Acute Gall Bladder Disease and Pancreatitis

Question 1

What are the risk factors for developing gall stones?

Answer 1

The five Fs and others.

Fat OR rapid weight loss
Female
Forty- pre-menopausal oestrogen increase
Fertile- multiparty
Fair- caucasian

Others- FOOD
Family history
Oral contraception
Older age
Diabetes

Question 2

What are gallstones made of?

Answer 2

Cholesterol (80%), bile pigments or a mixture.

Question 3

Name the conditions caused by gallstones in different anatomical locations.

Answer 3

Cholelithiasis-
Gallstones in the gallbladder
Presentation- Acute and chronic cholecystitis, biliary colic.
Mirizzi’s syndrome is a rare complication where stones in the gallbladder or cystic duct cause obstructive jaundice via external compression of the CBD.

Choledocholithiasis-
Gallstones in the common bile duct (CBD)
Presentation- obstructive jaundice acute cholangitis or acute pancreatitis.

Gallstone ileus-
Gallstones obstructing small bowel.

Question 4

Define biliary colic.

Answer 4

Biliary obstruction without infection, causing pain as the gallbladder contracts against it. Due to stone impaction in the gallbladder neck or cystic duct.

Question 5

What are the signs and symptoms of biliary colic?

Answer 5

• Continuous RUQ or epigastric pain- may radiate to the back (below the right scapula). Pain worse following a fatty meal. Patients report the pain as severe and may be writhing in pain.
• Nausea and vomiting
• Will usually resolve in <6 hours
• No fever, peritonism or raised WBC

Question 6

How is biliary colic investigated?

Answer 6

Initially-
Abdominal US
LFTs

Consider MRCP if there is duct dilatation on ultrasound and US and/or abnormal LFTs.
Endoscopic US if MRCP inconclusive.

90% of gallstones are radiolucent on XR, unlike renal stones, therefore abdominal XR is not useful.

Question 7

How is biliary colic managed?

Answer 7

Non-operative-
Analgesia- for severe pain, give parenteral opioid or PR diclofenac.
Avoid triggering foods and drinks ie. low fat diet.

Operative-
Laparoscopic cholecystectomy. May be done as a day case. Offer early (<1 week) in an acute presentation requiring hospital admission.
If there are CBD stones- remove them via ERCP, or CBD clearance during cholecystectomy. This may be offered to asymptomatic patients with CBD stones.
After treatment should be able to consume normal diet, including previous triggers.

Question 8

Define acute cholecystitis.

Answer 8

Acute gallbladder inflammation due to stone impaction in the cystic duct or gallbladder neck.
May initially look like, or be a complication of biliary colic.
Usually sterile chemical inflammation- or at least initially- but becomes infective in ~1/3. Pathogens include E.coli and Klebsiella.

Question 9

What are the signs and symptoms of acute cholecystitis?

Answer 9

Continuous RUQ or epigastric pain, which may radiate to the back (below the right scapula) as in biliary colic. Boas sign- increased sensitivity below right scapula.
Fever and local peritonism- but patient will lie still.
Murphy’s sign- with 2 fingers pressed on the RUQ, there is pain on inspiration (but no pain when in LUQ)
There may be a palpable RUQ mass- phlegm (inflamed omentum and bowel around gallbladder)
Vomiting
Jaundice(10%)- due to compression, inflammation, or stone impaction on the CBD. If there is infection of the CBD, it is cholangitis.

Question 10

How is acute cholecystitis investigated?

Answer 10

Bloods-
FBC- Raised WBC
Raised CRP
LFTs- ~33% have raised all phos, raised bilirubin and/or raised GGT.

Imaging-
Abdominal US- 4 hours nil by mouth beforehand will help to distend the gallbladder. May show stones, thickened gallbladder wall and/or shrunken gallbladder (if chronic).
Positive Murphy’s sign is pain on compressing gallbladder with probe. Dilated CBD if there are stones, but stones lower down may not be visualised.

MRCP indications- US showing dilated CBD, obstructive LFTs failing to improve. Endoscopic ultrasound (EUS) if MRCP not conclusive.

OTHER- HIDA cholescintigraphy (nuclear med) can show cystic duct obstruction
CT abdomen for differentials- however most gallstones are radiolucent.

Question 11

How is acute cholecystitis managed?

