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Pancreatitis and Gallbladder Disease Stefan Da Silva Jan 18th 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 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 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 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 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 Pancreatitis Etiology con’t Alcohol Mechanism unclear 5 to 10 yrs of chronic EtOH abuse before onset Pancreatitis Etiology con’t Drugs Tylenol Steroids Ranitidine Valproic Acid ASA Lasix etc 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 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 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?? Pancreatitis Lab Tests Lipase/Amylase CBC LDH LFTs CH6 Ca Albumin 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 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 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? Pancreatitis Ranson’s Criteria 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 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 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? 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 Pancreatitis DDX Perforated viscus PUD GB disease Gastro Ectopic Pregnancy AAA Bowel Obstruction Bowel Ischemia MI Pericarditis Pneumonia 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? Pancreatitis Management Primarily supportive Volume replacement Pain control Narcotic analgesia (most narcotics may affect the function of the sphincter of Oddi) Nutrition 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!!!! Hypotension Respiratory Failure Hyperglycemia (treat cautiously as will self-correct) Hypocalcemia Hypomagnesiumia Pancreatitis ERCP??? Medications Recommended in severe obstruction pancreatitis H2 blockers: no evidence Antibiotics: used in severe pancreatitis and resultant sepsis. Broad spectrum Surgery Indicated if necrotic, hemmorhagic, abscess drainage Pancreatitis Disposition Admission for all ICU vs Medicine vs Hospitalist Unpredictable course…overall mortality is 8% 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. Gallbladder Disease Biliary Colic Cholecystitis Cholangitis Sclerosing Cholangitis Gallbladder Disease Case #5 45 yr old female presenting with RUQ pain episodic after eating a cheeseburger. Afebrile BMI 40 Do you 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 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. 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 Gallbladder Disease Biliary Colic Physical Exam Vitals: tachy (from pain or dehydration) Abdomen: RUQ tenderness but no guarding or rebound 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 Gallbladder Disease Biliary Colic Management Correct any fluid/lyte imbalances Symptomatic treatment Pain control Definitive management is surgery Admission for refractory pain and dehydration 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% 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 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 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% GallBladder Disease DDX Hepatitis Pancreatitis Pyleo Hepatic Abscess RLL pneumonia PUD 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 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 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 Gallbladder Disease Acalculous Cholecystitis 5 – 15% Elderly, pt’s recovering from nonbiliary tract surgery, HIV pt’s Worse with mortality approaching 40% 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% 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? Gallbladder Disease Cholangitis 3 things needed Obstruction Increased intraluminal pressure Bacteria infection E.coli, Klebsiella, Enterococcus Gallbladder Disease Presentation Charcot’s Triad RUQ pain, fever, jaundice Not specific Reynold’s Pentad RUQ pain, fever, jaundice, sepsis, confusion Gallbladder Disease Lab Values Leukocytosis Elevated bili, ALP Mod. Elevated ALT, AST Imaging U/S usually shows dilated common and intrahepatic ducts Gallbladder Disease Treatment Supportive care Broad-spectrum abx Early biliary tract decompression Either with ERCP or surgery 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