5. Gallstones and Pancreatitis Flashcards
Describe the types of gallstones.
List some risk factors for gallstones.
What drugs carry a risk of gallstone formation?
1. Cholesterol: large, often solitary, 90%. Causes: female, age, obesity
2. Pigmented: small, friable, irregular, <10%. Causes: haemolysis
3. Low phospholipid associated cholelithiasis: rare genetic hepatic disease (association of ABCB4 mutations) characterised by cholestrol gallbladder and intrahepatic stones
Female, increasing age, obese, fertile, family hx, rapid weight loss, total parenteral nutrition (IV). Possibly cirrhosis, Crohn’s, sickle cell
COCP, HRT, fenofibrate (fibric acid derivatives)
What 2 factors contribute to formation of cholesterol stones?
How do pigmented stones form?
Most patients with gallstones are asymptomatic. What symptoms might they experience?
Differentiate between biliary colic, acute cholecystitis and cholangitis (charcot triad) in terms of:
a) pain
b) WCC/fever
c) jaundice
Cholesterol supersaturation. Impaired gallbladder motility
Changes in heme metabolism or bilirubin absorption. Increase in bilirubin concentration
Colicky pain; in upper abdomen (RUQ), post-prandial (after food), N+V
[Table]
Biliary colic: symptomatic gallstones with cystic duct obstruction or passed into CBD. RUQ pain radiates to the back +/- jaundice
Acute cholecystitis: follows stone/sludge impaction in neck of gallbladder, may cause continuous epigastric/RUQ pain referrered to R shoulder. Main diff from biliary colic is inflammatory component (local peritonism)
Cholangitis: bile duct infection causing RUQ pain, jaundice, rigors (Charcot’s triad)
What would you look/test for in examining a patient with RUQ pain (suspected gallstones)?
What investigations would you do for a patient with gallstones?
How would gallstones be managed at a hospital compared to at home?
Skin - jaundice
Abdomen - Murphy’s sign (2 fingers over RUQ, pt breathes in, causes pain and arrest of inspiration as inflamed GB impinges on fingers. Only +ve if same test in LUQ does not cause pain. +ve = acute cholecystitis or chlolangitis)
Courvisier sign (a palpable enlarged nontender GB + jaundice is likely not to be gallstones but malignancy of GB/pancreas)
Bloods, imaging (US abdomen, chest/abdo XR, MRCP - magnetic resonance cholangiopancreatography), urine
Hospital: conservative mx or surgical mx - cholecystectomy
Home: diet control
What are some differential diagnoses of RUQ pain apart from gallstones (GI and non-GI)?
What are some complications of gallstones?
GI: peptic ulcer, dyspepsia, pancreatitis, hepatitis, perforated peptic ulcer
Non-GI: pyelonephritis, pneumonia, acute coronary syndrome
Chronic cholecysitis (chronic inflammation +/- colic, flatulent dyspepsia), pancreatitis, mucocele (mucus cyst), empyema, Mirizzi syndrome (stone in GB presses on BD causing jaundice), fistula (cholecystoduodenal/ cholecystocolonic/ cholecystojujenal), bowel obstruction (gallstone ileus, bouveret syndrome - pylorus obstruction), perforation, obstructive jaundice, malignancy
Differentiate between acute and chronic pancreatitis.
What are the endocrine and exocrine functions (parasympathetic) of the pancreas?
Describe the pathogenesis of pancreatitis.
Acute: rapid onset inflammatory process of pancreas
Chronic: progressive inflammation of the pancreas + destruction of pancreatic secretory cells. Epigastric pain ‘bores through’ to the back
Endocrine: secretes hormones into blood. Made of islets of langerhans which contain α-cells (glucagon), β-cells (insulin), δ-cells (somatostatin)
Exocrine: acinar glands secrete digestive enzymes into small intestine - alkaline secretion e.g. chymotrypsin
[Pic]
What is the mnemonic for remembering the causes of pancreatitis?
Describe the Atlanta criteria classification for mild, moderate and severe pancreatitis.
How might the history of the presenting complaint differ between acute and chronic pancreatitis?
