Pancreatitis and Pancreatitis and Gallbladder Disease Gallbladder Disease Stefan Da Silva Stefan Da Silva Jan 18 Jan 18 th th 2006 2006
Dec 28, 2015
Pancreatitis and Pancreatitis and Gallbladder DiseaseGallbladder Disease
Stefan Da SilvaStefan Da Silva
Jan 18Jan 18thth 2006 2006
PancreatitisPancreatitis
Case #1Case #1 47 yr old male with hx of chronic EtOH 47 yr old male with hx of chronic EtOH
presenting with epigastric tenderness and presenting with epigastric tenderness and vomitingvomiting
Do you:Do you: A) Ask him what his “poison” is and join in..A) Ask him what his “poison” is and join in.. B) Proceed by “scolding” him on drinking too muchB) Proceed by “scolding” him on drinking too much C) Chalk it up to EtOH induced gastritis, call the C) Chalk it up to EtOH induced gastritis, call the
drunk tank and go for coffeedrunk tank and go for coffee D) Astutely consider multiple causes of his D) Astutely consider multiple causes of his
presentation and proceed to work him up presentation and proceed to work him up
PancreatitisPancreatitis
Some backround Some backround PathophysiologyPathophysiology
Poorly understood Poorly understood thought to be direct thought to be direct cellular toxicity or increased ductal pressurecellular toxicity or increased ductal pressure
Release of inflammatory mediators may Release of inflammatory mediators may cause systemic immune response syndrome cause systemic immune response syndrome resulting in multi-organ failureresulting in multi-organ failure
PancreatitisPancreatitis
EtiologyEtiology 80% caused by gallstones (45%) or 80% caused by gallstones (45%) or
alcohol (35%)alcohol (35%) GET SMASHEDGET SMASHED
Gallstones, ethanol, tumors, scorpion bite?, Gallstones, ethanol, tumors, scorpion bite?, microbiology (bacteria, virus, parasites), autoimmune microbiology (bacteria, virus, parasites), autoimmune (SLE, PAN, Crohn’s), surgery/trauma, hyperlipidemia/ (SLE, PAN, Crohn’s), surgery/trauma, hyperlipidemia/ hypercalcemia, emboli/ischemia, drugshypercalcemia, emboli/ischemia, drugs
Also: pregnancy, liver disease, DKAAlso: pregnancy, liver disease, DKA
PancreatitisPancreatitis
Etiology con’tEtiology con’t GallstonesGallstones
Obstruction either directly (stone in Obstruction either directly (stone in pancreatic duct and CBD) or indirectly pancreatic duct and CBD) or indirectly (stone in bile duct applies transmural (stone in bile duct applies transmural pressure on pancreatic duct)pressure on pancreatic duct)
Leads to activation of pancreatic enzymes Leads to activation of pancreatic enzymes resulting in pancreatitisresulting in pancreatitis
PancreatitisPancreatitis
Etiology con’tEtiology con’t AlcoholAlcohol
Mechanism unclearMechanism unclear 5 to 10 yrs of chronic EtOH abuse before 5 to 10 yrs of chronic EtOH abuse before
onsetonset
PancreatitisPancreatitis
Etiology con’tEtiology con’t DrugsDrugs
TylenolTylenol SteroidsSteroids RanitidineRanitidine Valproic AcidValproic Acid ASAASA LasixLasix etcetc
PancreatitisPancreatitis
Clinical FeaturesClinical Features Epigastric pain (but can be diffuse)Epigastric pain (but can be diffuse) Relatively rapid onsetRelatively rapid onset Can radiate to mid-backCan radiate to mid-back Degree of pain does not correlate with Degree of pain does not correlate with
severity of diseaseseverity of disease Approx 50% of patients will have hx of Approx 50% of patients will have hx of
similar abdo pain in pastsimilar abdo pain in past
PancreatitisPancreatitis
Physical ExaminationPhysical Examination HypotensionHypotension TachycardiaTachycardia TachypneaTachypnea Low-grade feverLow-grade fever JaundiceJaundice Rales or diminshed breath soundsRales or diminshed breath sounds Cullen’s sign (blood around the umbilicus)Cullen’s sign (blood around the umbilicus) Grey Turner’s sign (discoloration of flank)Grey Turner’s sign (discoloration of flank) Rarely peritoneal findings since pancreas is Rarely peritoneal findings since pancreas is
retroperitoneal organretroperitoneal organ
PancreatitisPancreatitis
Case #2Case #2 60 yr old male complaining of epigastric 60 yr old male complaining of epigastric
pain radiating to back. Looks pale and pain radiating to back. Looks pale and diaphoretic. Diminished breath sounds. diaphoretic. Diminished breath sounds. Denies any hx of EtOH abuse.Denies any hx of EtOH abuse.
