Biliary - GI Flashcards
Gallstone Formation
- Insidious onset, asymptomatic for decades
- Bile is produced in the liver, travels down hepatic duct to gallbladder
- 50% stored in the gallbladder
- Gallbladder contracts in response to a fatty meal
- Bile travels down cystic duct to common duct through Sphincter of Oddi into second portion of the duodenum
- Cholesterol and bile salts are needed to digest fats. If ratio of cholesterol is high or the bile is very concentrated then you form gallstones.
Types of Stones
Cholesterol (85%)
- Pure vs. Mixed
- Risk Factors: obesity, high-calorie diet, females, OCPs/estrogen medications
Pigmented (15%)
- Brown
- Calcium bilirubinate and calcium-soaps
- Asians
- Black: Excessive bilirubin + calcium bilirubinate, MC in chronic hemolysis, alcoholic cirrhosis, advanced age
General Symptoms Related to Gallstones
Abdominal Pain:
- RUQ is MC, can be epigastric
- Radiates to the back, usually tip of the scapula (right upper back)
- Visceral – vague, achiness, gnawing
- Parietal – sharp in quality, localized
Biliary Colic
- Waxes and wanes
- May be constant w/ waxing and waning
- May be constant
- Onset is w/in 15-60 minutes of eating, usually worse w/ fatty meal
- Lasts 15 minutes -> hours, resolve spontaneously
- Caused by obstruction of bile flow in the gallbladder, the cystic duct or common bile duct
- Jaundice
- Itching: Associated with cholestasis, worse at night; hands and feet (does not differentiate biliary vs. hepatic obstruction)
Gen PE Findings of gallstones
- Appearance: restless, anxious, uncomfortable
- Vitals: possibly normal, Fever = infection/inflammation, Tachycardic, HTN
- Eyes – icterus
- Heart/Lung – normal
- Skin – jaundice
- Rectal – GI bleed
- Abdominal: RUQ tenderness, Guarding on light palpation = peritonitis
- Positive Murphy’s test: Pain on palpation of, RUQ with deep inspiration, Pain during RUQ US due to pressure
Labs - Gallstone
Labs:
- CBC (infection)
- Liver Function Tests: Alk phosphatase, ALT, AST, bilirubin, Amylase & Lipase (pancreatitis)
- Renal function
- BUN, Cr
- UA
- Electrolytes
- Glucose
General Gallstone - Imaging
- EKG – if suspect cardiac disease
- Chest xray – perforated bowel (free air under the diaphragm), other cardiac/pulmonary dz
- US – TEST OF CHOICE: Fast, noninvasive, cheap, 95% accurate, not a good image for pancreas
- Nuclear Scintigraphy (HIDA scan): Sensitive and specific for cholecystitis, Second line if suspect with normal/inconclusive US
Cholelithiasis
-Etiology – stones in gallbladder resulting in acute RUQ pain
Symptoms
-RUQ pain, Nausea & Vomitting
PE findings
- Appear uncomfortable
- Positive Murphy’s sign
Diagnosis
-H&P -Risk Factors -Rule out cholecystitis (CBC), cholangitis, pancreatitis -History of gallstones on US
Management
-Analgesics (hydrocodone) -Anti-emetics (Odansetron, proclorperazine) -IV fluids -Surgery Consult
-Admission if severe, unrelenting, or unclear etiology
Acute cholecystitis
- Inflammation of the gallbladder due to obstructed cystic or bile duct.
- Begins after 5 hours of biliary-like pain.