GET SMASHED: Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bite, Hypertriglyceridemia/Lipidemia, E - post ERCP, Drugs (valproate, opioids, corticosteroids)
Mild: no organ failure or local/systemic complication i.e. pancreatic necrosis
Moderate: transient organ failure (resolves in 48hrs), local/systemic complication
Severe: persistent organ failure
Acute: mainly upper abdo pain (radiates to back), N+V, abdo distension
Chronic: constant abdo pain, recurrent pancreatitis, pancreatic insufficiency (steatorrhea/fat malabsorption), diabetes
What might you find when examining a patient with mild pancreatitis?
What might you find when examining a patient with moderate/severe pancreatitis?
General appearance: pain +++
Skin: jaundice (+/-)
Abdomen: tenderness +++
Observations: fever (+/-)/mild tachycardia/normal obs
Skin: jaundice, +/- ecchymosis (bruising: preiumbilical - Cullen’s sign or over flanks - Grey Turner’s sign, from BV autodigestion and retroperitoneal haemorrhage [Pic])
Abdomen: tenderness (generalised/epigastric), distension ++
Observation: tachycardia/ +/- fever
Lungs: pleural effusion
What investigations would you do for a pt with suspected pancreatitis?
Describe the modified Glasgow criteria for predicting severity of pancreatitis.
Bloods: FBC, LFT, ABG, serum triglyceride level, CRP
Imaging: CXR, AXR, US abdo, CT abdo-pelvis/MRCP/EUS
- *3 or more** +ve factors detected within 48h of onset suggest severe pancreatitis and prompt transfer to ITU. Valid for gallstone and alcohol-induced pancreatitis. Mnemonic: PANCREAS:
- *PaO2** <8kPa, Age >55, Neutrophils >15, Calcium <2mmol/L, Renal function >16 (urea), Enzymes; LDH >600/ AST >200, Albumin <32g/dl, Sugar >10
How is mild pancreatitis managed?
How is moderate/severe pancreatitis managed?
What are some management complications?
Analgesia +/- IV fluids, +/- antiemetics. NMB until N+V settles
NBM, NG tube, IV fluids - aggressive hydration, IV analgesia, IV antiemetics, IV abx (+/-), catheter, hourly obs monitoring.
TREAT CAUSE e.g. gallstone - pancreatitis: cholecystectomy (gallbladder removal), ERCP (endoscopic retrograde cholangio-pancreatography). Chronic pancreatitis - pancreatic enzymes
Pancreatic ascites, chronic pancreatitis, acute lung injury, fistula (pancreas-parietal pleura of lung- pancreatic effusion), renal failure, fatty necrosis, pancreatic necrosis, pancreatic pseudocyst, pancreatic cancer
Case 1
46yo lady presents to A&E with a history of colicky epigastric and RUQ pain which occurs about 15 min after eating and lasts 1-2 hours. This pain has been happening for about 1 month, 2-3 times a week, especially after eating takeaways. She has no medical or surgical history. Currently taking oral contraceptive pill.
Examination findings below.
What would you suspect?
Gallstones
COCP, Colicky pain; in upper abdomen (RUQ), post-prandial (after food), N+V
Case 2
A 45yo female presents with a complaint of abdominal pain for the past 3 days. She localizes the pain to her epigastric area and states that it radiates to her right upper quadrant. She notes that it became markedly worse after eating dinner last night. She recalls a past history of similar pain, but has never had any diagnostic workup. She has had one episode of vomiting over the last 3 days. Her past medical history is significant for hypertension and hypercholesterolemia.
Examination findings below.
What would you suspect?
Acute cholecystitis
Murphy’s sign, continuous RUQ pain
Case 3
A 44yo woman presents to the emergency room with a history of right upper quadrant pain, shaking chills, and jaundice. This pain came on suddenly six hours earlier and has been progressing. She took her temperature at home and it was 38.7. She vomited once at the onset of the pain. She has had intermittent episodes of epigastric and right upper quadrant pain after eating for the past six months. The pain always abated after thirty to sixty minutes. No other medical or surgical history.
Examination findings below.
What would you suspect?
Cholangitis
Bile duct infection causing RUQ pain, jaundice and rigors = Charcot’s triad
Case 4
A 44yo man presents to ED complaining of severe epigastric pain, which has lasted for three hours and radiates to his back. The pain began suddenly whilst he was out at the pub with his friends. He has vomited 3 times since the pain started. He claims sitting forward helps relieve the pain. Further questioning reveals he drinks about 38 units of alcohol a week.
Examination findings below
What would you suspect?
Alcohol-related acute pancreatitis