Vitals 37.8, 110, 25RR, 100/50, 90% RAVitals 37.8, 110, 25RR, 100/50, 90% RA EDE shows no AAAEDE shows no AAA Aside from initial ABCs and resusitation Aside from initial ABCs and resusitation
what lab values do you want??what lab values do you want??
PancreatitisPancreatitis
Lab TestsLab Tests Lipase/AmylaseLipase/Amylase CBCCBC LDHLDH LFTsLFTs CH6CH6 CaCa AlbuminAlbumin
PancreatitisPancreatitis
AMYLASEAMYLASE Cleaves Cleaves
carbohydratecarbohydrate Pancreas, salivary Pancreas, salivary
glands, other glands, other organsorgans
Rises in 6hrsRises in 6hrs Peaks in 48hrsPeaks in 48hrs Falls over 1weekFalls over 1week
LIPASELIPASE Hydrolyzes TGHydrolyzes TG Occurs in pancreas Occurs in pancreas
and other tissuesand other tissues Rises in 6 hrsRises in 6 hrs Peaks in 24 hrsPeaks in 24 hrs Falls over 1 - 2 Falls over 1 - 2
weeksweeks
PancreatitisPancreatitis
AMYLASEAMYLASE Sensitivity 80 - 95%Sensitivity 80 - 95% Specificity 70%Specificity 70% If 3X normal then If 3X normal then
specificity approaches specificity approaches 100% but sensitivity 100% but sensitivity decreases to 60%decreases to 60%
Can be seen elevated in Can be seen elevated in ectopic pregnancy, ectopic pregnancy, parotitis, renal failure, parotitis, renal failure, ischemic bowel, ischemic bowel, obstruction, obstruction,
LIPASELIPASE Sensitivity 80 - Sensitivity 80 -
95%95% Specificity 90%Specificity 90% 5X normal gives 60% 5X normal gives 60%
sensitivity and 100% sensitivity and 100% specificity. Generally specificity. Generally regarded that 2X normal is regarded that 2X normal is gives adequate sensitivity gives adequate sensitivity and specificity to diminish and specificity to diminish possibility of missing possibility of missing pancreatitispancreatitis
Case #2 con’tCase #2 con’t OK so you’ve ordered the labs are here are OK so you’ve ordered the labs are here are
some of the magic numberssome of the magic numbers WBC 14.00WBC 14.00 AST: 200 U/L AST: 200 U/L LDH: 400 IU/LLDH: 400 IU/L Glucose: 12Glucose: 12
You call up your friendly neighbourhood You call up your friendly neighbourhood internist you states “wow, we just admitted a internist you states “wow, we just admitted a pancreatitis 2 days ago and has a Ranson’s pancreatitis 2 days ago and has a Ranson’s Criteria of 6.” You have a medical student with Criteria of 6.” You have a medical student with you today and decide to quiz him on the you today and decide to quiz him on the “Ranson’s Criteria”. What does he say?“Ranson’s Criteria”. What does he say?