Answer 11

Non-operative-
Supportive treatment- fluids and analgesia. ITU if there is perforation.
IV antibiotics

Operative-
Although 90% resolve without surgical management, recurrence is common so surgery is offered to most patients.
Early (<1 week) laparoscopic cholecystectomy. Doing it early prevents re-admission and second illness episode.
If there are CBD stones- ERCP pre-op or intra-operative bile duct clearance.
Percutaneous cholecystectomy tube for drainage can be used as an urgent treatment in perforation, or in patients unsuitable for surgery.

Question 12

What are the complications of acute cholecystitis?

Answer 12

Infarction- gangrenous cholecystitis or perforation. Can lead to peritonitis, with high mortality risk.
Gallbladder empyema (suppurative cholecystitis)
Chronic cholescystitis- repeated episodes lead to fibrosed and shrunken gallbladder.

Question 13

Define acute cholangitis.

Answer 13

Infection of the bile duct, usually with Klebsiella, E.coli or Enterobacter.
Risk factors- ERCP, biliary malignancy.
AKA ascending cholangitis.

Question 14

What are the clinical features of acute cholangitis?

Answer 14

Charcot’s triad-
RUQ pain
Jaundice
Fever

(ALL 3 PRESENT IN OVER 60%)

Question 15

How is acute cholangitis investigated?

Answer 15

Bloods-
FBC- raised WBC
LFTs- raised bilirubin, raised alk phos, raised GGT

Imaging-
US
MRCP

Question 16

How is acute cholangitis managed?

Answer 16

IV antibiotics
Fluids
ERCP once stable. Involves sphincterotomy and stone clearance. Stenting if stones cannot be retrieved.
Cholecystectomy /CBD clearance is an alternative option.

Question 17

Define/describe gallstone ileus.

Answer 17

Large gallstone erodes through gallbladder and into duodenum, causing small bowel obstruction.
Stones that are small enough to pass through the sphincter of Oddi are unlikely to cause obstruction.
Usually impacts at narrowest point in small bowel, 2 feet proximal to the ileocecal valve.
Abdominal XR shows dilated loops of bowel and air in the biliary tree (entered through the fistula)

Question 18

What is acute pancreatitis?

Answer 18

Involves intra- pancreatic activation of pancreatic enzymes and auto-digestion.
Inflammation leads to oedema, fluid shifts and hypovolaemia.
In severe disease, there is erosion of vessel walls and intra-abdominal bleeding.

Question 19

What are the causes of acute pancreatitis?

Answer 19

I GET SMASHED

Idiopathic (20%)
Gallstones (50%) common in women
Ethanol (20%) common in men
Trauma
Steroids
Mumps/ Malignancy
Auto-immune
Scorpion Sting
Hyperlipidaemia/Hypercalcaemia
ERCP
Drugs eg. valproate, azathioprine, thiazides.

Question 20

How does acute pancreatitis present?

Answer 20

Sudden onset epigastric or LUQ pain and tenderness. radiates to back.
Nausea, anorexia and vomiting.
SIRS
May be jaundiced if due to gallstones.
Pleural effusion and ascites if severe.
In haemorrhage pancreatitis, bruising over both flanks (Grey-Turner’s sign) and or peri-umbilicus (Cullen’s sign)

Question 21

How is acute pancreatitis diagnosed?

Answer 21

Diagnosis requires 2 out of 3 from-

• Compatible hx/exam
• Raised amylase or lipase (<3 times upper limit) lipase is more sensitive and specific and elevated for longer.
• Compatible CT, MRI or US findings.

Question 22

What other investigations might you do in acute pancreatitis?

Answer 22

Bloods-
FBC- raised WBC, raised RBC (dehydration) or low RBC (haemorrhage)
Raised CRP
Raised LFT- especially gallstones
ABG- may show lactic acidosis or hypoxia
Low calcium- common in severe pancreatitis

Imaging-
Abdominal XR- dilated gut next to pancreas
CXR- pleural effusions
Ultrasound- May show pancreatic inflammation, but mainly done to find gallstones. Repeat after acute phase if gallstones are found.
Abdominal CT with contrast or MRCP are the gold standard, but only needed if diagnosis is uncertain.

Question 23

How is acute pancreatitis managed?

