Gallbladder and PancreasGallbladder and Pancreas

Hope Leblanc, MDHope Leblanc, MDEmergency Medicine, PGY 3Emergency Medicine, PGY 3

11/19/0811/19/08

ObjectivesObjectives

GallbladderGallbladderCholelithiasis/BiliaryCholelithiasis/Biliary coliccolicCholecystitisCholecystitisAcalculousAcalculous cholecystitischolecystitisCholangitisCholangitisComplications of Complications of cholecystitischolecystitisTumorsTumors

PancreasPancreasAcute versus Chronic PancreatitisAcute versus Chronic PancreatitisTumorsTumors

Risk Factors for GallstonesRisk Factors for Gallstones

““FortyForty””““FemaleFemale””““FertileFertile””““FatFat””MedicationsMedicationsPregnancyPregnancyEthnicityEthnicityProfound weight lossProfound weight lossProlonged fastingProlonged fasting

TPNTPNHigh spinal cord High spinal cord injuryinjuryChronic intravascular Chronic intravascular hemolysishemolysisLiver diseaseLiver diseaseCystic fibrosisCystic fibrosisHypertriglyceridemiaHypertriglyceridemiaChronic parasitic Chronic parasitic infectionsinfections

Anatomy 101Anatomy 101

Gallstone CompositionGallstone Composition

Gallbladder DiseaseGallbladder Disease

Cholecystitis

Cholangitis

Biliary Colic

Empyema or Gangrenous Gallbladder

Signs and Symptoms*Signs and Symptoms*CholelithiasisCholelithiasis Right upper quadrant or Right upper quadrant or epigastricepigastric pain, pain,

maymay be colicky and postprandialbe colicky and postprandialPain Pain maymay radiate to upper back, shoulder radiate to upper back, shoulder

or around waistor around waistNausea and vomiting Nausea and vomiting maymay be presentbe present

CholecystitisCholecystitis Same manifestations as Same manifestations as cholelithiasischolelithiasis, , plusplus Murphy sign presentMurphy sign presentLasts longer than 6 hoursLasts longer than 6 hoursFever and chills Fever and chills may may be presentbe present

CholangitisCholangitis Same manifestations as Same manifestations as cholecystitischolecystitis, plus, plusJaundiceJaundiceAltered mental statusAltered mental statusShockShock

AcalculousAcalculous CholecystitisCholecystitis

10% of patients with 10% of patients with acute acute cholecystitischolecystitis

Indistinguishable with Indistinguishable with 2 exceptions:2 exceptions:

patients frequently are patients frequently are gravely ill gravely ill Is a complication from Is a complication from another processanother process

Risk factors:Risk factors:elderly elderly DMDMmultiple traumamultiple traumaextensive burn injuryextensive burn injuryprolonged laborprolonged labormajor surgerymajor surgerygallbladder torsiongallbladder torsionsystemic systemic vasculiticvasculiticinfections of infections of biliarybiliary tract tract

Differential Diagnosis of Differential Diagnosis of CholecystitisCholecystitis

GastritisGastritisGERDGERDPancreatitisPancreatitisHepatitisHepatitisPUDPUDAcute MIAcute MIRenal colic Renal colic PyelonephritisPyelonephritis

Appendicitis Appendicitis (in pregnancy or patients (in pregnancy or patients with a with a retrocecalretrocecal appendix) appendix) PIDPIDFitz HughFitz Hugh--Curtis Curtis Ectopic pregnancyEctopic pregnancyPneumoniaPneumoniaPleural effusionPleural effusion

DiagnosisDiagnosis

Poor predictive valuePoor predictive valueHistoryHistoryPhysicalPhysicalLabsLabs

UltrasoundUltrasoundSensitivity 94%Sensitivity 94%Specificity 78%Specificity 78%

HIDA scanHIDA scanSensitivity 97%Sensitivity 97%Specificity 90%Specificity 90%

TreatmentTreatmentBiliaryBiliary ColicColic Supportive careSupportive care

Possible ED dischargePossible ED dischargeElective surgeryElective surgery

CholecystitisCholecystitis Surgery within 1Surgery within 1--3 days3 daysSupportive careSupportive careSingleSingle--coverage antibioticscoverage antibiotics

