disease
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• Case 5
• 45 yr old female presenting with RUQ pain
  episodic after eating a cheeseburger.
• Afebrile
• BMI 40

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• Do you
• A) Ask her where she ate her cheeseburger
• B) Give her a pink lady
• C) Rub her belly
• D) Perform a thorough history and physical

29
Gallbladder Disease

• Biliary Colic
• Cholelithiasis
• 2 categories of stones
• Cholesterol stones
• From elevated concentration of cholesterol in the
  bile
• Risk factors age, gender, weight, CF, drugs, FH
• Pigmented stones
• 2 types Black and Brown (assoc with infection)
• Both contain calcium bilirubinate
• Point of Interest ? for a stone to be radiopaque
  it must contain at least 4 calcium by wt.

30
GallBladder Disease

• Biliary Colic
• Presentation
• Colic is a misnomer as pain is steady but not
  usually greater than 6 hrs.
• Radiation of pain to base of scapula or shoulder
• N V
• Relationship to eating

31
Gallbladder Disease

• Biliary Colic
• Physical Exam
• Vitals tachy (from pain or dehydration)
• Abdomen RUQ tenderness but no guarding or
  rebound

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Gallbladder Disease

• Biliary Colic
• Lab Tests
• ALT and AST to evaluate for evidence of hepatitis
• Bilirubin and ALP to evaluate for evidence of
  obstruction of CBD
• Amylase/Lipase to evaluate for pancreatitis
• Imaging
• U/S
• Ensure to r/o any cardiopulmonary pathology

33
Gallbladder Disease

• Biliary Colic
• Management
• Correct any fluid/lyte imbalances
• Symptomatic treatment
• Pain control
• Definitive management is surgery
• Admission for refractory pain and dehydration

34
Gallbladder Disease

• Cholecystitis
• Sudden inflammation of gallbladder
• Similar risk factors as for gallstones
• 4 Fs fat, female, forty, fertile
• Result of cystic duct obstruction
• 95 of patients with cholecystitis will have a
  gallstone (usually in CBD in pts with acalculous
  cholecystitis)
• Acalculous cholecystitis 2 12

35
Gallbladder Disease

• What happens???
• Obstruction of cystic duct leads to filling and
  distention of GB ? inflammation and wall ischemia
  due to increased pressure and/or cytotoxic
  products of bile metabolism
• Bacteria in 50 75 of cases
• E.coli, enterococcus, Klebsiella, Proteus

36
Gallbladder Disease

• Presentation
• Right upper quadrant pain
• Constant with radiation to tip of scapula
• N V
• Murphys sign (tenderness and inspiratory pause
  with palpable of RUQ during deep breath) ? not
  specific but gt 95 sensitive (much less in
  elderly pt though)
• Not always febrile

37
Gallbladder Disease

• Lab Values
• Leukocytosis with shift (however normal WBC in up
  to 40 of pts)
• ALT, AST, Bili, ALP can be mildly elevated or
  normal
• U/S is still best diagnostic tool
• Presence of stones, thickened wall, and
  pericholecystic fluid has PPV gt 90
• No stones ? NPV 90

38
GallBladder Disease

• DDX
• Hepatitis
• Pancreatitis
• Pyleo
• Hepatic Abscess
• RLL pneumonia
• PUD

39
Gallbladder Disease

• Management
• Supportive
• Fluids, pain control, anti-emetics
• Antibiotics
• Rosens states unless septic then 2nd or 3rd
  generation cephalosporin adequate
• Sanfords states Pip/Taz or 3rd generation
  cephalosporin plus flagyl and if septic then
  imepenim

40
Gallbladder Disease

• Heads Up!!
• Most serious complication of cholecystitis is
  gangrene of gallbadder ? leads to perforation and
  sick patients
• Diabetic pts more prone to development of
  emphysematous gallbladder due to increased risk
  of bacterial seeding of GB wall

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Gallbladder Disease

• So the patient has cholecystitis.
• Admit to gen surg
• Antibiotics
• NPO
• Fluids
• Some surgeons may choose to wait until GB isnt
  as hot to do surgery

42
Gallbladder Disease

• Acalculous Cholecystitis
• 5 15
• Elderly, pts recovering from nonbiliary tract
  surgery, HIV pts
• Worse with mortality approaching 40

43
Gallbladder Disease

• Emphysematous Cholecystitis
• Gas in GB wall
• More common in diabetics
• Gas producing organisms (e.coli, Kleb, Clost)
• 50 of time acalculous
• High incidence of necrosis and gangrene
• Mortality approx. 15

44

• Case 6
• 65 yr old female with fever, RUQ pain, confusion
  and jaundice
• Vitals 40.5, 110HR, 26RR, 80/50, glucose 12.0
• What do you think?

45
Gallbladder Disease

• Cholangitis
• 3 things needed
• Obstruction
• Increased intraluminal pressure
• Bacteria infection
• E.coli, Klebsiella, Enterococcus

46
Gallbladder Disease

• Presentation
• Charcots Triad
• RUQ pain, fever, jaundice
• Not specific
• Reynolds Pentad
• RUQ pain, fever, jaundice, sepsis, confusion

47
Gallbladder Disease

• Lab Values
• Leukocytosis
• Elevated bili, ALP
• Mod. Elevated ALT, AST
• Imaging
• U/S ? usually shows dilated common and
  intrahepatic ducts

48
Gallbladder Disease

• Treatment
• Supportive care
• Broad-spectrum abx
• Early biliary tract decompression
• Either with ERCP or surgery

49
Gallbladder Disease

• Sclerosing Cholangitis
• Idiopathic inflammatory disorder affecting the
  biliary tree
• Fibrosis and narrowing of both intra and extra
  hepatic bile ducts
• Assoc with UC
• Rarely develop infectious cholangitis
• Sx of lethargy, wt loss, jaundice, puritus
• ERCP helpful in diagnosis
• Management primarily symptomatic