Biliary & Pancreatic Disorders

Question 1

Acute Cholecystitis

Answer 1

• Definition: inflammation & infx of the gallbladder due to obstruction of the cystic duct by gallstones
• Bugs:
  
  • E.coli (most common)
  • klebsiella, streptococcus
• S/sxs:
  
  • steadily increasing RUQ abd pain: may be precipitated by fatty foods or large meals
  • Fever
  • nausea, anorexia
• PE:
  
  • enlarged palpable gallbladder
  • Murphy’s sign: RUQ pain or inspiratory arrest when the provider hooks their hand under the rib cage and the pt takes a deep breath
  • Boas sign: referred pain to right shoulder, due to phrenic nerve irritation
• Dx:
  
  • US = 1st line imaging → thickened gallbladder wall, pericholecystic fluid
  • Labs:
    
    • Leukocytosis, increased bilirubin, increased alkaline phosphatase, increased LFTs
  • HIDA: = Gold Standard
• Tx:
  
  • NPO, IV fluids
  • IV abx (ceftriaxone + Metronidazole)
  • Laparoscopic cholecystectomy
  • Cholecystostomy drain: consider if the patient is too sick for surgery

Question 2

Acalculous Cholecystitis

Answer 2

• Definition:
  
  • acute necroinflammatory disease of the gallbladder NOT due to gallstones
• Pathophys:
  
  • gallbladder stasis & ischemia → local inflammatory rxn
• Risk:
  
  • current hospitalization, criticall ill patient
• Classic Patient: forty + fat + fertile
• S/sxs:
  
  • abd discomfort
  • fever
  • jaundice
  • sepsis
• Dx:
  
  • US: thickened gallbladder wall, pericholecystic fluid
  • Labs: leukocytosis
• Tx:
  
  • supportive care: IV fluids, pain control
  • IV abx
  • consider cholecystectomy

Question 3

Chronic Cholecystitis

Answer 3

• Definition: fibrosis & thickening of the gallbladder due to chronic inflammatory cell infiltration of the gallbladder
  
  • almost always associated with gallstones
• Complications:
  
  • Calcium deposition → Porcelain gallbladder → Gallbladder cancer
  • *likely to occur in a pt with obesity, fatty diet, hypercalcemia, comorbidities

Question 4

Cholangitis

Answer 4

• Definition:
  
  • inflammation and infection of the bile duct** **system secondary to the obstruction of the common bile duct (gallstones)
• Bugs:
  
  • E.coli (most common), Klebsiella, Enterobacter
• S/sxs:
  
  • Charcot’s Triad:
    
    • -RUQ abd pain
    • -Fever
    • -Jaundice
  • Reynold’s Pentad: *If severe
    
    • -AMS
    • -Hypotension
    • +Charcot’s triad
• Grade:
  
  • I: symptomatic
  • II: systemic inflammation
  • III: organ dysfunction
• PE:
  
  • light-colored stools
  • dark tea-colored urine
• Dx:
  
  • US = good initial test
    
    • thickened bile duct
  • **in patients with Charcot’s triad and abnormal liver tests, proceed directly to ERCP to confirm the diagnosis and provide biliary drainage
  • ERCP: modality of choice because it is both diagnostic & therapeutic
  • Labs:
    
    • leukocytosis, increased alkaline phosphatase, increased bilirubin
• tx:
  
  • Medical Emergency → Admit pt to the hospital for eval and tx
  • (NPO!!!!)
  • IV abx
  • Endoscopic retrograde cholangiopancreatography: common bile duct decompression and stone extraction, insert a stent, repair sphincter
  • cholecystectomy performed post-acute

Question 5

Cholelithiasis

Answer 5

• Definition:
  
  • stones in the gallbladder without inflammation
• Types:
  
  • Cholesterol: most common (90%)
  • pigmented
  • blackstones: hemolysis, EtOH related cirrhosis
  • brown stones: asian, parasitic, bacterial infection
• Risks:
  
  • increased secretion of cholesterol
  • genetics
  • estrogen (OCP, women, pregnancy)
  • gallbladder hypomobility
  • rapid weight loss
  • **5 Fs: fat, fair, female, forty, fertile**
• S/sxs:
  
  • *Most are asymptomatic (incidental finding)
  • Biliary colic:
    
    • episodic RUQ abd pain exacerbated by fatty foods – resolves after 30 mins to a few hours
• Dx:
  
  • US: stones in gallbladder → after 8 hours of fasting (b/c gallstones are visualized better in distended, bile filled gallbladder)
  • Labs:
    
    • tend to be normal
    • ALK-P: normal, elevated if cholestasis
    • GGT: often used to confirm if ALK-P elevation is hepatic in origin
• Tx:
  
  • If asymptomatic = observation or oral bile dissolution tx
  • if symptomatic = laparoscopic cholecystectomy
• Complications:
  
  • choledocholithiasis, acute cholangitis, acute cholecystitis

Question 6

Choledocholithiasis

Answer 6

• Definition: stones in the common bile duct → cholestasis due to blockage
• S/sxs:
  
  • prolonged biliary colic (episodic RUQ abd pain exacerbated with fatty foods
  • N/V
  • Pale, fatty stool (b/c bile is not absorbing fat)
• PE:
  