- Starts as chemical irritation -> bacterial infection
- Symptoms: Nausea/vomiting, febrile, abdominal pain (RUQ)x 6 hrs
- Physical Exam: Fever, tachycardia, hypertension, Positive Murphy’s, RUQ tenderness w/ possible peritonitis signs
Acute Cholecystitis - Management
- Acute hospital admission
- IV fluids, NPO, pain management, correct electrolyte disorders
- IV antibiotics: Broad spectrum cephalosporins, Gram (-) and anerobic coverage
- Do not delay antibiotics while evaluating the patient
- Acute hospital admission + surgery consult
Cholecystectomy
- Laparoscopic (cost, definitive, safety, convenient)
- Open cholecystectomy (successful, longer recovery)
Non-surgical management
- Oral bile salt therapy
- Contact dissolution
- Extracorpeal shock-wave lithotripsy
choledocholithiasis
- Presence of 1+ gallstones in common bile duct
- Impacts the Ampulla of Vater (place where CBD and pancreatic duct join before entering duodenum)
- Abdominal pain, jaundice, loss of appetite, fever
- Stagnant bile can become infected -> back-up into the liver -> ascending cholangitis or pancreatitis
- Labs: Bilirubin, CBC, LFTs. Pancreatic enzymes
- Gastroenteritis or surgery referral
- May be candidate for ERCP (Enteroscopic retrograde cannulation pancreas) + sphincterotomy
- Surgical cut into the muscle in the common bile duct to allow stones to pass or be removed
Cholangitis
- Infection of the biliary system caused by an obstruction of the extrahepatic bile ducts
- Life-threatening illness
Presentation
- Variable presentation
- Charcot Triad – fever, RUQ pain, jaundice (20-70%)
- Sepsis, nausea, vomiting
Evaluation
- CBC, LFTs, amylase, lipase, blood cultures, US
- GI (ERCP) and Surgery Consultations
Treatment
- Emergent, broad spectrum antibiotics
- IV resuscitation
- Supportive care, ICU admission
Pancreatitis
- Inflammatory process where pancreatic enzymes autodigests the gland + an insulin/glucagan deficiency
- Premature activation of enzymes -> organ injury from inflammatory response and autodigestion -> hemorrhage, edema, necrosis -> systemic complications (ARDS, bacteremia, GI hemorrhage, ARF, shock)
Acute Pancreatitis - causes
Gallstones
- Most common
- Women>men
- Lodge into the Sphincter of Oddi
- Acinar cell injury -> increased ductal pressure
Alcohol
- 35% of cases
- Increased digestive enzymes -> leaks to parenchyma -> damage
- After 5-10 years drinking
- Men>Women
- Infections: mumps, HIV, viruses
- ERCP (endoscopic retrograde cholangiopancreatography)
- Medications – Azathioprine, sulfonamides, tetracycline, VPA, methyldopa, estrogen, furosemide, steroids
- Others: trauma, toxins, hypercalcemia, hypertriglyceridemia >1000mg/dL
Acute Pancreatitis- Age of Onset
- Alcohol-related - 39 years
- Biliary tract–related - 69 years
- Trauma-related - 66 years
- Drug-induced etiology - 42 years
- ERCP-related - 58 years
Acute pancreatitis - Long term complications
- Recurrent of chronic pancreatitis
- Diabetes Mellitus
- Digestive/malabsorption issues
- Manifestations: both appear as acute episode
Acute pancreatits - symptoms
Abdominal Pain – steady, boring through the back
- Epigastric
- Radiates to the back
- Rapid onset (over the course of a day)
- Constant
- Severe
- Not related to food
- Nausea/vomiting
- Possibly improved when sitting up/on their side
- Restless, uncomfortable
- Moderate distress
Vitals
- Normal
- Tachycardia, tachypnea, hypertensive
- Fever (can be low grade, usually not high grade)
ACUTE PANCREATITIS – PE
Abdomen
- Distended
- Discoloration (black & blue) if hemorrhagic pancreatitis
- Periumbilical – Cullen’s sign
- Flank – Grey Turner’s Sign
-Epigastric tenderness
+/- murphy’s sign
-No guarding likely
-Possible tympani if ileus
-Auscultation-decrease to absent bowel sounds
-Rectal Exam – possibly positive
-Pulmonary: Rales, decreased breath sounds if pleural effusion, Decrease breath sounds from hypoventilation 2/2 pain
-Cardiac – tachycardic
-Eyes – icterus if obstruction/alcoholic hepatitis
-Stigmata ofchronic alcoholic: Spider angiomas, Jaundice, Palmar erythema, Gynecomastia, Ascites, Encephalopathy, Asterixis.
