A woman with abdominal pain….

1. A woman with abdominal pain…. Michelle Papandony Amanda Vo Veronica Mezhov Wei De Tee

2. Patient • Mrs Wong • 65 yo • Migrated from China 5 years ago with her family

3. HOPC • Presented to ED with • Pseudocolic • RUQ pain 7/10, no radiation • Started 30 mins after dinner • No relieving/ aggravating factors • 2-3 similar episodes over the last 2 months but each lasting 10-15 mins • Slightly nauseated, no vomiting

4. Relevant negatives • No abdominal distension • Denies change in appearance of stool or urine • No diarrhoea • No jaundice • No fever/ rigors • No recent travel • No sick contacts • No take-away food • No cough • No CV or resp symptoms • No urinary symptoms

5. PHx • GORD • Hyperlipidaemia (diet control) • Salpingectomy and hysterectomy 15 years ago due to peri-menopausal dysmenorrhea and menorrhagia

6. Medications • Omeprazole • NKDA

7. No relevant family history • No smoking history • Social drinker • Lives at home with her husband and two daughters • No financial/ other stressors

8. Examination • Vital Signs (HR 90, BP 150/90, RR 18, Temp 36.9) • Mild truncal obesity • Slight scleral icterus, nil other peripheral stigmata of liver disease • Small xanthelasma bilaterally

9. Nil scars or distension of abdomen • No peritonism • Tender RUQ • Positive Murphy’s sign • Liver non palpable due to pain • Liver span normal • Bowel sounds present • Kidneys not ballotable • No hernia detected • PR not performed • Chest clear • S1S2 NAD, no murmur • Peripheral examinations unremarkable • FWT: NAD

10. Ddx • Cholecystitis ?Ascending cholangitis • Hepatitis • Pancreatitis • AMI • Lower lobe pneumonia • PID – not in this patient • Appendicitis – anatomical variant • Perforated peptic ulcer • Pyelonephritis – unlikely

11. Ix • Bloods • FBE + CRP • U&E • LFT + Coags • Lipase/ Amylase • Imaging • Abdo USS • Ix to rule out other dx if suspected eg. ECG

12. While in ED, Mrs Wong became febrile (38.5) and developed rigors. While her skin was not jaundiced, her scleral icterus appeared to worsen. • Mx Plan • IV Fluids • Morphine + Metaclopramide • NBM • IV antibiotics (Ceftriaxone and Metronidazole)

13. Ix Results • Mildly increased WCC • Raised CRP (250) • Markedly raised ALP and GGT • Mildly raised ALT and AST • Raised bilirubin • Coags NAD • Lipase NAD • U/S showed: • Enlarged common bile duct of 10mm • Gallbladder wall thickened • Stones within the gallbladder and the common bile duct • Mrs Wong was diagnosed with cholecystitis with secondary ascending cholangitis (Charcot’s triad).

14. Mx • Endoscopic Retrograde Cholangiopancreatography (ERCP) • Cholecystectomy 6 weeks after

15. Biliary Disease

16. Gallstone(s) Defn: Solid crystal deposits that form within biliary tract Types: Mixed (80%) Cholesterol Pigment stones a) Black (2° haemolytic disease) b) Brown (2° infection)

17. Definitions Cholestasis = Cholelithiasis = Choledocholithiasis = Obstruction of bile flow Gallstone(s) within the gallbladder Gallstone(s) within the CBD *CBD = common bile duct

18. Overview of Biliary Disease • Biliary colic • Cholecystitis • Acute • Chronic • Cholangitis • Acute • Primary Sclerosing (PSC) cholangitis • Primary Biliary Cirrhosis (PBC)

19. Overview of Biliary Disease Defn: Cystic duct obstruction • 2° gallstone Features • Epigastric / RUQ pain • Resolves <6hrs • Usu. constant • Otherwise: colicky • Intermittent pain 2° gallbladder contractn • Quality: • Aching • Tightness • Location: • Epigastric (usually) • RUQ ± Referred pain: shoulder / scapula • Biliary colic • Cholecystitis • Acute • Chronic • Cholangitis • Acute • Primary Sclerosing (PSC) • Primary Biliary Cirrhosis (PBC)

20. Overview of Biliary Disease Defn: Gallbladder inflammation • 2° cholestasis from blocked cystic duct Features • Epigastric / RUQ pain • Persists >6hrs • Usu. constant • Otherwise: colicky • Intermittent pain 2° gallbladder contractn • Quality: • Aching • Tightness • Location: • Epigastric (usually) • RUQ ± Referred pain: shoulder / scapula • Biliary colic • Cholecystitis • Acute • Chronic • Cholangitis • Acute • Primary Sclerosing (PSC) • Primary Biliary Cirrhosis (PBC)

21. Overview of Biliary Disease Defn: Infection & inflammation of CBD Features (CHARCOT’s TRIAD) • RUQ pain • Jaundice • Fever • Biliary colic • Cholecystitis • Acute • Chronic • Cholangitis • Acute • Primary Sclerosing (PSC) • Primary Biliary Cirrhosis (PBC)

22. Cholecystitis

23. Aetiology 90% ‘Calculous cholecystitis’: gallstones obstructing of cystic duct causing inflammation of gallbladder 10% ‘Acalculous cholecystitis’: inflammation of gallbladder without associated stones Bile cultures are positive for bacteria in 50-75% of cases but bacterial proliferation may be A RESULT of cholecystitis and not the precipitating factor

