Clinical Radiological Conference:Clinical Radiological Conference:

Non-Neoplastic Biliary and Pancreatic DiseasesNon-Neoplastic Biliary and Pancreatic Diseases

Paul James, MD MScPaul James, MD MSc

Wael Shabana, MDWael Shabana, MD

September 22rd, 2015

ObjectivesObjectivesEtiology, risk factors and clinical presentation for:Etiology, risk factors and clinical presentation for:

1. Gallstone disease1. Gallstone disease CholecystitisCholecystitis

Choledocholithiasis Choledocholithiasis CholangitisCholangitis

2. Acute pancreatitis2. Acute pancreatitis

3. Chronic pancreatitis3. Chronic pancreatitis

Case 1Case 1

A 46 year old female presents to ER @ 2 am with several A 46 year old female presents to ER @ 2 am with several hours of severe upper abdominal pain, nausea, vomiting, hours of severe upper abdominal pain, nausea, vomiting, chills and chills. Her pain and nausea gets worse with chills and chills. Her pain and nausea gets worse with meals.meals.

On examination: She is unwell and in pain. BMI 29.On examination: She is unwell and in pain. BMI 29.

Vitals: HR 112, Bpm, BP 150/86, T 38.2, OVitals: HR 112, Bpm, BP 150/86, T 38.2, O22 96% 96%

Abdo: 8/10, sharp, epigastric and right upper quadrant Abdo: 8/10, sharp, epigastric and right upper quadrant tenderness on palpation.tenderness on palpation.

Clinical case—contd.Clinical case—contd.

Hb 132Hb 132 WBC 16WBC 16

Plts 425Plts 425 Cr 115Cr 115

INR 1.1INR 1.1 Electrolytes normal.Electrolytes normal.

Q: What is your differential diagnosis?Q: What is your differential diagnosis?

Q: What other information do you require to Q: What other information do you require to help you with a diagnosis?help you with a diagnosis?

Clinical case—contd.Clinical case—contd.

Bilirubin 35Bilirubin 35 (Nr <20)(Nr <20)

AST 60AST 60 (Nr <30)(Nr <30)

ALT 55ALT 55 (Nr <30)(Nr <30)

ALP 190ALP 190 (Nr <120)(Nr <120)

Lipase 25Lipase 25 (Nr <30)(Nr <30)

RadiologyRadiology

In a patient with RUQ pain and clinical findings indicating possible gallstone disease, what is the best first imaging test to confirm the diagnosis?

a)Computed tomography (CT) scan of the abdomen

b)Magnetic Resonance Cholangiopancreatography (MRCP)

c)Abdominal Ultrasound (US)

d)Hepatobiliary scintigraphy with 99mTcIDA (HIDA scan)

e)Endoscopic Retrograde Cholangiopancreatography (ERCP)

Answer: Abdominal Ultrasound

1. Ultrasound uses sound waves (no radiation) and is a excellent test for acute cholecystitis. High specificity for CBD stones as well.

2. It is inexpensive and broadly available.3. US permits the diagnosis of other causes of RUQ and

appropriate triage of patients to investigations or management in many cases.

Limitations: a. Operator-dependentb. < 75% sensitivity for CBD stones = can miss a CBD stone in 1 in 4

cases.

Case 1Case 1

Ultrasound shows…Ultrasound shows…

2 common bile duct stones

Radiology

Ultrasound: cholecystitisUltrasound: cholecystitis

Points for considerationPoints for consideration

• Plain abdominal radiography has no place in suspected Plain abdominal radiography has no place in suspected acute cholecystitisacute cholecystitis

• Ultrasound is highly accurate in the diagnosis of acute Ultrasound is highly accurate in the diagnosis of acute cholecystitis, particularly if the signs of gallbladder wall cholecystitis, particularly if the signs of gallbladder wall thickening/oedema, pericholecystic fluid, gallstones and thickening/oedema, pericholecystic fluid, gallstones and positive ultrasonic Murphy's sign are all presentpositive ultrasonic Murphy's sign are all present

• Negative or technically unsatisfactory ultrasound with Negative or technically unsatisfactory ultrasound with continuing high clinical suspicion of acute cholecystitis continuing high clinical suspicion of acute cholecystitis should be followed by Tc-HIDA nuclear medicine scanshould be followed by Tc-HIDA nuclear medicine scan

Radiology

Points for considerationPoints for consideration

• Ultrasound is the first imaging modality used in the algorithm for the Ultrasound is the first imaging modality used in the algorithm for the investigation of cholestatic jaundice.investigation of cholestatic jaundice.

