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Pancreas and hepatobiliary disorders

Pancreas and hepatobiliary disorders. Feb 12 2004 Andrea Wilson. Case 1 (emedhome.com). 28 yo male “ulcer pain acting up”. Has a known peptic ulcer. Epigastric tenderness intermittent x 2 days not relieved with antacids No rebound or guarding. Normal rectal. Busy shift

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Pancreas and hepatobiliary disorders

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  1. Pancreas and hepatobiliary disorders Feb 12 2004 Andrea Wilson

  2. Case 1 (emedhome.com) • 28 yo male • “ulcer pain acting up”. Has a known peptic ulcer. • Epigastric tenderness intermittent x 2 days not relieved with antacids • No rebound or guarding. Normal rectal. • Busy shift • Pt felt better after demerol and wanted to go home.

  3. Grey-Turner’s sign • associated with hemorrhagic pancreatitis. • However, this sign develops in <3% of patients with acute pancreatitis • retroperitoneal hemorrhage, splenic rupture, ruptured aortic aneurysm, and ectopic pregnancy. • blood along fascial planes and cause ecchymoses over the flanks. (lateral edge of the quadratus lumbrum muscle)

  4. Acute Pancreatitis • Up to 80% of pts will have uneventful recovery • Ranson’s criteria correlate with risk of major complications and death • Overall mortality ranges from 7-20%

  5. At admission or diagnosis Age > 55 years WBC > 16,000/mm3 Blood glucose > 200mg/dl Serum LDH > 350 IU/ml SGOT > 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 Ranson’s criteria

  6. So… • Hypotension, • tachycardia >130, • PO2 <60, • oliguria, • increasing BUN/Cr • and hypocalcemia • = BAD

  7. Pancreatitis • Obstruction of ampulla with reflux of bile into pancreatic duct then activation of digestive enzymes and autodigestion of the pancreas • Gallstones + Etoh = >70%

  8. Other causes • 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

  9. Symptoms Sharp epigastric pain Radiates to back Improves leaning frwd N&V Pain referred to RUQ or LUQ Aggravated by eating Signs Jaundice Tachycardia (pain or volume depletion) Fever Grey Turner’s -flank Cullen’s – umbil (neither specific) Acute pancreatitis

  10. Amylase – If 3x N then 80-90%sens , 75% spec may return to normal within 24 hrs of pain onset Fallopian tubes, ovaries, testes, adipose tissue, small bowel, lung, thyroid, sk muscle, neoplasms Lipase 90% sens and specific Remain elevated for several days after pain onset (7-14 ) Diagnostic evaluation

  11. What else would you order? • AXR – calcification of the pancreas or gallstones if calcified, free air, ileus, colon “cut-off” if transverse colon involved • CXR – atelectasis, effusion • U/S and CT if further evaluation needed – diffusely enlarged pancreas, dilated CBD • CT negative in 30% of mild pancreatitis

  12. Complications • Phlegmon 18% - • Pancreatic abscess 3% • Pancreatic pseudocyst 10% • Ascites • Thrombosis of the central portal system • Shock, ARDS and MSOF • Profound metabolic disturbances including hyperglycemia and hypocalcemia

  13. Management • 1) hemodyanmic stabilization • 2) allevation of pain • 3) stop progression of damage • 4) tx of local and systemic complications • Admit • NPO, IV analgesics, NG if emesis/ileus • Aminoglycoside or cephalosporin if deterioration suggests abscess

  14. Chronic Pancreatitis • Fibrosis, ductal abnormality, calcification and cellular atrophy • Leads to chronic pancreatic insufficiency and chronic pain. • Autodigestion from pancreatic digestive enzymes + other vasoactive substances causing chemical irritation ->edema – hemorrhage/necrosis

  15. Chronic pancreatitis • ALCOHOL • DM, protein-calorie malnutrition, hereditary pancreatitis, cystic fibrosis, hyperparathyroidism, pancreas divisum • Pseudocyst, ascites, CBD stricture • If>90% exocrine function lost then trouble! • Steatorrhea (fat), azotorrhea (protein), progressive weight loss.