PancreatitisPancreatitis
At admission or diagnosisAt admission or diagnosis Age > 55 yearsAge > 55 years WBC > 16,000/mm3WBC > 16,000/mm3 Blood glucose > 200mg/dlBlood glucose > 200mg/dl Serum LDH > 350 IU/mlSerum LDH > 350 IU/ml AST > 250 Sigma-Frankel AST > 250 Sigma-Frankel
units/dlunits/dl
During initial 48 hoursDuring initial 48 hours Hematocrit fall > 10%Hematocrit fall > 10% BUN rise > 5 mg/dlBUN rise > 5 mg/dl Serum calcium level < 8.0Serum calcium level < 8.0
Arterial oxygen pressure < Arterial oxygen pressure < 60 mm Hg60 mm Hg
Base deficit > 4 mEq/LBase deficit > 4 mEq/L Estimated fluid sequestration Estimated fluid sequestration
> 6,000 ml> 6,000 ml
Ranson’s CriteriaRanson’s Criteria
PancreatitisPancreatitis
What do we use it for???What do we use it for??? Add total number at 48hrsAdd total number at 48hrs
> 7 then mortality is 100%> 7 then mortality is 100% 5 – 6 = 40%5 – 6 = 40% 3 – 4 = 15%3 – 4 = 15% 0 – 3 = 1%0 – 3 = 1%
May not be as accurate in pt’s with AIDS May not be as accurate in pt’s with AIDS due to HIV-induced lab changesdue to HIV-induced lab changes
Other scoring systems: APACHE-IIOther scoring systems: APACHE-II
Case #3Case #3 65 yr old male with previous gallstone 65 yr old male with previous gallstone
disease presenting with epigastric pain, disease presenting with epigastric pain, diaphoresis and low grade fever. PMH diaphoresis and low grade fever. PMH for diabetes, GERD, CAD, COPDfor diabetes, GERD, CAD, COPD
What would be a short differential What would be a short differential diagnosisdiagnosis
What, if any, imaging studies would you What, if any, imaging studies would you want to perform and why?want to perform and why?
PancreatitisPancreatitis
Radiographic studiesRadiographic studies AXRAXR
May exclude other causes of abdo pain including bowel obstruction May exclude other causes of abdo pain including bowel obstruction or perforationor perforation
CXRCXR May show pleural effusion or ARDSMay show pleural effusion or ARDS
U/SU/S Better visualization of biliary tractBetter visualization of biliary tract Recommended in 1Recommended in 1stst 24 hrs to determine if stones are the cause 24 hrs to determine if stones are the cause Insert studies!!!Insert studies!!!
CT CT Best look at pancreas, pseudocysts, hemorrhageBest look at pancreas, pseudocysts, hemorrhage Useful in ED to exclude other diagnosis of abdominal painUseful in ED to exclude other diagnosis of abdominal pain Recommended when: 1) uncertain dx 2) severe clinical Recommended when: 1) uncertain dx 2) severe clinical
pancreatitis, leukocytosis, elevated temp 3) Ranson’s score > 3 pancreatitis, leukocytosis, elevated temp 3) Ranson’s score > 3 4) APACHE score > 8 5) No improvement in 72 hrs 6) acute 4) APACHE score > 8 5) No improvement in 72 hrs 6) acute deteriorationdeterioration
Contrast does not worsen pancreatitisContrast does not worsen pancreatitis
PancreatitisPancreatitis
DDXDDX Perforated viscusPerforated viscus PUDPUD GB diseaseGB disease GastroGastro Ectopic PregnancyEctopic Pregnancy AAAAAA Bowel ObstructionBowel Obstruction Bowel IschemiaBowel Ischemia MIMI PericarditisPericarditis PneumoniaPneumonia
Case #4Case #4 You’ve got a 49 yr old female that you’ve You’ve got a 49 yr old female that you’ve
diagnosed with pancreatitis, thinking pretty diagnosed with pancreatitis, thinking pretty good about your self that you’ve made the good about your self that you’ve made the diagnosis you strut around the department diagnosis you strut around the department giving high fives. Suddenly you here a page giving high fives. Suddenly you here a page overhead asking you to go to Bed 5. You arrive overhead asking you to go to Bed 5. You arrive and see your “pancreatitis” patient in mild and see your “pancreatitis” patient in mild respiratory distress.respiratory distress.
What are the initial management options in What are the initial management options in pancreatitis?pancreatitis?
What are the complications of pancreatitis?What are the complications of pancreatitis?
