Transcript Pancreatitis and Gallbladder Disease

Pancreatitis and Gallbladder
Disease
Stefan Da Silva
Jan 18th 2006
Pancreatitis
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Case #1
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47 yr old male with hx of chronic EtOH presenting
with epigastric tenderness and vomiting
Do you:
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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
Pancreatitis
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Some backround
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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
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Pancreatitis
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Etiology
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80% caused by gallstones (45%) or alcohol
(35%)
GET SMASHED
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Gallstones, ethanol, tumors, scorpion bite?, microbiology
(bacteria, virus, parasites), autoimmune (SLE, PAN, Crohn’s),
surgery/trauma, hyperlipidemia/ hypercalcemia,
emboli/ischemia, drugs
Also: pregnancy, liver disease, DKA
Pancreatitis
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Etiology con’t
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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
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Pancreatitis
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Etiology con’t
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Alcohol
Mechanism unclear
 5 to 10 yrs of chronic EtOH abuse before onset
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Pancreatitis
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Etiology con’t
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Drugs
Tylenol
 Steroids
 Ranitidine
 Valproic Acid
 ASA
 Lasix
 etc
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Pancreatitis
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Clinical Features
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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
Pancreatitis
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Physical Examination
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Hypotension
Tachycardia
Tachypnea
Low-grade fever
Jaundice
Rales or diminshed breath sounds
Cullen’s sign (blood around the umbilicus)
Grey Turner’s sign (discoloration of flank)
Rarely peritoneal findings since pancreas is
retroperitoneal organ
Pancreatitis
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Case #2
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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??
Pancreatitis
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Lab Tests
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Lipase/Amylase
CBC
LDH
LFTs
CH6
Ca
Albumin
Pancreatitis
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AMYLASE
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Cleaves carbohydrate
Pancreas, salivary
glands, other organs
Rises in 6hrs
Peaks in 48hrs
Falls over 1week
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LIPASE
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Hydrolyzes TG
Occurs in pancreas
and other tissues
Rises in 6 hrs
Peaks in 24 hrs
Falls over 1 - 2 weeks
Pancreatitis
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AMYLASE
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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,
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LIPASE
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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
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Case #2 con’t
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OK so you’ve ordered the labs are here are some of
the magic numbers
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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 Ranson’s Criteria of 6.” You have a
medical student with you today and decide to quiz
him on the “Ranson’s Criteria”. What does he say?
Pancreatitis
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Ranson’s Criteria
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At admission or diagnosis
Age > 55 years
WBC > 16,000/mm3
Blood glucose > 200mg/dl
Serum LDH > 350 IU/ml
AST > 250 Sigma-Frankel units/dl
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During initial 48 hours
Hematocrit fall > 10%
BUN rise > 5 mg/dl
Serum calcium level < 8.0
Arterial oxygen pressure < 60
mm Hg
Base deficit > 4 mEq/L
Estimated fluid sequestration >
6,000 ml
Pancreatitis
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What do we use it for???
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Add total number at 48hrs
> 7 then mortality is 100%
 5 – 6 = 40%
 3 – 4 = 15%
 0 – 3 = 1%
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May not be as accurate in pt’s with AIDS due
to HIV-induced lab changes
Other scoring systems: APACHE-II
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Case #3
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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?
Pancreatitis
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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) Ranson’s score > 3 4) APACHE score > 8
5) No improvement in 72 hrs 6) acute deterioration
 Contrast does not worsen pancreatitis
Pancreatitis
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DDX
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Perforated viscus
PUD
GB disease
Gastro
Ectopic Pregnancy
AAA
Bowel Obstruction
Bowel Ischemia
MI
Pericarditis
Pneumonia
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Case #4
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You’ve got a 49 yr old female that you’ve diagnosed
with pancreatitis, thinking pretty good about your self
that you’ve 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?
Pancreatitis
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Management
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Primarily supportive
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Volume replacement
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Pain control
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Narcotic analgesia (most narcotics may affect the function of the sphincter of
Oddi)
Nutrition
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Monitor vitals and urine output and lytes
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!!!!
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Hypotension
Respiratory Failure
Hyperglycemia (treat cautiously as will self-correct)
Hypocalcemia
Hypomagnesiumia
Pancreatitis
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ERCP???