-Skin: Stigmata of chronic alcoholic, Xanthomas of hyperlipidemia
Acute pancreatitis Diagnosis
- H&P (illness, risk factors)
- Physical
Labs
- Amylase/Lipase
- CBC – elevated WBC
- LFTS: ALT greater than 3x normal (>150) -> biliary marker, Alk Phos, bilirubin -> assess biliary function
- Imaging
- Prognostic Factors
Pancreatitis Labs - AMYLASE
- Rises within 6-24 hours
- Peaks 48 hours, normalizes in 5-7 days
- 3x normal = diagnostic - 70% specific
- Normal in chronic pancreatitis
- Can be elevated: ectopic pregnancies, parotitis, renal failure, bowel infarction/ischemia, perforated ulcer
Pancreatitis Labs - Lipase
- Increase in 4-8 hours
- Levels fall over 8-14 days
- Can be elevated in: duodenal ulcers, bowel obstruction, idiopathic
- More specific and equally sensitive to amylase (80-99% specific, more sensitive the higher the value)
- Degree of elevation of amylase/lipase does not equal severity of illness.
- Pick Lipase over Amylase if have to choose only one. Doing both is more specific for pancreatitis
Pancreatitis - Imaging
Xray Chest
- Air under diaphragm
- Pleural effusion
- Infiltrates in ARDS
Xray: Flat and upright of abdomen
-Gallstones, free air, ileus, bowel obstruction
CT abdomen
- Oral & IV Contrast
- Evaluate for other causes of pain & complications
- Not a good tool for biliary issues
US
- If evaluating for gallstones
- Do within 24 hours
Pancreatitis - Management
- Hospital Admission (unless stable)
- IV fluids (normal saline, I&O’s)
- Pain management (IV narcotics)
- Remove inciting factors: NPO, no etoh, start H2RB or PPI to block enzymes
-Treat metabolic abnormalities
Hyperglycemia – IV Insulin
Hypocalcemia – calcium gluconate
Hypomagnesemia – IV MgSO4
-GI referral (possible ERCP if common duct stone)
Nutritional Supplement
- TPN -> oral
- Pancreatic enzyme replacement if evidence of malabsorption
Surgery Consult
- If infected necrotic pancreas
- Pseudocyst
- Possible cholecystectomy
Follow up
- CD treatment
- Nutritional counseling
- Treat hypertriglyceridemia
Chronic pancreatitis
- Recurrent episodes -> permanent functional and morphological loss of the gland (fibrosis)
- 87,000 cases annually
- 3x more hospitalizations in AA than whites
- M>F
- Survival rates: 70% at 10 years, 45% at 20 years
Chronic pancreatitis - symptoms
- Chronic severe abdominal pain (mid-abdomen or left upper abdomen, can radiate bandlike around the mid-back)
- Pain lasts several hours
- Not affected by food
- Impairment of endocrine/exocrine function leading to diarrhea and steatorrhea (advanced stages).
Chronic pancreatitis - PE/Labs
-Exam may/may not be helpful.
-If during an attack: laying on left side, flexing spin and drawing knees up to the chest.
-Possible tender fullness/mass in epigastrium
-Signs of malnutrition.
Labs:
-Amylase/Lipase likely normal or mildly elevated
-Causes: Triglycerides (elevated TG), elevated serum calcium
-DM Type II (late complication)
-Steatorrhea
-Imaging: xrays show pancreatic calcification (pathopneumonic) 30% of cases
Chronic pancreatitis - Management
Management
- Outpatient
- Pain medications
- Similar to acute pancreatitis treatment,
- Pancreatic enzyme replacement if steatorrhea
Prevention
Pharm
-Treat hypertriglyceridemia
-Supplement of fat soluble vitamins & B12 due to malabsorption
Nonpharmacologic
- No alcohol
- low fat diet
- six small feedings
- Watch for glucose intolerance