CholangitisCholangitis and other and other complicated diseasecomplicated disease

Aggressive resuscitationAggressive resuscitationBroadBroad--spectrum antibiotics spectrum antibiotics Immediate surgeryImmediate surgery

Antibiotics in Complicated InfectionAntibiotics in Complicated Infection

Ampicillin, Ampicillin, gentamicingentamicin, and , and metronidazolemetronidazoleCiprofloxacinCiprofloxacin and and metronidazolemetronidazoleZosynZosynUnasynUnasynTicarcillinTicarcillin--clavulanateclavulanateImipenemImipenemThirdThird--generation cephalosporin and generation cephalosporin and metronidazolemetronidazole or or clindamycinclindamycinAztreonamAztreonam and and clindamycinclindamycin

ComplicationsComplications

Ascending Ascending CholangitisCholangitisGallstone PancreatitisGallstone PancreatitisGallstone Gallstone IleusIleusGallbladder EmpyemaGallbladder EmpyemaEmphysematous (Gangrenous) Emphysematous (Gangrenous) CholecystitisCholecystitisPorcelain GallbladderPorcelain Gallbladder

Gallstone Gallstone IleusIleus

Gallstone erodes into the bowelGallstone erodes into the bowelFistula forms between Fistula forms between biliarybiliary tract and intestinetract and intestineElderly and femalesElderly and femalesIntestinal obstruction if stone > 2 cmIntestinal obstruction if stone > 2 cmMechanical obstruction not an Mechanical obstruction not an ileusileusMay be intermittent: May be intermittent: ““tumbling phenomenontumbling phenomenon””

Gallstone Gallstone IleusIleus

NauseaNauseaVomitingVomitingPain Pain ConstipationConstipationHistory of History of biliarybiliary diseasediseaseRarely have Rarely have biliarybiliary symptoms directly symptoms directly before episodebefore episode

Gallstone Gallstone IleusIleus

RiglerRigler’’ss TriadTriadPartial or complete obstructionPartial or complete obstructionPneumobiliaPneumobiliaEctopic gallstone in intestineEctopic gallstone in intestine

CT scan up to 93% sensitive in diagnosing CT scan up to 93% sensitive in diagnosing gallstone gallstone ileusileusUrgent Urgent LaparotomyLaparotomy

Ascending Ascending CholangitisCholangitis

Complete Complete biliarybiliary obstruction + bacterial obstruction + bacterial infectioninfectionCharcot triad (25%)Charcot triad (25%)ReynoldReynold’’ss pentadpentadMortality approaches 100% if untreatedMortality approaches 100% if untreatedFluids, Fluids, VasopressorsVasopressors, IV antibiotics and , IV antibiotics and Surgical decompressionSurgical decompression

Gallbladder EmpyemaGallbladder Empyema

Complete cystic duct obstruction + Complete cystic duct obstruction + bacterial infection + abscess formationbacterial infection + abscess formationReynoldReynold’’ss pentadpentadRisk Factors: elderly, DM, trauma, burns, Risk Factors: elderly, DM, trauma, burns, vasculitisvasculitisFrequently develop gramFrequently develop gram--negative sepsisnegative sepsisFluids, Fluids, VasopressorsVasopressors, IV antibiotics and , IV antibiotics and Surgical decompressionSurgical decompression

Gangrenous Gangrenous CholecystitisCholecystitis

Focal or diffuse gangrene Focal or diffuse gangrene Gallbladder wall becomes ischemic, then develop Gallbladder wall becomes ischemic, then develop bacterial infection and gangrenebacterial infection and gangrene1% of 1% of cholecystitischolecystitis ptpt’’s, but 30% of these are s, but 30% of these are acalculousacalculousReynoldReynold’’ss pentadpentadKUB may demonstrate KUB may demonstrate pneumobiliapneumobiliaRecommend CT scanRecommend CT scanSimilar treatmentSimilar treatment

