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Pancreatitis and Gallbladder Disease

Pancreatitis and Gallbladder Disease. Stefan Da Silva Jan 18 th 2006. 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

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Pancreatitis and Gallbladder Disease

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  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, Crohn’s), surgery/trauma, hyperlipidemia/ hypercalcemia, emboli/ischemia, drugs • Also: pregnancy, liver disease, DKA

  5. Pancreatitis • Etiology con’t • 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 con’t • Alcohol • Mechanism unclear • 5 to 10 yrs of chronic EtOH abuse before onset

  7. Pancreatitis • Etiology con’t • 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 • Cullen’s sign (blood around the umbilicus) • Grey Turner’s 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 con’t • OK so you’ve 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 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?

  15. Ranson’s Criteria Pancreatitis • 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 • 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

  16. Pancreatitis • What do we use it for??? • Add total number at 48hrs • > 7 then mortality is 100% • 5 – 6 = 40% • 3 – 4 = 15% • 0 – 3 = 1% • May not be as accurate in pt’s 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) Ranson’s score > 3 4) APACHE score > 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 • 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?

  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 course…overall 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

  26. Gallbladder Disease

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

  28. 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

  32. 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 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%

  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 • 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

  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 > 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 • 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

  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

  41. Gallbladder Disease • So the patient has cholecystitis…. • Admit to gen surg • Antibiotics • NPO • Fluids • Some surgeons may choose to wait until GB isn’t as “hot” to do surgery

  42. Gallbladder Disease • Acalculous Cholecystitis • 5 – 15% • Elderly, pt’s recovering from nonbiliary tract surgery, HIV pt’s • 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 • Charcot’s Triad • RUQ pain, fever, jaundice • Not specific • Reynold’s 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

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