• Further imaging depends on whether the bile ducts are dilated.Further imaging depends on whether the bile ducts are dilated.• If the bile ducts are dilated and an ultrasound fails to demonstrate a If the bile ducts are dilated and an ultrasound fails to demonstrate a

cause, further imaging depends on a provisional clinical diagnosis. cause, further imaging depends on a provisional clinical diagnosis. Investigations may the include CT scan of the abdomen, CT Investigations may the include CT scan of the abdomen, CT cholangiogram, Magnetic Resonance Cholangiopancreatography cholangiogram, Magnetic Resonance Cholangiopancreatography (MRCP) and Endoscopic US (EUS).(MRCP) and Endoscopic US (EUS).

• If the bile ducts are not dilated, hepatocellular causes of jaundice If the bile ducts are not dilated, hepatocellular causes of jaundice should be excluded prior to further imaging.should be excluded prior to further imaging.

• Endoscopic Retrograde Cholangiopancreatography (ERCP) is Endoscopic Retrograde Cholangiopancreatography (ERCP) is reserved for therapeutic indications or if there remains ongoing reserved for therapeutic indications or if there remains ongoing clinical doubt with non-diagnostic imaging studies.clinical doubt with non-diagnostic imaging studies.

Radiology

MRCP: CBD StoneMRCP: CBD Stone

MRCP: CBD StoneMRCP: CBD Stone

MRCP: CBD StoneMRCP: CBD Stone

HIDA scanHIDA scan

Radiology

Case presentation (contd)Case presentation (contd)ImpressionImpression: :

Obstructing CBD stones, fever and elevated WBCs = Acute Obstructing CBD stones, fever and elevated WBCs = Acute cholangitis ± cholecystitis.cholangitis ± cholecystitis.

PlanPlan::

1.1. ABCs, IV fluid resuscitation.ABCs, IV fluid resuscitation.

2.2. Admit to hospital.Admit to hospital.

3.3. Blood cultures and repeat labs daily.Blood cultures and repeat labs daily.

4.4. IV antibiotics to cover gram – organism.IV antibiotics to cover gram – organism.

5. Arrange from non-invasive stone extraction = ERCP.5. Arrange from non-invasive stone extraction = ERCP.

A What? ERCPA What? ERCP

Common bile duct stones

Summary: Acute cholangitisSummary: Acute cholangitis

• Prompt clinical recognitionPrompt clinical recognition• Labwork and imaging for diagnosisLabwork and imaging for diagnosis

• Confirm presence of CBD stonesConfirm presence of CBD stones

• Stabilise and start antibioticsStabilise and start antibiotics• Definitive therapy is therapeutic ERCPDefinitive therapy is therapeutic ERCP

Case 2Case 2

56 year old male presents to ER with acute 56 year old male presents to ER with acute sharp epigastric pain radiating to his back. sharp epigastric pain radiating to his back. Nausea and vomiting. Also notes dark Nausea and vomiting. Also notes dark urine and pale stools. No chills.urine and pale stools. No chills.

Q: What is your initial clinical impression?Q: What is your initial clinical impression?

Case presentationCase presentation

Hb 160Hb 160 WBC 18WBC 18 Plts 450Plts 450

Bilirubin 93Bilirubin 93 (Nr <20)(Nr <20)

AST 300AST 300 (Nr <30)(Nr <30)

ALT 282ALT 282 (Nr <30)(Nr <30)

ALP 310ALP 310 (Nr <120)(Nr <120)

Lipase 1,600Lipase 1,600 (Nr <30)(Nr <30)

Q: Now what do you think?Q: Now what do you think?

Q: What is the next step in diagnosis?Q: What is the next step in diagnosis?