Porcelain GallbladderPorcelain Gallbladder

Incidence 0.6Incidence 0.6--0.8% 0.8% Pathological finding of a brittle gallbladder with Pathological finding of a brittle gallbladder with bluish discoloration resulting from extensive bluish discoloration resulting from extensive calcification of the gallbladder wallcalcification of the gallbladder wallRelevance is based on high association between Relevance is based on high association between gallbladder cancer and porcelain gallbladdergallbladder cancer and porcelain gallbladderDiagnosis:Diagnosis:

hard mass in the RUQ hard mass in the RUQ incidental findings on KUB, US, or CT incidental findings on KUB, US, or CT

Prophylactic Prophylactic cholecystectomycholecystectomy

TumorsTumors

CholangiocarcinomaCholangiocarcinomaPrimary Gallbladder Primary Gallbladder CancerCancer

CholangiocarcinomaCholangiocarcinoma

Neoplasm from intraNeoplasm from intra-- or or extrahepaticextrahepaticbile duct epitheliumbile duct epitheliumSecond most common primary hepatic Second most common primary hepatic tumortumorAverage age 50 yrsAverage age 50 yrsIncreasing incidence in USIncreasing incidence in US1 case per 100,000 per year1 case per 100,000 per yearRisk factor: primary Risk factor: primary sclerosingsclerosingcholangitischolangitis

CholangiocarcinomaCholangiocarcinoma

Most Most cholangiocarcinomascholangiocarcinomas remain clinically silent remain clinically silent until advanced stagesuntil advanced stages

ExtrahepaticExtrahepatic: : biliarybiliary obstruction results in painless obstruction results in painless jaundicejaundiceIntrahepaticIntrahepatic: RUQ pain and : RUQ pain and cachexiacachexia and malaiseand malaise

CT and MRI with MRCP help with diagnosis and CT and MRI with MRCP help with diagnosis and stagingstagingSurgical resection or liver transplantation and Surgical resection or liver transplantation and chemotherapychemotherapyOverall survival 6 months in 90% of ptOverall survival 6 months in 90% of pt’’ss

Primary Gallbladder CancerPrimary Gallbladder Cancer

Incidence 0.8% to 1.2%Incidence 0.8% to 1.2%Female: Male, 3:1Female: Male, 3:1Aged 62Aged 62--66yrs66yrsHighest in American Indians and Hispanic Highest in American Indians and Hispanic Most patients not diagnosed until advanced Most patients not diagnosed until advanced disease as no specific signs or symptomsdisease as no specific signs or symptomsRisk factor is chronic inflammationRisk factor is chronic inflammation

>75 % inflammation is cholesterol gallstones>75 % inflammation is cholesterol gallstones

Signs and SymptomsSigns and Symptoms

Similar symptoms of gallstones and Similar symptoms of gallstones and biliarybiliary coliccolicAbdominal pain may be of a more diffuse and Abdominal pain may be of a more diffuse and persistent naturepersistent natureCourvoisier sign: Palpable mass in the RUQCourvoisier sign: Palpable mass in the RUQSister Mary Joseph nodes: Sister Mary Joseph nodes: PeriumbilicalPeriumbilical LADLADVirchow node: Left Virchow node: Left supraclavicularsupraclavicular adenopathyadenopathyPelvic seeding: Mass is palpated on DREPelvic seeding: Mass is palpated on DRE

Diagnosis and TreatmentDiagnosis and Treatment

May see elevated alkaline May see elevated alkaline phosphatasephosphatase and and bilirubinbilirubin levelslevelsUS or CT scan completed due to RUQ painUS or CT scan completed due to RUQ pain1010--20% of patients present with tumor confined20% of patients present with tumor confinedComplete surgical resection in early diseaseComplete surgical resection in early diseaseGallbladder replaced by the cancerGallbladder replaced by the cancer50% of patients have lymph node 50% of patients have lymph node metsmetsAdvanced disease, palliative treatment onlyAdvanced disease, palliative treatment only55--year survival rates of 15year survival rates of 15--20%20%

