Gallbladder and Pancreas Diseases

Question 1

Give causes of pancreatitis

Answer 1

Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune disease eg SLE, Scorpion, Hypercalcemia, ERCP, Drugs eg diuretics or NSAIDS

Question 2

How would you assess severity of pancreatitis?>

Answer 2

Severity of pancreatitis assessed via modified glasgow critera.
Mnemonic is PANCREAS:
P - PaO2 less than 8kPa
A - Age 55+-years-old
N - Neutrophilia: WCC more than 15x10(9)/L
C - Calcium less than 2 mmol/L
R - Renal function: Urea more than 16 mmol/L
E - Enzymes: LDH more than 600iu/L; AST more than 200iu/L
A - Albumin less than 32g/L (serum)
S - Sugar: blood glucose more than 10 mmol/L

Question 3

Investigations if pancreatitis suspected?

Answer 3

• Serum amylase - 3x upper limit of normal
  
  • LFTs - gallstones can cause pancreatitis
  • Serum lipase
  • Imaging - USS AP and CT scan

Question 4

Clinical features of pancreatitis?

Answer 4

• Sudden onset Epigastric pain, may radiate to back
  
  • N&V
  • Severe pancreatitis - guarding and rigid abdomen
  • Grey turners and cullens sign

Question 5

Management of panreatitis?

Answer 5

• High flow O2
  
  • IV fluids - 500ml/hr of crystalloid
  • Nasogastric tube if pt vomiting
  • Catheterisation to monitor urine output
  • Opioid analgesia

Question 6

Risk factors for biliary colic?

Answer 6

5 Fs - Fair, Fat, Forty, Fertile, Family history

Question 7

Management of biliary colic?

Answer 7

• Analgesia eg morphine.
  
  • Elective cholecystectomy can avoid future recurrence with worse consequences
  • Offer lifestyle advice

Question 8

Symptoms and clinical features of biliary colic?

Answer 8

• No inflammatory response
	• Sudden pain, dull, colicky (waxes and wanes, not true colick)
	• RUQ focus
	• N&V
	• Fatty foods make worse
Settles with analgesia

Question 9

How to distinguish between biliary colic and cholecystitis

Answer 9

Biliary colic does not involve any inflammation. Colic also settles with analgesia where as cholecystitis does not

Question 10

Investigations if biliary colic is suspected?

Answer 10

• FBC and CRP for inflammation
  
  • U&Es - assess for dehydration
  • LFTs - damage to liver can occur

Amylase - damage to pancreas can occur

Question 11

What imaging would you use for biliary colic and cholecystitis? What are you looking for?

Answer 11

Use USS AP. Look for:
• Presence of gallstones
• Gallbladder wall thickness - thicker = inflamed
• Bile duct dilatation

Can also use a CT scan with higher sensitivity. MRCP is gold standard.

Question 12

Symptoms of cholecystitis

Answer 12

• RUQ pain, sudden, dull colicky
  
  • N&V
  • Inflammatory response
  • More persistent despite analgesia
  • Positive murphys sign - Apply pressure on RUQ and ask to inspire, will result in halt in inspiration due to pain.

Question 13

Management of cholecystitis

Answer 13

• Antibiotics - IV coamox and metronidazole
  
  • Fluid resus pathway if signs of sepsis evident
  • NG tube if pt vomiting
  • Cholecystectomy necessary

Question 14

Investigations if cholecystitis suspected?

Answer 14

• FBC and CRP for inflammation
  
  • U&Es - assess for dehydration
  • LFTs - damage to liver can occur
  • Amylase - damage to pancreas can occur

Question 15

What is cholangitis? what is it caused by?

Answer 15

Infection of biliary tracts, potentially caused by any condition that occludes biliary tree. Common causes are gallstones, ERCP, cholangiocarcinoma.

Question 16

Why is cholangitis not a complete diagnosis?

Answer 16

CHOLANGITIS IS NOT A COMPLETE DIAGNOSIS - There is always an underlying cause that must be treated

Question 17

Symptoms of cholangitis?

Answer 17

• RUQ pain - Charcots triad
  
  • Fever - Charcots triad
  • Jaundice - Charcots triad
  • Pruritis

Question 18

Management of cholangitis?

Answer 18

• Fluid resus pathway if septic signs
  
  • Broad spectrum IV antibiotics - Coamox and metronidazole
  • ERCP to remove biliary obstruction. Can also place stent

Question 19

Investigations of cholangitis?

Answer 19

• FBC - raised WCC
  
  • LFTs - raised Alp and bilirubin

Blood cultures

Question 20

Imaging for cholangitis?

Answer 20

• USS AP - bile duct dilatation,

* ERCP is diagnostic and therapeutic but invasive

Question 21

What is cholangiocarcinoma? Where is it most likely found and whats that called?

Answer 21

Cancer of bile duct system. Most common area is bifurcation of right and left hepatic ducts (klatskin tumours)

Question 22

Investigations for cholangiocarcinoma

?

Answer 22

• Elevated bilirubin, ALP, gamma-GT
  
  • Tumour markers CEA and CA19-9

Deranged LFTs

Question 23

Imaging for cholangiocarcinoma

Answer 23

• USS to confirm obstruction
  
  • CT to stage disease
  • MRCP to diagnose if unsure by CT.

Question 24

Risk factors for cholangiocarcinoma?

Answer 24

• UC
  
  • Infective - hep virus, HIV
  • Toxins
  • Congenital
  • Alcohol

Diabetes

Question 25

Management of cholangiocarcinoma

Answer 25

• Complete surgical resection
	• Radiotherapy
	• Palliative most likely needed:
		○ Stent to get rid of obstructive symptoms
		○ Radiotherapy to prolong survival

Question 26

Clinical features of cholangiocarcinoma? How late does it present?

Answer 26

• Asymptomatic until late stage
  
  • Jaundice, pruritis
  • Pale stools
  • Dark urine

Courvoisiers law - presence of jaundice and enlarged/palpable gallbladder, suspect biliary or pancreatic cancer