  16. Case 2 • 56 yo male • new onset diabetes • Dull epigastric pain worse at hs • 10 lb weight loss in past 6 months • Mildly jaundiced • ?palpable gallbladder • No Murphy’s

  17. Pancreatic cancer • Males: females 2:1 • 6 month survival • Usually ductal cell adenocarcinoma and usually in the head of the pancreas • Smoking, high fat/protein diet, DM, DDT exposure • Courvoisier’s law

  18. 4 main gallstone problems • Symptomatic cholelithiasis (biliary colic) • Cholecystitis • Cholangitis • Pancreatitis

  19. Back to med school… • Bile needed for absorption of fats and fat soluble nutrients from small intestine • Imbalance of chol + solubilizing agents • 70% of gallstones are >70% cholesterol (radiolucent) • 20% are pigment stones bc of abnormal solubility of unconjugated bilirubin with the precipitation of calcium salts • 10% mixed

  20. Gallstone risk factors • Cholesterol – female, 20-40, pregnant/OCP, parity, obsesity/ profound weight loss, TPN, fam hx, C.F., Crohn’s, clofibrate, ceftriaxone, Pima indians • (fat, female, forty, fertile, ethnic, estrogen, diet, drugs) • Pigment stones – Asian, chronic biliary tract infection, chronic liver disease, intravasc hemolysis (sickle cell or spherocytosis)

  21. Protective factors • ascorbic acid (?increased cholesterol catabolism) • coffee (3-4 cups/day 40% less likely to develop gallstones) Yeah!

  22. Biliary colic • Stone lodged in cystic or CBD -> inc in intraluminal pressure/ distention -> N&V& pain (15%) • Usually constant (not colic) but <6 hrs • Epig or RUQ dull/visceral pain with radiation to R post shoulder + N&V • Eating after fasting or fatty meal • May have post-attack soreness for 1-2 days

  23. Cholecystitis • If obstruction persists – inflammation +/- infection of gallbladder wall • May develop gangrene +/- perf -> more localized pain/ peritonitis • More parietal pain • Murphy’s sign (97% sens, only 48% in elderly) • May have fever/chills

  24. Acalculous cholecystitis • 5-10% of cholecystitis • Elderly + DM + immunosuppressed ( trauma, burn, labor, surgery, vasculitis, gallbladder torsion, parasitic or bacterial infections of the biliary tract.) • Do worse

  25. Investigations • CBC (but WBC may be Normal) ? Low Hb • Lipase +/- liver function tests (may be normal) • U/S sensitivity >95% for stones > 2mm, spec 78% • False neg and pos rates 2-4% may miss cholecystitis • Emergency physician U/S • HIDA/DISIDA best for cholecystitis sensitivity almost 100%, spec 90% but start with U/S • 12 lead ECG, U/A, preg test, AXR, CXR

  26. DDx • Gastritis, PUD, hepatitis, hepatic abscess, intraabd abscess, ischemic gut, Fitz-Hugh-Curtis syndrome (GC or Chlamydial perihepatitis), pancreatitis, GERD, Appendicitis • Renal colic, pyelonephritis • Pneumonia, acute MI, • PID +/- TOA, ectopic pregnancy

  27. Bactobilia • 35-65% of pts with cholecystitis • E. coli or Klebsiella in 70% • Also Enterococcus, Bacteroides, Clostridium, GDS, Staph • For non-septic: third generation cephalosporin • Septic: amp, gent and clinda

  28. Cholangitis • Complete obstruction + bacteria = cholangitis • Backup into lymphatic vessels and hepatic veins • High mortality rate • Stone, stricture, Ca • Increased ALP, GGT, bili (late) +/- AST, ALT • E. coli, Klebsiella, Pseudomonas