PancreasPancreas

Acute PancreatitisAcute PancreatitisChronic PancreatitisChronic PancreatitisPancreatic CancerPancreatic Cancer

PathophysiologyPathophysiology of Acute Pancreatitisof Acute Pancreatitis

A stress/trigger starts the activation of A stress/trigger starts the activation of proenzymesproenzymes and digestive zymogensand digestive zymogensResults in Results in autodigestionautodigestion of the pancreasof the pancreasCauses edema, interstitial hemorrhage, Causes edema, interstitial hemorrhage, vascular damage, coagulation, and cellular vascular damage, coagulation, and cellular necrosisnecrosisMay get extension of the localized process May get extension of the localized process into a generalized systemic inflammatory into a generalized systemic inflammatory responseresponse

Acute PancreatitisAcute Pancreatitis

United StatesUnited States90% due to alcohol abuse or 90% due to alcohol abuse or cholelithiasischolelithiasis5% due to medications5% due to medicationsRemaining due to infection, inflammation, Remaining due to infection, inflammation, trauma, and metabolic disturbances trauma, and metabolic disturbances

Etiology different in other countriesEtiology different in other countriesPrevalence is 0.5%Prevalence is 0.5%

Medications Associated with PancreatitisMedications Associated with PancreatitisAntiarrhythmicsAntiarrhythmics:: AmiodaroneAmiodarone, , amlodipineamlodipineAntiasthmaticAntiasthmatic:: MontelukastMontelukastAntibiotics:Antibiotics: ErythromycinErythromycin, , azithromycinazithromycin, , clarithromycinclarithromycin, , sulfamethoxazolesulfamethoxazole, , quinolonesquinolones, , pentamidinepentamidine, , paromomycinparomomycin, , rifampinrifampin, , dalfopristindalfopristin--quinupristinquinupristinAntiepilepticsAntiepileptics: : CarbamazepineCarbamazepine, , valproicvalproic acidacid, , topiramatetopiramateAntifungals:Antifungals: MetronidazoleMetronidazoleAntihypertensivesAntihypertensives:: DiazoxideDiazoxide, , indapamideindapamide, , methyldopamethyldopaAntilipemicAntilipemic agents:agents: All typesAll typesAntineoplasticAntineoplastic agents:agents: LL--AsparaginaseAsparaginase, , pegaspargasepegaspargase, , cytarabinecytarabine, , tamoxifentamoxifen, , mycophenolatemycophenolate, , vinorelbinevinorelbine, , anagrelideanagrelide, interleukin2 , interleukin2 ((ILIL--22) analogues, ) analogues, interferonsinterferons

AntipsychoticsAntipsychotics: : RisperidoneRisperidoneAntiretroviralsAntiretrovirals: All types: All types

DiphenoxylateDiphenoxylate (opiate agonist) (opiate agonist) Diuretics:Diuretics: ThiazidesThiazides, , furosemidefurosemide, , ethacrynicethacrynic acidacid, , metolazonemetolazoneErgotaminesErgotaminesEstrogensEstrogens: All types: All typesEtanerceptEtanercept (anti(anti--TNF) TNF) EthanolEthanolGastrointestinal agentsGastrointestinal agents: : CholestyramineCholestyramine, , cimetidinecimetidine, , octreotideoctreotide, , ranitidineranitidine, proton pump inhibitors, proton pump inhibitorsGlucocorticoidsGlucocorticoids:: All typesAll typesHydroxyureaHydroxyureaNonsteroidalNonsteroidal antianti--inflammatory agents:inflammatory agents: All All typestypesRetinoic acidRetinoic acid derivativesderivativesSalicylatesSalicylatesSomatropinSomatropin ((growth hormonegrowth hormone))

Signs and SymptomsSigns and SymptomsMidepigastricMidepigastric or LUQ or LUQ pain pain Constant, boring pain Constant, boring pain Radiates to back, Radiates to back, flanks, chest, or lower flanks, chest, or lower abdomen abdomen Worse in supine Worse in supine position position Relieved by sitting, Relieved by sitting, knees flexed knees flexed Nausea and vomitingNausea and vomitingAbdominal bloatingAbdominal bloating

