Pancreatitis and Gallbladder Disease

Pancreatitis and Pancreatitis and Gallbladder DiseaseGallbladder Disease

Stefan Da SilvaStefan Da SilvaJan 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 drunk C) Chalk it up to EtOH induced gastritis, call the drunk

tank and go for coffeetank 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


AlcoholAlcohol Mechanism unclearMechanism unclear 5 to 10 yrs of chronic EtOH abuse before 5 to 10 yrs of chronic EtOH abuse before

onsetonset


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 for diaphoresis and low grade fever. PMH for diabetes, GERD, CAD, COPDdiabetes, 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 or May exclude other causes of abdo pain including bowel obstruction or

perforationperforation 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 pancreatitis, Recommended when: 1) uncertain dx 2) severe clinical pancreatitis,

leukocytosis, elevated temp 3) Ranson’s score > 3 4) APACHE score leukocytosis, elevated temp 3) Ranson’s score > 3 4) APACHE score > 8 5) No improvement in 72 hrs 6) acute deterioration> 8 5) No improvement in 72 hrs 6) acute deterioration

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 good diagnosed with pancreatitis, thinking pretty good about your self that you’ve made the diagnosis about your self that you’ve made the diagnosis you strut around the department giving high you strut around the department giving high fives. Suddenly you here a page overhead asking fives. Suddenly you here a page overhead asking you to go to Bed 5. You arrive and see your you to go to Bed 5. You arrive and see your “pancreatitis” patient in mild respiratory distress.“pancreatitis” patient in mild 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 bileFrom elevated concentration of cholesterol in the bile 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 must for a stone to be radiopaque it must contain at least 4% calcium by wt.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


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


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 pathologyEnsure to r/o any cardiopulmonary pathology


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% sensitive not specific but > 95% sensitive (much less in elderly pt though)(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

Pancreatitis and Gallbladder Disease

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