Acute PancreatitisAcute Pancreatitis

Diagnosis – AmylaseDiagnosis – Amylase

• Elevates within HOURS and can remain Elevates within HOURS and can remain elevated for 4-5 dayselevated for 4-5 days

• High specificity when using levels >3x normalHigh specificity when using levels >3x normal• Many false positivesMany false positives• Most specific = pancreatic isoamylase Most specific = pancreatic isoamylase

(fractionated amylase)(fractionated amylase)

Diagnosis – Amylase ElevationDiagnosis – Amylase Elevation

• Pancreatic SourcePancreatic Source– Biliary obstructionBiliary obstruction– Bowel obstructionBowel obstruction– Perforated ulcerPerforated ulcer– AppendicitisAppendicitis– Mesenteric ischemiaMesenteric ischemia– PeritonitisPeritonitis

• SalivarySalivary– ParotitisParotitis– DKADKA– AnorexiaAnorexia– Fallopian tubeFallopian tube– MalignanciesMalignancies

• Unknown SourceUnknown Source– Renal failureRenal failure– Head traumaHead trauma– BurnsBurns– PostoperativePostoperative

Diagnosis – LipaseDiagnosis – Lipase

• The preferred test for diagnosisThe preferred test for diagnosis• Begins to increase 4-8H after onset of symptoms Begins to increase 4-8H after onset of symptoms

and peaks at 24Hand peaks at 24H• Remains elevated for daysRemains elevated for days• Sensitivity 86-100% and Specificity 60-99%Sensitivity 86-100% and Specificity 60-99%• >3X normal S&S ~100%>3X normal S&S ~100%

Causes of Acute PancreatitisCauses of Acute Pancreatitis

EtiologiesEtiologies– IIdiopathicdiopathic– GGallstones (or other allstones (or other

obstructive lesions)obstructive lesions)– EEtOH tOH – TTraumarauma– SSteroidsteroids– MMumps (& other umps (& other

viruses: CMV, EBV)viruses: CMV, EBV)– AAutoimmune (SLE, utoimmune (SLE,

polyarteritis nodosa)polyarteritis nodosa)

– SScorpion stingcorpion sting– HHyper Ca, TG yper Ca, TG – EERCPRCP– DDrugs (thiazides, rugs (thiazides,

sulfonamides, ACE-I, sulfonamides, ACE-I, NSAIDS, azathioprine)NSAIDS, azathioprine)

EtOH and gallstones EtOH and gallstones account for 60-70% account for 60-70% of casesof cases

PrognosisPrognosis

Many different scoring systems

-Ranson (most popular)

-APACHE II

-CT severity IndexLimited clinical application

PrognosisPrognosis

5% with <2 signs20% with 3-5 signs60% with 6-8 signs>75% with >8 signs

CT scan of the abdomenCT scan of the abdomen

CT scan of the abdomenCT scan of the abdomen

CT scan of the abdomenCT scan of the abdomen

Role of Imaging in acute pancreatitisRole of Imaging in acute pancreatitis

• Exclude an underlying cause (eg gallstones)Exclude an underlying cause (eg gallstones)• Detect complicationsDetect complications• Guide the management of complications Guide the management of complications

(eg fluid collection drainage)(eg fluid collection drainage)

Radiology

US and CT in pancreatitisUS and CT in pancreatitis

• Ultrasound: – To help determine aetiology of pancreatitis

Assess for gallstone-induced pancreatitis

Assess bile duct if abnormal liver function

• CT SCAN - Routine CT scan is NOT indicated• Indications for CT scan include:

– Where diagnosis is in doubt– Clinically severe cases to assess degree of pancreatic

necrosis– Failure to improve or sudden deterioration– Imaging complications of pancreatitis

Radiology

Radiology

ManagementManagement

1.1. Remove offending agentRemove offending agent

2.2. Supportive careSupportive care

3.3. Monitor for complicationsMonitor for complications

Supportive CareSupportive Care

• NPO to clear fluid diet as toleratedNPO to clear fluid diet as tolerated

• IV fluid and electrolyte replacementIV fluid and electrolyte replacement

• AnalgesiaAnalgesia

• Nutritional supportNutritional support

When To Consider AntibioticsWhen To Consider Antibiotics

• CholangitisCholangitis

• Infected necrosisInfected necrosis

• AbscessAbscess

• Infected pseudocystInfected pseudocyst

Note: Note:

In each of these cases, an intervention is In each of these cases, an intervention is required to address the infection source.required to address the infection source.