LowLow--grade fevers grade fevers Tachycardia Tachycardia Hypotension Hypotension Cullen sign Cullen sign Grey Turner signGrey Turner signHypovolemicHypovolemic shock shock Multisystem organ Multisystem organ failurefailure

Complications of Acute PancreatitisComplications of Acute Pancreatitis

PulmonaryPulmonaryL Pleural effusionsL Pleural effusionsAtelectasisAtelectasisHypoxemiaHypoxemiaARDS (>50% mortality)ARDS (>50% mortality)

MetabolicMetabolicHypocalcemiaHypocalcemiaHyperglycemiaHyperglycemiaHyperlipidemiaHyperlipidemiaCoagulopathyCoagulopathyDIC DIC

CardiovascularCardiovascularMyocardial depressionMyocardial depressionHemorrhageHemorrhageHypovolemiaHypovolemia

OtherOtherHemorrhageHemorrhageColonic perforationColonic perforationRenal failureRenal failureErythemaErythema--nodosumnodosumArthritisArthritisPseudocystPseudocystAbscessAbscess

Laboratory tests and diagnostic valueLaboratory tests and diagnostic value

Test CharacteristicTest Characteristic AmylaseAmylase LipaseLipase

SensitivitySensitivity 8080––90%90% 90%90%

SpecificitySpecificity 75%75% 90%90%

Suggested best cutoffSuggested best cutoff 3x upper limit of normal3x upper limit of normal 2x upper limit of normal2x upper limit of normal

Prognostic valuePrognostic value PoorPoor PoorPoor

Rate of riseRate of rise RapidRapid RapidRapid

Return to baselineReturn to baseline 33––4 days4 days 77––14 days14 days

DiagnosisDiagnosis

ALT: 3 X upper limit of normalALT: 3 X upper limit of normalPositive predictive value 95% for gallstone etiologyPositive predictive value 95% for gallstone etiology

FilmFilmRules out other diseaseRules out other disease

UltrasoundUltrasoundImportant in ruling out gallstones as etiologyImportant in ruling out gallstones as etiologyMay visualize pancreatic edema or May visualize pancreatic edema or pseudocystspseudocysts

CT scanCT scanInsensitive in early or mild diseaseInsensitive in early or mild diseasePhlegmonsPhlegmons, abscesses, or , abscesses, or pseudocystspseudocysts

Prognostic Markers?Prognostic Markers?

RansonRanson’’ss CriteriaCriteriaAPACHE IIAPACHE IILevel of amylase or lipaseLevel of amylase or lipase

RansonRanson’’ss CriteriaCriteria

At admission:At admission:Age > 55 years Age > 55 years WBC > 16000WBC > 16000Glucose > 200Glucose > 200serum serum ASTAST > 250> 250serum serum LDHLDH > 350> 350

After 48 hours:After 48 hours:Calcium < 8.0 Calcium < 8.0 HHCT drop > 10% CT drop > 10% Oxygen PO2 < 60 Oxygen PO2 < 60 BUNBUN increased by 5increased by 5Base deficit > 4Base deficit > 4Fluid Sequestration > Fluid Sequestration > 6 L6 L

Treatment Mild to Moderate Treatment Mild to Moderate PancreatitisPancreatitis

90%90%"rest the pancreas" "rest the pancreas" IV fluid resuscitationIV fluid resuscitationClear liquidsClear liquidsUOP = 100 ml/hrUOP = 100 ml/hrIV narcotics and IV narcotics and antiemeticsantiemeticsBiliaryBiliary etiology: elective etiology: elective vsvs urgent surgeryurgent surgery

Treatment of Severe PancreatitisTreatment of Severe Pancreatitis

1010--20% develop necrosis or systemic 20% develop necrosis or systemic complicationscomplicationsSupportive careSupportive careNPONPOIV antibioticsIV antibiotics

PolymicrobialPolymicrobialImipenemImipenem (or FQ) + (or FQ) + metronidazolemetronidazole

VasopressorsVasopressorsConsider surgical interventionConsider surgical intervention