Answer 23

Initial-
Supportive care- including plentiful fluids (plus catheterisation and fluid chart), analgesia, anti-emetics.
Antibiotics if there are signs of infection.
Routine nil by mouth not indicated. NG or NJ tube for nutrition if severe vomiting.
Calcium replacement if needed.
If due to alcohol, give benzodiazepines and micronutrients (thiamine, folate & B12)

Interventional Treatments-
Necrosectomy if there is infected necrosis- removal of necrotic tissue and placement of irrigation tubes.
Drainage of pseudocyst (endoscopic US guided or surgical) if symptomatic or infected.
If due to gallstones, offer cholecystectomy or ERCP after recovery. Perform ERCP acutely if there is CBD obstruction or cholangitis.

Question 24

What is the Glasgow Prognostic Score?

Answer 24

Risk stratify with Glasgow Prognostic Score-
PANCREAS
PaO2<8
Age>55
Neutrophilia WBC>15
Ca<2mmol/L
Renal impairment (urea>16mmol/L)
Enzymes (raised LDH&AST)
Albumin<32g/L
Sugar (glucose)>10mmol/L

Score equal to or greater than 3 is SEVERE.

Question 25

What are the complications of acute pancreatitis?

Answer 25

• 20% mortality if severe, but 1% if mild (80% of cases)
• Pancreatic necrosis and infection suggested by rising CRP
• Pancreatic abscess, pancreatic insufficiency or chronic pancreatitis
• Pseudocyst- fluid in lesser peritoneal sac
• Sepsis and DIC
• Multi-organ failure- AKI, ARDS, paralytic ileus

Question 26

Define chronic pancreatitis.

Answer 26

• Similar causes to acute pancreatitis and may follow repeated episodes.
• Distinguished from repeated acute episodes by presence of exocrine or endocrine dysfunction.
• Commonest cause- alcohol (75%), idiopathic.

Question 27

How does chronic pancreatitis present?

Answer 27

• Recurrent or chronic epigastric pain radiating to back.
• Exocrine pancreatic insufficiency causing steatorrhea and malnutrition.
• Diabetes

Question 28

How is chronic pancreatitis investigated?

Answer 28

Blood glucose.

CT (ideally) or US: pancreatic calcifications.

Question 29

How is chronic pancreatitis managed?

Answer 29

Analgesia
Enzyme supplements.
Diabetes management.
Dietician support.
Manage alcohol problems.

Question 30

Describe laparoscopic cholecystectomy.

Answer 30

Laparoscopic cholecystectomy
Procedure
First port is placed in umbilicus, abdomen is insufflated, then three other ports are placed.
Operative cholangiogram can be performed to check for CBD stones, and removal if found.
Gallbladder removed through umbilicus.
Outcomes vs. open surgery
Shorter stay and quicker recovery.
No difference in mortality or complications.
Complications
General complications of abdominal laparoscopic surgery:

Surgical pneumoperitoneum reduces venous return causing cardiorespiratory strain. May be poorly tolerated by patient with heart or lung disease.
Technically more difficult than open surgery, so requires longer training and more equipment.
May require conversion to open surgery.
Specific to laparoscopic cholecystectomy:

Bleeding. Relative to open surgery, it may be harder to deal with intraoperative bleeding (e.g. cystic or hepatic artery), so a bleeding disorder is a contraindication.
Common bile duct injury, though similar risk as open surgery.
Missed CBD stones.
Sub-hepatic abscess.
Bowel injury.
Potential seeding of tumour if gallbladder cancer is present. Suspected cancer is therefore a contraindication.

Question 31

Describe ERCP.

Answer 31

Endoscopic retrograde cholangiopancreatography (ERCP)
Procedure
Upper GI endoscopy with injection of radiocontrast into the biliary tree and pancreas. Can then proceed to biliary or pancreatic sphincterotomy, stone clearance, and biliary or pancreatic stenting.

Indications and uses
Common bile duct stones.
Acute cholangitis.
Can be used for diagnostic purposes, but given risks, MRCP is better in such cases, with ERCP reserved for therapeutic use.
Complications
Inflammatory:

Acute pancreatitis.
Cholangitis
Traumatic:

Bleeding. If sphincterotomy being performed, minimize bleeding risk by stopping warfarin, clopidogrel, and ticagrelor 5 days before, and DOACs 2 days before. For stenting, continue warfarin (if in range), clopidogrel, and ticagrelor as normal, and omit DOAC on morning of procedure.
GI perforation.
Bile duct injury.
Percutaneous transhepatic cholangiography (PTC)
An alternative to ERCP in those with hilar obstruction.