Case 3Case 365 year old male with years of epigastric pain radiating through to the 65 year old male with years of epigastric pain radiating through to the

back—aggravated by food and relieved by tylenol with codeine. back—aggravated by food and relieved by tylenol with codeine. Antacids do not help. Antacids do not help.

Over the past 6 months:Over the past 6 months:Lost 8 Kg in weight over 2 years. Lost 8 Kg in weight over 2 years. Feels bloated.Feels bloated.4-8 loose pale stools per day.4-8 loose pale stools per day.

Smoking: 40 pack-yearsSmoking: 40 pack-yearsAlcohol: Over 20 standard drinks/ week. Rye.Alcohol: Over 20 standard drinks/ week. Rye.

Physical examination: Thin, 135lbs. BMI 21. Physical examination: Thin, 135lbs. BMI 21. No icterus. Epigastric tenderness. Otherwise normal.No icterus. Epigastric tenderness. Otherwise normal.

Case 3.Case 3.

Q: What is your clinical impression?Q: What is your clinical impression?

Q: Where is the pain from?Q: Where is the pain from?

Q: Why is there weight loss?Q: Why is there weight loss?

Q: Why is alcohol intake important ?Q: Why is alcohol intake important ?

Q: How would you investigate this patient?Q: How would you investigate this patient?

CT Scan of the AbdomenCT Scan of the Abdomen

Radiology

CT scan of the abdomenCT scan of the abdomen

Radiology

Points for consideration Points for consideration

• In suspected chronic pancreatitis, CT is moderately accurate in diagnosis

• Ultrasound may also be indicated to assess gallstone disease

• In equivocal cases, MRCP or endoscopic ultrasound can be considered.

• Endoscopic retrograde pancreatography (ERCP) should be reserved for intervention. ERCP is not a diagnostic procedure.

Radiology

Radiology

Chronic PancreatitisChronic Pancreatitis

Pathophysiology of Pathophysiology of Chronic PancreatitisChronic Pancreatitis

Irreversible parenchymal (acinar cell) Irreversible parenchymal (acinar cell) destruction leading to pancreatic dysfunctiondestruction leading to pancreatic dysfunction

Exocrine insufficiencyExocrine insufficiency – enzymes – enzymes = weight loss and steatorrhea= weight loss and steatorrhea

Endocrine insufficiencyEndocrine insufficiency - islet cell - islet cell = diabetes= diabetes

Sources of Pain in Sources of Pain in Chronic PancreatitisChronic Pancreatitis

Etoh (>80%)Idiopathic

Other rare causes include:GallstonesHyperparathyroidismAutoimmuneCongenital malformationGenetics: Cystic Fibrosis

Causes of Chronic PancreatitisCauses of Chronic Pancreatitis

Pancreatic Enzyme TherapyPancreatic Enzyme Therapy

Goal:Goal:

Replace needed enzymes lost due to Replace needed enzymes lost due to exocrine insufficiencyexocrine insufficiency

Improves:Improves:

1.Pain

2.Diarrhea

3.Nutrient absorption

Pain Relief AlgorithmPain Relief AlgorithmConfirm Diagnosis

History, Imaging, Pancreatic Function Testing

Assess for Reversible Causes/ComplicationsEtOH and smoking cessation

Biliary stonesCollectionsMalignancy

Treat

Medical TherapyAnalgesics

Pancreatic enzymesPsychiatry

Dilated Main Pancreatic Duct•ERCP•Endoscopic nerve block•Surgery

Normal Main Pancreatic Duct•Endoscopic nerve block•Pancreas Islet Cell Transplant

Thank youThank you

GI: pjames@toh.on.caGI: pjames@toh.on.ca

Radiology: wshabana@toh.on.caRadiology: wshabana@toh.on.ca