DispositionDisposition

Level of disease, PO tolerance, follow upLevel of disease, PO tolerance, follow up

HomeHomeMedical floorMedical floorICUICUConsider Surgical consultConsider Surgical consult

Chronic PancreatitisChronic Pancreatitis

Prevalence from 0.04 to 5 %Prevalence from 0.04 to 5 %Irreversible damage to pancreatic Irreversible damage to pancreatic structure and functionstructure and function

Interstitial inflammation with duct obstruction Interstitial inflammation with duct obstruction and dilatation leads to and dilatation leads to parenchymalparenchymal loss and loss and fibrosisfibrosisResults in impairment of both exocrine and Results in impairment of both exocrine and endocrine pancreatic functionsendocrine pancreatic functionsEndocrine impairment occurs much laterEndocrine impairment occurs much later

Etiology of Chronic PancreatitisEtiology of Chronic Pancreatitis

Alcohol abuseAlcohol abuseIdiopathicIdiopathicMalnutrition Malnutrition HyperparathyroidismHyperparathyroidismPancreas Pancreas divisumdivisumAmpullaryAmpullary stenosisstenosisCystic fibrosisCystic fibrosisHereditaryHereditaryTraumaTrauma

Signs and SymptomsSigns and Symptoms

Similar to acute pancreatitisSimilar to acute pancreatitisProgresses from discrete attacks to no Progresses from discrete attacks to no pain free periodspain free periodsAppear chronically illAppear chronically ill

Weight lossWeight lossSteatorrheaSteatorrheaClubbingClubbingPolyuriaPolyuriaMay have stigmata of liver diseaseMay have stigmata of liver disease

DiagnosisDiagnosis

Amylase and Lipase may be elevated or Amylase and Lipase may be elevated or normalnormalUS or CTUS or CT

Consider when pain increasing and intractableConsider when pain increasing and intractableCheck for complications (abscess, Check for complications (abscess, pseudocystpseudocyst))Rule out pancreatic cancerRule out pancreatic cancer

Short and Long Term TreatmentShort and Long Term Treatment

Supportive careSupportive careTreat complicationsTreat complications

Relieve mechanical obstructionRelieve mechanical obstructionCorrect Correct malabsorptionmalabsorptionAlteration of the disease course Alteration of the disease course

Pancreatic extractsPancreatic extractsAlcohol abstinenceAlcohol abstinenceCeliac plexus nerve blockCeliac plexus nerve block

DispositionDisposition

HomeHomeRuled out complicationsRuled out complicationsClose followClose follow--upupPain under controlPain under control

AdmissionAdmissionComplicationsComplicationsPain reliefPain relief

Pancreatic CancerPancreatic Cancer

Incidence has increased over the last decadesIncidence has increased over the last decades1010thth most common cancer in the USmost common cancer in the USPoor overall 5Poor overall 5--year survival rate of 5%year survival rate of 5%Why prognosis so poorWhy prognosis so poor

lack of early symptomslack of early symptomsearly and frequent vessel wall involvementearly and frequent vessel wall involvementhigh incidence of liver metastaseshigh incidence of liver metastasesonly 7% are localized to the organ without only 7% are localized to the organ without spreading or distant spreading or distant metsmetspain, jaundice, weight loss, and obstruction are late pain, jaundice, weight loss, and obstruction are late symptomssymptoms

Pancreatic CancerPancreatic Cancer

Cancer screening in general population:Cancer screening in general population:Low incidenceLow incidenceLack of accurate, inexpensive, and Lack of accurate, inexpensive, and noninvasive diagnostic tests for early diseasenoninvasive diagnostic tests for early disease

Screening in highScreening in high--risk populations:risk populations:Strong family history pancreatic cancerStrong family history pancreatic cancerPancreatitisPancreatitisHereditary cancer syndromesHereditary cancer syndromes

SummarySummary

1.1. Stop DrinkingStop Drinking2.2. Learn how to do gallbladder ultrasounds.Learn how to do gallbladder ultrasounds.3.3. If youIf you’’re feeling fine, you may have re feeling fine, you may have

cancer!cancer!

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