PancreatitisPancreatitis
ManagementManagement Primarily supportivePrimarily supportive
Volume replacementVolume replacement Monitor vitals and urine output and lytesMonitor vitals and urine output and lytes
Pain controlPain control Narcotic analgesia (most narcotics may affect the function of the sphincter Narcotic analgesia (most narcotics may affect the function of the sphincter
of Oddi)of Oddi) NutritionNutrition
NPO in severe cases BUT recent studies have shown that pts with mild to NPO in severe cases BUT recent studies have shown that pts with mild to moderate pancreatitis have shown no benefit from fasting or NG suctionmoderate pancreatitis have shown no benefit from fasting or NG suction
NG suction only in cases of intractable vomiting and some enteral feeding NG suction only in cases of intractable vomiting and some enteral feeding should begin early (if unable then parental nutrition should be initiated)should begin early (if unable then parental nutrition should be initiated)
Complications!!!!Complications!!!! HypotensionHypotension Respiratory FailureRespiratory Failure Hyperglycemia (treat cautiously as will self-correct)Hyperglycemia (treat cautiously as will self-correct) HypocalcemiaHypocalcemia HypomagnesiumiaHypomagnesiumia
PancreatitisPancreatitis
ERCP???ERCP??? Recommended in severe obstruction pancreatitisRecommended in severe obstruction pancreatitis
MedicationsMedications H2 blockers: no evidenceH2 blockers: no evidence Antibiotics: used in severe pancreatitis and Antibiotics: used in severe pancreatitis and
resultant sepsis. Broad spectrumresultant sepsis. Broad spectrum SurgerySurgery
Indicated if necrotic, hemmorhagic, abscess Indicated if necrotic, hemmorhagic, abscess drainagedrainage
PancreatitisPancreatitis
DispositionDisposition Admission for allAdmission for all
ICU vs Medicine vs HospitalistICU vs Medicine vs Hospitalist Unpredictable course…overall mortality Unpredictable course…overall mortality
is 8%is 8%
PancreatitisPancreatitis
Chronic PancreatitisChronic Pancreatitis EtOH, EtOH, EtOH…..EtOH, EtOH, EtOH….. Supportive careSupportive care Pain controlPain control Usually lab values are not helpful, Usually lab values are not helpful,
clinical diagnosisclinical diagnosis R/O other causes of abdominal painR/O other causes of abdominal pain Can be managed as outpt.Can be managed as outpt.
Gallbladder DiseaseGallbladder Disease
Biliary ColicBiliary Colic CholecystitisCholecystitis CholangitisCholangitis Sclerosing CholangitisSclerosing Cholangitis
Gallbladder DiseaseGallbladder Disease
Case #5Case #5 45 yr old female presenting with RUQ 45 yr old female presenting with RUQ
pain episodic after eating a pain episodic after eating a cheeseburger. cheeseburger.
AfebrileAfebrile BMI 40BMI 40
Do youDo you A) Ask her where she ate her A) Ask her where she ate her
cheeseburgercheeseburger B) Give her a “pink” ladyB) Give her a “pink” lady C) Rub her belly C) Rub her belly D) Perform a thorough history and D) Perform a thorough history and
physicalphysical
Gallbladder DiseaseGallbladder Disease
Biliary ColicBiliary Colic CholelithiasisCholelithiasis
2 categories of stones2 categories of stones Cholesterol stonesCholesterol stones
From elevated concentration of cholesterol in the From elevated concentration of cholesterol in the bilebile
Risk factors: age, gender, weight, CF, drugs, FHRisk factors: age, gender, weight, CF, drugs, FH Pigmented stonesPigmented stones
2 types: Black and Brown (assoc with infection)2 types: Black and Brown (assoc with infection) Both contain calcium bilirubinateBoth contain calcium bilirubinate
Point of Interest Point of Interest for a stone to be radiopaque it for a stone to be radiopaque it must contain at least 4% calcium by wt.must contain at least 4% calcium by wt.
GallBladder DiseaseGallBladder Disease
Biliary ColicBiliary Colic PresentationPresentation
Colic is a misnomer as pain is steady but not Colic is a misnomer as pain is steady but not usually greater than 6 hrs.usually greater than 6 hrs.