24. Calculous Cholecystitis: Female sex Obesity or rapid weight loss Increasing age Pregnancy (elevated progesterone levels cause biliary stasis) Drugs- especially hormonal therapy in women Acalculous Cholecystitis: Conditions associated with biliary stasis Critical illness Major surgery/severe burns or trauma Sepsis Long-term total parenteral nutrition (TPN) Prolonged fasting Risk factors

25. Clinical Presentation-History • Pain begins in epigastric region • Localizes to RUQ, radiating to the scapula/right shoulder • Pain described as colicky initially but usually becomes constant • Nausea and vomiting • Fever • History of biliary pain but differentiated from biliary colic by persistence of severe constant pain >6hours

26. Clinical Presentation-Examination • Fever, tachycardia • Tenderness in RUQ often with guarding or rebound tenderness • ‘Murphy Sign’ tenderness and inspiratory pause elicited during palpation of RUQ • Palpable gallbladder in 30-40% • Jaundice in 15%

27. Clinical Presentation • Absence of findings does not rule out cholecystitis, many present with diffuse epigastric pain without localization to RUQ • Elderly patients and patients with diabetes have often atypical presentations including absence of fever and localized tenderness with only vague symptoms

28. Ix/Dx Lab Tests • Leukocytosis • AST/ALT may be elevated in cholecystitis or common bile duct obstruction • Bilirubin and ALP are elevated in common duct obstruction, ALP is raised in 25% of cholecystitis • Amylase/Lipase used to evaluate for pancreatitis • Urinalysis used to rule out pyelonephritis and renal calculi • All females of childbearing age should undergo pregnancy testing

29. Ix/Dx Abdo Xray: • Gallstones visualized in 10-15% of cases Abdo US: • First line investigation • 90-95% sensitive and 80% specific for cholecystitis CT/MRI: • Sensitivity and specificity are >95% • Unlike ERCP, both are non-invasive but not therapeutic

30. Ix/Dx Hepatobiliary Scintigraphy (HBS): • Isotopes are taken up by hepatocytes and secreted into bile, delineating the biliary tree • If the cystic duct and gallbladder do not take up the isotope, it indicates acute cholecystitis Endoscopic Retrograde Cholangiopancreatography (ERCP): • Endoscope passed through duodenum, catheter into ampulla of Vater and contrast medium injected • Allows direct visualization of biliary tree and pancreatic ducts and can perform therapeutic interventions including stone extraction • Better for biliary obstructive jaundice

31. Ix/Dx

32. Management • Gallstones that are not symptomatic do not need treatment • Some people are able to manage mild symptoms with a combination of low fat diet and painkillers

33. Alternatives to Surgery • Dissolution Agent: Ursodeoxycholic Acid (Urdox tablets) • Medication used to dissolve the gallstones • Not effective – takes too long to dissolve gallstone and recurs post treatment cessation • Suitable gallstones • Small • Radiolucent (do not show up on xray) • Gallbladder needs to have the ability to contract • Lithotripsy: using a beam of sound energy to blast the stone • The gallbladder is diseased  blasting the stone is not treating • Fragments of the shattered stone will still need to be removed by ERCP • Commonly used for kidney stones

34. Surgery • Laparoscopic cholecystectomy • Removal of the gallbladder and gallstones together (if gallbladder left behind, likely that further stones will develop) • In under 5% of cases  convert to open surgery

35. Indications for Cholecystectomy

36. Cholecystitis • Nil orally • IV fluids • Pain relief: Pethidine • Surgery

37. Complications of surgery • General • DVT • Anaesthetic complications • Specific • Infection of the wound • Bleeding  Cystic artery • Damage to the common bile duct • Damage to abdominal visci

38. Complications: Gallbladder • Biliary colic • Colic: intermittent pain that increases in intensity and them completely disappears • In this case, the pain is PSEUDO-Colic: pain never completely disappears • Chemical cholecystitis • Laceration of gallbladder wall by a stone • Bile to leak into the submucosa  Infection

39. Empyema of the gallbladder Continued inflammation  pus  Empyema (collection of pus in organ)

40. Gangrene and necrosis • Inflammation  swelling  increase in interstitial pressure  interstitial pressure = arterial pressure (Cystic artery that supplies gallbladder)  stop in arterial flow  gangrene and necrosis of gallbladder wall • Perforation (Peritonitis) • Gangrene and necrosis of the gallbladder wall  perforation  contents seep into peritoneum  peritonitis

41. Complications: Other • Obstructive jaundice (stone in common bile duct) • Bile from the liver cannot flow into duodenum • Ascending cholangitis: inflammation of common bile duct • Liver abscess • Infection spread to the liver • Pancreatitis

42. Gallstone ileus • Impaction of a gallstone in the terminal ileum by passing through a biliary-enteric fistula (often from duodenum)

43. LFT’s

45. Normal LFTs

46. Interpreting LFTs 1 Jaundice, viral prodrome (lethargy, nausea, vague abdominal discomfort)

47. Acute hepatitis ACUTE HEPATITIS (acute inflammation) e.g. OD on paracetamol, viral hep, EBM/ CMV, autoimmune hepatitis Jaundice, viral prodrome (lethargy, nausea, vague abdominal discomfort)

48. Interpreting LFTs 2

49. Obstructive jaundice OBSTRUCTIVE JAUNDICE Pain  cholangitis (sudden dilatation) Painless  pancreatic tumour (gradual increase in pressure)

50. Interpreting LFTs 3 + Increased WCC