  • RUQ tenderness
  • Jaundice
• Dx:
  
  • US: stones, dilated bile ducts
  • Labs:
    
    • elevated AST/ALT, increased alkaline phosphatase, increased GGT, increased bilirubin (conjugated & unconjugated)
  • ERCP: modality of choice b/c both diagnostic & therapeutic
• Tx:
  
  • ERCP for stone extraction

Question 7

Acute Pancreatitis: def, etiology, types, S/sxs, PE

Answer 7

• Definition:
  
  • sudden onset of inflammation of the pancreas → acinar cell injury → intracellular activation of pancreatic enzymes → autodigestion of the pancreas
• Etiology:
  
  • gallstones (40%), EtOH abuse (30%), elevated triglycerides
  • **GET SMASHED: gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion sting, hypercalcemia/hyperlipidemia, ERCP, drugs
• Types:
  
  • interstitial: mild
  • necrotizing: severe, increased risk with smoking, obesity, DM, EtOH
• S/sxs:
  
  • **Acute onset
  • Epigastric pain: radiates to the back, worse if lying supine, relieved by leaning forward
  • N/V, abd distention, FEVER
• PE:
  
  • epigastric tenderness, tachycardia, hypotension, distress/anxious , pulmonary effusion: rales, decreased breath sounds, ARDS
  • Necrotizing → pancreating bleeding:
    
    • Cullen’s sign: periumbilical ecchymosis
    • Grey Turner sign: flank ecchymosis

Question 8

Cullen’s Sign

Answer 8

associated with acute pancreatitis

periumbilical ecchymosis

Question 9

Grey Turner Sign

Answer 9

associated with acute pancreatitis

flank ecchymosis

Question 10

Acute Pancreatitis Dx & Tx

Answer 10

• Dx:
  
  • Need 2 of the following:
    
    • -characteristic abd pain
    • -lipase or amylase >3x normal
    • -characteristic findings of acute pancreatitis on imaging (CT, MRI, US)
  • Labs:
    
    • -increased amylase & lipase (levels do NOT equal severity)
    • CBC: hemoconcentration (Hct > 44, elevated WBC)
    • CMP: elevated glucose, BUN > 22, bilirubin, AST, ALP
  • abdominal CT = imaging of choice
  • AXR:
    
    • sentinel loop (localized ileus of a segment of small bowel in LUQ), colon cutoff sign (abrupt collapse of colon near pancreas)
  • US: to assess for gallstones
  • MRI: distinguishes liquid from solid, more important in surveillance rather than diagnosis
  • -EKG
• Tx:
  
  • *90% recover without complications in 3-7 days & require support care only
  • aggressive fluid resuscitation with LR (less acidic than normal saline → used when concern for metabolic acidosis)
  • NPO (x 24 hours at least)
    
    • diet change x 72 hours
      
      • DO NOT USE TPN
  • no role for abx use without a positive cx
  • glycemic control (insulin if elevated TGs)
  • ERCP (endoscopic retrograde cholangiopancreatography):
    
    • ONLY for patients with cholangitis or jaundice
  • Cholecystectomy:
    
    • if uncomplicated GS pancreatitis add to OR list as soon as admitted, if severe with necrosis may need necrosectomy (chole during debridement)
  • surgery:
    
    • infected or walled off necrosis

Question 11

Chronic Pancreatitis: definition, Pathophys, Risks, Etiology

Answer 11

• Definition: progressive inflammatory changes to the pancreas → scarring & structural changes → loss of pancreatic endocrine & exocrine function
• Pathophys:
  
  • inflammation → fibrosis, collagen deposition, irreversible parenchymal changes, destruction of acinar cells & B-cell function
• Risks:
  
  • men, cystic fibrosis, hereditary pancreatitis, EtOH, smoking, autoimmune, metabolic (hypercalcemia, hyperTG)
• Etiology:
  
  • autoimmune: lymphocytic/granulocytic → often present with jaundice
  • pancreatic ductal obstruction: neoplasm, trauma, inflammatory stricture

Question 12

Chronic Pancreatitis: S/sxs, Dx, & Tx

Answer 12

• S/sxs:
  
  • Epigastric pain: radiates to the back, worse if lying supine, relieved by leaning forward
  • Weight loss
  • jaundice
  • new onset insulin-dependent DM
    
    • endocrine insufficiency
  • steatorrhea
    
    • malabsorption - exocrine insufficiency
  • *Triad: Pancreatic calcification, steatorrhea, new onset DM
• Dx:
  
  • Amylase & Lipase are usually NORMAL
  • elevated glucose
  • CT/MRI: calcium deposition, pancreatic atrophy, pancreatic duct with stones/beading/enarlged
  • Pancreatic function testing
    
    • fecal elastase < 200 = abnormal
      
      • pancreatic stimulation with secretion (expensive and invasive)
  • Dx of autoimmune pancreatitis:
    
    • histology, imaging, serology (IgG4)
    • responds to steroids, dx of autoimmunity in another organ
• Tx:
  
  • analgesics: neuromodulators
  • glycemic control
  • Diet:
    
    • low fat, quit tobacco & alcohol
  • Oral pancreatic enzyme replacement
  • pancreatectomy
    
    • if retractable pain (however, this does not necessarily improve pain)