Radiation of pain to base of scapula or Radiation of pain to base of scapula or shouldershoulder
N + VN + V Relationship to eatingRelationship to eating
Gallbladder DiseaseGallbladder Disease
Biliary ColicBiliary Colic Physical ExamPhysical Exam
Vitals: tachy (from pain or dehydration)Vitals: tachy (from pain or dehydration) Abdomen: RUQ tenderness but no guarding Abdomen: RUQ tenderness but no guarding
or reboundor rebound
Gallbladder DiseaseGallbladder Disease
Biliary ColicBiliary Colic Lab TestsLab Tests
ALT and AST to evaluate for evidence of hepatitisALT and AST to evaluate for evidence of hepatitis Bilirubin and ALP to evaluate for evidence of Bilirubin and ALP to evaluate for evidence of
obstruction of CBDobstruction of CBD Amylase/Lipase to evaluate for pancreatitisAmylase/Lipase to evaluate for pancreatitis
ImagingImaging U/SU/S
Ensure to r/o any cardiopulmonary Ensure to r/o any cardiopulmonary pathologypathology
Gallbladder DiseaseGallbladder Disease
Biliary ColicBiliary Colic ManagementManagement
Correct any fluid/lyte imbalancesCorrect any fluid/lyte imbalances Symptomatic treatmentSymptomatic treatment
Pain controlPain control Definitive management is surgeryDefinitive management is surgery Admission for refractory pain and Admission for refractory pain and
dehydrationdehydration
Gallbladder DiseaseGallbladder Disease
CholecystitisCholecystitis Sudden inflammation of gallbladderSudden inflammation of gallbladder Similar risk factors as for gallstonesSimilar risk factors as for gallstones
4 F’s: fat, female, forty, fertile4 F’s: fat, female, forty, fertile Result of cystic duct obstructionResult of cystic duct obstruction 95% of patients with cholecystitis will 95% of patients with cholecystitis will
have a gallstone (usually in CBD in pt’s have a gallstone (usually in CBD in pt’s with acalculous cholecystitis)with acalculous cholecystitis)
Acalculous cholecystitis 2 – 12%Acalculous cholecystitis 2 – 12%
Gallbladder DiseaseGallbladder Disease
What happens???What happens??? Obstruction of cystic duct leads to filling Obstruction of cystic duct leads to filling
and distention of GB and distention of GB inflammation inflammation and wall ischemia due to increased and wall ischemia due to increased pressure and/or cytotoxic products of pressure and/or cytotoxic products of bile metabolismbile metabolism
Bacteria in 50 – 75% of casesBacteria in 50 – 75% of cases E.coli, enterococcus, Klebsiella, ProteusE.coli, enterococcus, Klebsiella, Proteus
Gallbladder DiseaseGallbladder Disease
PresentationPresentation Right upper quadrant painRight upper quadrant pain Constant with radiation to tip of scapulaConstant with radiation to tip of scapula N + VN + V Murphy’s sign (tenderness and inspiratory Murphy’s sign (tenderness and inspiratory
pause with palpable of RUQ during deep pause with palpable of RUQ during deep breath) breath) not specific but > 95% not specific but > 95% sensitive (much less in elderly pt though)sensitive (much less in elderly pt though)
Not always febrileNot always febrile
Gallbladder DiseaseGallbladder Disease
Lab ValuesLab Values Leukocytosis with shift (however normal Leukocytosis with shift (however normal
WBC in up to 40 % of pts)WBC in up to 40 % of pts) ALT, AST, Bili, ALP can be mildly ALT, AST, Bili, ALP can be mildly
elevated or normalelevated or normal U/S is still best diagnostic toolU/S is still best diagnostic tool
Presence of stones, thickened wall, and Presence of stones, thickened wall, and pericholecystic fluid has PPV > 90%pericholecystic fluid has PPV > 90%
No stones No stones NPV ~ 90% NPV ~ 90%
GallBladder DiseaseGallBladder Disease
DDXDDX HepatitisHepatitis PancreatitisPancreatitis PyleoPyleo Hepatic AbscessHepatic Abscess RLL pneumoniaRLL pneumonia PUDPUD
Gallbladder DiseaseGallbladder Disease
ManagementManagement Supportive Supportive
Fluids, pain control, anti-emeticsFluids, pain control, anti-emetics AntibioticsAntibiotics