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Medications
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Recommended in severe obstruction pancreatitis
H2 blockers: no evidence
Antibiotics: used in severe pancreatitis and resultant
sepsis. Broad spectrum
Surgery
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Indicated if necrotic, hemmorhagic, abscess drainage
Pancreatitis
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Disposition
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Admission for all
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ICU vs Medicine vs Hospitalist
Unpredictable course…overall mortality is 8%
Pancreatitis
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Chronic Pancreatitis
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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.
Gallbladder Disease
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Biliary Colic
Cholecystitis
Cholangitis
Sclerosing Cholangitis
Gallbladder Disease
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Case #5
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45 yr old female presenting with RUQ pain
episodic after eating a cheeseburger.
Afebrile
BMI 40
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Do you
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A)
B)
C)
D)
Ask her where she ate her cheeseburger
Give her a “pink” lady
Rub her belly
Perform a thorough history and physical
Gallbladder Disease
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Biliary Colic
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Cholelithiasis
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2 categories of stones
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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.
GallBladder Disease
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Biliary Colic
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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
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Gallbladder Disease
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Biliary Colic
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Physical Exam
Vitals: tachy (from pain or dehydration)
 Abdomen: RUQ tenderness but no guarding or
rebound
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Gallbladder Disease
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Biliary Colic
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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
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Imaging
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U/S
Ensure to r/o any cardiopulmonary pathology
Gallbladder Disease
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Biliary Colic
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Management
Correct any fluid/lyte imbalances
 Symptomatic treatment
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Pain control
Definitive management is surgery
 Admission for refractory pain and dehydration
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Gallbladder Disease
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Cholecystitis
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Sudden inflammation of gallbladder
Similar risk factors as for gallstones
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4 F’s: fat, female, forty, fertile
Result of cystic duct obstruction
95% of patients with cholecystitis will have a
gallstone (usually in CBD in pt’s with
acalculous cholecystitis)
Acalculous cholecystitis 2 – 12%
Gallbladder Disease
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What happens???
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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
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E.coli, enterococcus, Klebsiella, Proteus
Gallbladder Disease
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Presentation
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Right upper quadrant pain
Constant with radiation to tip of scapula
N+V
Murphy’s sign (tenderness and inspiratory
pause with palpable of RUQ during deep
breath)  not specific but > 95% sensitive
(much less in elderly pt though)
Not always febrile
Gallbladder Disease
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Lab Values
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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 > 90%
 No stones  NPV ~ 90%
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GallBladder Disease
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DDX
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Hepatitis
Pancreatitis
Pyleo
Hepatic Abscess
RLL pneumonia
PUD
Gallbladder Disease
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Management
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Supportive
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Fluids, pain control, anti-emetics
Antibiotics
Rosen’s states unless septic then 2nd or 3rd
generation cephalosporin adequate
 Sanford’s states Pip/Taz or 3rd generation
cephalosporin plus flagyl and if septic then
imepenim
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Gallbladder Disease
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Heads Up!!
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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
Gallbladder Disease
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So the patient has cholecystitis….
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Admit to gen surg
Antibiotics
NPO
Fluids
Some surgeons may choose to wait until GB
isn’t as “hot” to do surgery
Gallbladder Disease
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Acalculous Cholecystitis
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5 – 15%
Elderly, pt’s recovering from nonbiliary tract
surgery, HIV pt’s
Worse with mortality approaching 40%
Gallbladder Disease
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Emphysematous Cholecystitis
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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%
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Case #6
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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?
Gallbladder Disease
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Cholangitis
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3 things needed
Obstruction
 Increased intraluminal pressure
 Bacteria infection
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E.coli, Klebsiella, Enterococcus
Gallbladder Disease
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Presentation
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Charcot’s Triad
RUQ pain, fever, jaundice
 Not specific
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Reynold’s Pentad
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RUQ pain, fever, jaundice, sepsis, confusion
Gallbladder Disease
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Lab Values
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Leukocytosis
Elevated bili, ALP
Mod. Elevated ALT, AST
Imaging
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U/S  usually shows dilated common and
intrahepatic ducts
Gallbladder Disease
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Treatment
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Supportive care
Broad-spectrum abx
Early biliary tract decompression
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Either with ERCP or surgery
Gallbladder Disease
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Sclerosing Cholangitis
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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