Gallstones & Pancreatitis

Dr Alistair BrownAlistair.brown4@nhs.net

• What are gallstones?• Risk factors• The anatomy• Where the stones get stuck and how the

patient presents.

What are gallstones?

• Cholesterol 20% • Bile Pigment 5% (excess bilirubin – eg.

haemolytic anaemia)• Mixed 75%

Risk Factors

Cholesterol stones:– 6F’s FAIR, FAT, FEMALE, FORTY, FERTILE, FHx– Female:Male 2:1– Obesity– OCP– Fhx– Pregnancy– Hyperlipidaemia– Crohns

Bile pigment:– Red cell breakdown (eg. haemolytic anaemia)– Infection– cirrhosis

Asymtomatic

Biliary ColicPresentation: – RUQ pain – No Fever, No Jaundice– 2-3hrs after eating– Continuous– May radiate to inferior angle

right scapula

Complications: – infection

Inx: – Bloods, USS

Mx: – Analgesia– Cholecystectomy

Acute cholecystitisPresentation:

– RUQ pain – Fever– No Jaundice– Murphy’s positive

Complications: – Rarely empyema

Inx: – Bloods, USS

Mx: – Analgesia– Abx– Cholecystectomy or

Cholecystostomy– If duct dilated on USS will need on

table cholangiogram or pre-op MRCP

Choledocholithiasis

NB: – ERCP 5-20% of cases rise in AMY

after procedure– 0.5-5% risk of causing pancreatitis

Presentation: – RUQ pain – Jaundice– No Fever– Pale stools– Dark urine– Pruritus

Complications: – Ascending cholangitis– Vit A,D,E, K malabsorption

Inx: – Bloods, USS, MRCP or ERCP

Mx: – Analgesia– Abx– ERCP + sphincterotomy– Cholecystectomy

Ascending CholangitisPresentation:

– Charcot’s Triad– RUQ pain – Jaundice– Fever– Pale stools– Dark urine– Pruritus

Inx: – Bloods, USS, MRCP or ERCP

Mx: – Analgesia– Abx– ERCP + sphincterotomy– Cholecystectomy

Gallstone ileus

Presentation:– Small bowel obx

Inx: – AXR– CT scan

Mx:– Laparoscopy

+enterotomy +removal

Pancreatitis

Other diseases of the gallbladder are rare, so don’t worry about them!– Cholangiocarcinoma– Acalculus cholecystitis (probably vascular in origin)

Summary – think where can the stone get stuck!

• Asymptomatic• Biliary colic

– RUQ pain– No fever– No jaundice

• Cholecystitis– RUQ pain– Fever– No Jaundice

• Choledocholithiasis– RUQ pain– No Fever– Jaundice

• Ascending cholangitis– RUQ pain– Fever – Jaundice

• Gallstone ileus• Pancreatitis

The Pancreas

• Acute Pancreatitis– Causes– Presentation– Scoring– Management

• A word on chronic pancreatitis• Pancreatic cancer

Causes

• Learn the top three and a few more!– Gallstones 45-55%– Alcohol 20-30%– Idiopathic ?statin 15-20%

IGETSMASHED

Idiopathic ?statin relatedGallstonesEthanolTraumaSteroidsMumpsAutoimmuneScorpion StingHypercalcaemia, Hyperlipidaemia, HypothermiaERCPDrugs : Sulphonamydes, AZT, NSAIDS, diuretics

Acute pancreatitis• Epigastric or RUQ pain• Radiates through to the back• +/-jaundice• N/V

Other signs & sx:– Paralytic ileus– Respiratory distress– Grey Turner & Cullens sign (blood stained peritoneal exudate)– Oliguria

Diagnosis – Amylase 3x upper limit of normal

Severe pancreatitis can lead to multi-system organ failure (cytokines, toxic enzymes, haemolysis, DIC, fat necrosis)

When to call ITU?

• Scoring – Modified Glasgow score– PaO2 <8– Age >55– Neutophils WCC>15– Calcium <2– Renal urea >16– Enzymes LDH>600 AST>200– Albumin <32– Sugar >10

Score greater or equal to 3 d/w ITU

ManagementSupportive: ABC approach– Early:

• 1 Oxygen• 2 Access – central line if v. Severe, fluids• 3 catheter – monitor urine output• 4 Baseline ABG• 5 Analgesia • 6 NG – prevents vomiting and gastric dilation• 8 NBM• Anticoagulation

– Later:• 9 Consider nutrition NG/NJ/TPN• 10 Abx if severe or assoc. with gallstones• 11 PPI – prevent gastric erosions• 12 CT scan >day 5 to assess for complications

Chronic Pancreatitis• Causes

• 70-85% alcohol related• 10-15% idiopathic• Other: drugs, autoimmune

• Features• Recurrent abdominal pain• Steatorrhoea• Diabetes• Weight loss• Mildly raised amylase during acute attacks

• Management• Abstinence• Analgesia• Insulin• Pancreatic enzyme replacement & nutritional assessment

Pancreatic cancer• Courvoisiers Law – Jaundice in the presence of an enlarged non

tender gallbladder is unlikely to be gallstone related. Therefore likely to be pancreatic or GB cancer.

• Other features• Weight loss• Steatorrhoea • N&V• New onset diabetes

• Most are palliative -5yr survival ~3%• Abx for cholangitis• Biliary stent• Creon replacement• Chemotherapy

• 10-15% are surgical candidates – Whipples procedure

• Bliary colic• Cholangitis• Pancreatitis• Gallstone ileus• Empyema of gallbladder• Acute cholecystitis• Gallbladder mucocoele• Gallbladder

perforation/bilairy peritonitis

EMQ 1

1. 30yo female 2day hx constant pain RUQ associated with vomiting. Murphys positive. Febrile.

2. 56yo male 1week severe abdominal pain. Febrile. O/E: RUQ peritonism with a palpable lump. Bloods show increased WCC.

3. 60yo man 6hour hx of constant generalised abdo pain. O/E signs of shock. Abdomen is distended, generalised guarding and tenderness.

4. 38yo female 6hour hx of colicky RUQ pain radiating to back and shoulder. Afebrile, abdomen is soft & nontender.

5. 40yo female treated for acute cholecystitis with palpable non tender gallbladder. Afebrile and systemically well.

6. 78yo female known gallstones central colicky abdo pain and vomiting. Constipated for a few days. O/E increased bowel sounds and abdominal distension.

7. 42yo male sudden onset severe epigastric pain radiating through to the back. Vomiting and rething. O/E in shock, upper abdo tenderness, some guarding.

8. 60yo male presents with episodic RUQ pain, jaudice, fever and chills.

MCQ 1

• A 56 year old lady presents with pancreatitis. She is saturating 98% on air, BP is 80/50, HR 105, RR 16. BM 6, Calcium is within normal limits, WCC 20.2, albumin 36, Lfts derranged ALT 700, LDH 650. U&Es normal.

What is her score?a) 2 b) 3c) 4d) 5 c) 6

What should you do?

MCQ 2

• Which of these can cause a raised amylase?a) Severe DKAb) Renal Failurec) Perforated DUd) ERCPe) Chronic pancreatitis

MCQ 3

• Which of the following is diagnostic of pancreatitis?a) a serum amylase >3x upper limit of normalb) a serum amylase >1000c) a serum amylase >2x upper limit of normald) jaundice with obx lftse) RUQ pain and jaundice