  29. Triads and pentads • 25% Charcot’s triad • Fever jaundice, RUQ pain • Reynold’s pentad • Altered LOC, distributive shock

  30. Cholangitis management EMR Aug 12 , 2002 • Volume resuscitation +/- vasopressors • Broad-spectrum antibiotics • Surgery or endoscopic decompression

  31. Weird and wonderful • Gallbladder empyema • Emphysematous (gangrenous) cholecystitis (1% of cholecystitis) • Hydrops= mucous accumulation in gallbladder due to cystic duct obstruction • Gangrene perforation • Cholecystoenteric fistula (repeated attacks) • Gallstone ileus – cholecystoenteric connection with impacted stone at ileocecal valve, pneumobilia

  32. Management • Urgent biliary decompression for pts in extremis or with clinical deterioration • Consider operating if porcelain gallbladder (15-20% assoc Ca) , DM, hx of biliary pancreatitis • Demerol vs morphine, antiemetics • Admit, hydrate, antibiotics (even though questionable in cholecystitis)

  33. What about ERCP? • Severe pancreatitis, continuing biliary colic, cholangitis, obstructive jaundice, stones in CBD or CBD dilation • Ultimately endoscopic sphincterotomy and stone extraction followed by laparoscopic cholecystectomy is preferred tx for choledocholithiasis.

  34. Cholecystectomy • Best management for • Frequent or severe attacks • Hx of gallstone complications • Stones over 2 cm • Congenitally abnormal hepatobiliary system, • +/- DM

  35. Discharge home if: • Resolution of symptoms (4-6 hrs) • Correction of intravascular volume deficits • Restored ability to drink • Give them analgesics • Keep if high risk with CBD stones or if pregnant

  36. Then what? • Asymptomatic gallstones develop complications • 10% at 5 yrs • 15% at 10 yrs • 18% at 15-20 yrs • Close observation even for most diabetic patients

  37. Primary biliary cirrhosis • Autoimmune associations • Antimitochondrial antibody in >90% • Not fully understood. Necrotizing inflammation leading to bile duct fibrosis • Often detected by elevated ALP on routine screening • Women, age 35-60, pruritus, fatigue, jaundice, hyperpigmentation, eventual cirrhosis • Biopsy, colchicine, methotrexate/cyclosporine, ursodiol, transplant

  38. Secondary biliary cirrhosis • Postop strictures/ gallstones • Usually with superimposed infectious cholangitis • Congenital biliary atresia, CF, choledochal cysts • Signs and symptoms like PBC but also intermittent bouts of colic/cholangitis • AMA negative • Suspect if bile flow obstruction, especially postop

  39. Sclerosing cholangitis • Affects extrahepatic +/- intrahepatic • On ERCP see thickened ducts with narrow, beaded lumina • Often associated with IBD, fibrosing conditions, AIDS • Cholestyramine for pruritus, transplant • Age, bili, histologic stage and splenomegaly predict survival

  40. What should I remember • Pancreatitis – get smashed • Biliary colic - <6 hrs • Cholecystitis – usually antibiotics, consider acaculous cholecystitis • Weird and wonderful complications • When to discharge colic

  41. References • Cholangiography and Pancreatography, by M. Ohta, et al., Eds. Igaku-Shoin Ltd., Tokyo, University Park Press, Baltimore, 1978 • Emergency Medicine. Tintinalli, Kelen, Stapczynski. • Emergency Medicine Reports – Presentation and mangement of Acute biliary Tract Disorders in the Emergency Department – optimizing Assessment and Treatment of Cholelithiasis and cholecystitis Aug 12 2002 • Harrison’s principles of Internal Medicine 14th edition 1984 • http://www.bupa.co.uk/health_information/html/organ/liver.html • Presentation by Rob Hall 2002 • Thomson, A.B.R., Shaffer E.A First Principles of Gastroenterology. 1997 • www.emedhome.com

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