Rosen’s states unless septic then 2Rosen’s states unless septic then 2ndnd or 3 or 3rdrd generation cephalosporin adequategeneration cephalosporin adequate
Sanford’s states Pip/Taz or 3rd generation Sanford’s states Pip/Taz or 3rd generation cephalosporin plus flagyl and if septic then cephalosporin plus flagyl and if septic then imepenimimepenim
Gallbladder DiseaseGallbladder Disease
Heads Up!!Heads Up!! Most serious complication of Most serious complication of
cholecystitis is gangrene of gallbadder cholecystitis is gangrene of gallbadder leads to perforation and sick patients leads to perforation and sick patients
Diabetic pts more prone to development Diabetic pts more prone to development of emphysematous gallbladder due to of emphysematous gallbladder due to increased risk of bacterial seeding of GB increased risk of bacterial seeding of GB wallwall
Gallbladder DiseaseGallbladder Disease
So the patient has cholecystitis….So the patient has cholecystitis…. Admit to gen surgAdmit to gen surg AntibioticsAntibiotics NPONPO FluidsFluids Some surgeons may choose to wait until Some surgeons may choose to wait until
GB isn’t as “hot” to do surgeryGB isn’t as “hot” to do surgery
Gallbladder DiseaseGallbladder Disease
Acalculous CholecystitisAcalculous Cholecystitis 5 – 15%5 – 15% Elderly, pt’s recovering from nonbiliary Elderly, pt’s recovering from nonbiliary
tract surgery, HIV pt’stract surgery, HIV pt’s Worse with mortality approaching 40%Worse with mortality approaching 40%
Gallbladder DiseaseGallbladder Disease
Emphysematous CholecystitisEmphysematous Cholecystitis Gas in GB wallGas in GB wall More common in diabeticsMore common in diabetics Gas producing organisms (e.coli, Kleb, Gas producing organisms (e.coli, Kleb,
Clost)Clost) 50% of time acalculous50% of time acalculous High incidence of necrosis and gangreneHigh incidence of necrosis and gangrene Mortality approx. 15%Mortality approx. 15%
Case #6Case #6 65 yr old female with fever, RUQ pain, 65 yr old female with fever, RUQ pain,
confusion and jaundiceconfusion and jaundice Vitals 40.5, 110HR, 26RR, 80/50, Vitals 40.5, 110HR, 26RR, 80/50,
glucose 12.0glucose 12.0 What do you think?What do you think?
Gallbladder DiseaseGallbladder Disease
CholangitisCholangitis 3 things needed3 things needed
ObstructionObstruction Increased intraluminal pressureIncreased intraluminal pressure Bacteria infectionBacteria infection
E.coli, Klebsiella, EnterococcusE.coli, Klebsiella, Enterococcus
Gallbladder DiseaseGallbladder Disease
PresentationPresentation Charcot’s TriadCharcot’s Triad
RUQ pain, fever, jaundiceRUQ pain, fever, jaundice Not specificNot specific
Reynold’s PentadReynold’s Pentad RUQ pain, fever, jaundice, sepsis, confusionRUQ pain, fever, jaundice, sepsis, confusion
Gallbladder DiseaseGallbladder Disease
Lab ValuesLab Values LeukocytosisLeukocytosis Elevated bili, ALPElevated bili, ALP Mod. Elevated ALT, ASTMod. Elevated ALT, AST
ImagingImaging U/S U/S usually shows dilated common usually shows dilated common
and intrahepatic ductsand intrahepatic ducts
Gallbladder DiseaseGallbladder Disease
TreatmentTreatment Supportive careSupportive care Broad-spectrum abxBroad-spectrum abx Early biliary tract decompressionEarly biliary tract decompression
Either with ERCP or surgeryEither with ERCP or surgery
Gallbladder DiseaseGallbladder Disease
Sclerosing CholangitisSclerosing Cholangitis Idiopathic inflammatory disorder affecting the Idiopathic inflammatory disorder affecting the
biliary treebiliary tree Fibrosis and narrowing of both intra and extra Fibrosis and narrowing of both intra and extra
hepatic bile ductshepatic bile ducts Assoc with UCAssoc with UC Rarely develop infectious cholangitisRarely develop infectious cholangitis Sx of lethargy, wt loss, jaundice, puritusSx of lethargy, wt loss, jaundice, puritus ERCP helpful in diagnosisERCP helpful in diagnosis Management primarily symptomaticManagement primarily symptomatic