Transcript Liver pathology

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


Inflammatory markers


High WCC
CRP
Imaging

Abdominal Ultrasound scan
Management

Conservative
 NBM
 IVI
fluids
 Analagesia

Medical
 Antibiotics?

Surgical
 Laparascopic
+/- open cholecystectomy
Liver Functions

Digestion



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




processing digested food
breaking down food and turning it into energy
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


Clotting


Mitochondrial and cytosolic enzymes – ALT more specific
ALP


Processing function
Aminotransferases (AST+ALT)


Also synthetic - Prothrombin time (INR)
Total Bilirubin


General synthetic function + severity of Liver disease
Enzyme in the cells lining the biliary ducts of the liver
γGlutamyl-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

Bile salt loss in terminal Ileum in Crohn’s Disease
 Motility
 20%

of gall bladder
- “Pigment” Stones
 Calcium

factors
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


Inflammatory markers


High WCC
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



FBCs


CRP
Imaging



High WCC
Inflammatory markers


Serum bilirubin
ALP
Abdominal Ultrasound scan
CT
Special Tests


ERCP
MRCP
Management

Conservative
 NBM
 IVI
fluids
 Analagesia

Medical
 Antibiotics

Surgical
 ERCP
Pancreatitis
Pancreatitis

Mild:




Moderate:


Increasing local inflammation  bleeding, fluid collections and spreading local
oedema involving the mesentery and retroperitoneum  other organs.
Severe:




Enzymatic spillage
Inflammatory cascade activation and
Localized oedema. Local exudate may also lead to increased serum levels of
pancreatic enzymes.
Necrosis
Profound localized bleeding and fluid collections
Spread to local structures  mesenteric infarction, peritonitis and intraabdominal 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 Number
ITU admission
Death
1 (0-2points)
2%
2%
2 (3-4 points)
20%
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%






Gut perforation




Younger patients,
Previous post-ERCP pancreatitis
Females
Procedures that involve cannulation or injection of the pancreatic duct
Patients with sphincter of Oddi dysfunction
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
1
2
3

Complications/Presentations

Investigations

Ranson’s Criteria