GIS Case 3: Acute Pancreatitis

Question 1

Anatomy and Physiology of Hepato-Biliary tree and Pancreas

Answer 1

See lecture

Question 2

Acute Pancreatitis and its presentation

Answer 2

See lecture

Commonest etiologies:

1. Biliary tract disease
   - Gallstones
2. Alcoholism

Autodigestion of parenchyma by inappropriately activated enzymes

1. Pancreatic duct obstruction
2. Primary acinar cell injury
3. Defective intracellular transport

Clinical features:

1. Sudden abdominal pain + Vomiting after meal
2. Raised amylase level
3. Shock, acute renal failures, Adult respiratory distress syndrome

Complications:

1. Systemic organ failure
2. Chemical peritonitis
3. Retroperitoneal haemorrhage
4. Local abscess
5. Pseudocyst
6. Necrotising pancreatitis

Question 3

Types of gallstones and their etiologies

Answer 3

1. Cholesterol stone
   - yellow
   - ↑ secretion of cholesterol (Hyperlipidaemia)
   - ↓ bile acid pool —> ↓ solubility of cholesterol
2. Pigment stone
   - ↑ Bilirubin due to haemolysis, cirrhosis, biliary tract obstruction

• Black: pure calcium bilirubinate
  —> stasis / excess unconjugated bilirubin (Haemolysis)
  —> ***stay in gallbladder
• Brown: calcium salts of unconjugated bilirubin with **small amounts of cholesterol + protein
  —> due to inflammation / infection e.g. **Recurrent pyogenic cholangitis (Intrahepatic bile ducts)
  —> ***inside bile ducts which lead to obstruction

Question 4

Clinical presentations of gallstones

Answer 4

1. Asymptomatic
   - stones in gallbladder
2. Gallbladder
   - Cholescystitis
   - Obstruction of cystic duct —> infection —> Empyema
3. Bile ducts within liver
   - Cholangitis
4. Obstruction of common bile duct
   - Jaundice
   - Cholangitis
   - Pancreatitis

Question 5

Causes of severe abdominal pain

Answer 5

Epigastric pain DDX:

1. Acute MI
2. Acute pancreatitis
3. Chronic pancreatitis
4. Peptic ulcer
5. Gastritis
6. GORD
7. Functional dyspepsia
8. Gastroparesis
9. Gallstones

RUQ:

1. Biliary
   - Cholangitis
   - Cholecystitis
2. Hepatic
   - Hepatitis
   - Liver abscess
   - Portal vein thrombosis

LUQ:

1. Splenomegaly
2. Splenic rupture
3. Splenic infarct
4. Splenic abscess

Question 6

***Diagnosis of acute biliary pancreatitis

Answer 6

1. Physical examination
   - Acute onset of persistent severe epigastric pain
   - Tender on palpation
   - Abdominal distension
   - Hypoactive bowel sound ∵ ileus secondary to inflammation
   - Jaundice due to ***Choledocholithiasis (i.e. Common bile duct stone)
   - Hypotension ∵ fluid loss during pancreatitis + vomiting
   - Tachycardia to compensate
2. Blood test
   - ↑ Amylase / Lipase
   - ↑ Hct (∵ Hemoconcentration / decrease in plasma volume)
   - Leukocytosis (∵ Hemoconcentration / decrease in plasma volume)
   - ↑ Glucose (∵ Hypoinsulinaemia)
   - ↑ Blood urea nitrogen (∵ Hemoconcentration / decrease in plasma volume)

Presence of 2 of following 3 criteria:

1. Acute onset of persistent severe epigastric pain
2. Elevation of serum amylase (less specific due to saliva) / lipase (more specific) >=3 times above upper limit
3. Imaging
   - X-ray: **localised ileus of a segment of small intestine
   - CT: **interstitial edematous pancreatitis, necrotic tissue, visualise common bile duct stones
   - MRI: **enlargement of pancreas, margins of pancreas blurred
   - Transabdominal ultrasound: **enlargement of pancreas, **Hypoechoic secondary to fluid exudation, **gallstones visualised in gallbladder / bile duct

Question 7

Management of acute biliary pancreatitis

Answer 7

1. Remove insult
   - Endoscopic ultrasound (EUS)
   - Endoscopic retrograde cholangiopancreatography (ERCP)
   —> combine upper GI endoscopy + X-ray
   —> inject contrast medium
   —> X-ray to examine ducts
   —> pass tiny tools to open blocked ducts, break up / remove stones, biopsy, remove tumour, insert stents
2. Restricted oral intake
3. Fluid replacement: IV fluid / nutrition
4. Analgesic
5. Elective cholecystectomy
6. Medication to dissolve gallstones (take years and stones will recur after stopping)