Week 7/8 - C - Asymptomatic Gallstone, Acalculous cholecystitis, Gallstone ileus, Acute pancreatitis (pseudocyst, asbcess, necrosis)

Question 1

What is the treatment of a patient who is found to have gallstones incidentally? - asymptomatic gallstones

Answer 1

Asymptomatic gallstones which are located in the gallbladder are common and do not require treatment. However, if stones are present in the common bile duct there is an increased risk of complications such as cholangitis or pancreatitis and surgical management should be considered.

Question 2

What is acalculous cholecystitis?

Answer 2

Acalculous cholecystitis is an inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction It is a rare but usually more severe form of cholecystitis

Question 3

What is acalculous cholecystitis often a complication of?

Answer 3

* Acalculous cholecystitis can be caused by accidental damage to the gallbladder during major surgery or * Serious injuries (trauma) or burns * Sepsis * Severe malnutrition or * HIV/AIDS.

Question 4

How does acalculous cholecystitis present?

Answer 4

The presentation is the same as calculous acute cholecystitis Patient typically presents with RUQ pain, and fever However jaundice can occur with this (still cholangitis is more common but US / MRCP will differentiate)

Question 5

What is the treatment of acalculous cholecystitis?

Answer 5

Treatment is IV antibiotics and laproscopic cholecystectomy within 7 days (preferably within 48 hours)

Question 6

Gallstone ileus Patients with this condition may have a known history of previous cholecystitis and known gallstones - ie patients with chronic cholecystitis How does gallstone ileus occur?

Answer 6

In gallstone ileus, a fistula is formed between the gallbladder and the duodenum as a stone erodes through The large gallstone passes into the small bowel and usually obstructs the small bowel distally at the terminal ileum

Question 7

What are the presenting symptoms of gallstone ileus?

Answer 7

Typically patients have a long history of recurrent right upper quadrant pain, in keeping with chronic cholecystitis with repeated inflammatory event Small bowel obstruction symptoms * Abdo distension and vomiting (may be faeculent) * Borbogymia * Pain

Question 8

What is used to diagnosed the small bowel obstruction and what does it show? (just for small bowel obstruction - will ask what extra signs are seen in gallstone ileus)

Answer 8

AXR is typically used to diagnose small bowel obstruction (CT can be used if uncertain) Will show central gas shadows due to dilated small bowel with valvulae conniventes that completely cross the bowel

Question 9

What is the classical triad of signs seen on AXR in gallstone ileus? - state the name and the triad

Answer 9

The classic triad is known as Rigler’s triad Seen is * Air in the common bile duct - pneumobilia * Dilated small bowel due to small bowel obstruction * And a gallstone

Question 10

What is the treatment of gallstone ileus?

Answer 10

Urgent laparotomy - small bowel enterotomy to remove gallstone (aka enterolithotomy) Interval elective cholecystectomy in 3 months

Question 11

Pancreas What are the different parts of the pancreas? What are the two functioning parts of the pancreas?

Answer 11

Pancreatic head, neck, body, tail and uncinate process Exocrine pancreas - acinar cells secrete pancreatic digestive ezymes Endocrine pancreas- islets of langerhans secrete hormones into the blood

Question 12

Name some of the different secretions from the pancreatic acinar cells? What regulates secretion of the digestive enzymes?

Answer 12

Secretions are regulated by the vagus nerve and cholecystokinin (gastrin levels also play a part) * Proteases - trypsinogen and chymotrypsingoen are released as inactive forms in the pancreas and converted to active by enterokinases released from the dudoenum * Pancreatic amylase and pancreatic lipase is also released

Question 13

What are the cells of the iselts of langerhans and what do they release?

Answer 13

Most abdunant cell type Beta cells which secrete insulin (lowers blood glucose levels) Alpha cells which secrete glucagon (increases blood glucose levels) Delta cells which secrete somatostatin F cells which secrete pancreatic polypetpide

Question 14

Acute pancreatitis * Pancreatitis is an acute inflammatory response involving the pancreas and a common cause for hospital admissions * Inflammation of the pancreas may be acute or chronic - overlap does exist What are the different causes of acute pancreatitis? What is the most common cause?

Answer 14

* Gallstones - most common cause * Ethanol (alcohol) - second most common cause * Trauma * Steroids * Mumps (&infections eg coxsackie B & viral hepatitis) * Autoimmune (eg polyaerteritis nodosa) * Scorption bites * Hyperlipidaemia, hypothermia, hypercalcaemia * ERCP * Drugs (eg azathioprine)

Question 15

What is the possible pathophysiology of pancreatitis?

Answer 15

Acute pancreatitis occurs when there is abnormal activation of digestive enzymes within the pancreas. * eg gallstones obstructing ampulla of vater leading to reflux of bile into pancreas Potentially causes the autodigestion of pancreatic tissue by the pancreatic enzymes leading to pancreatic necrosis and hypovalaemia as extracellular fluid is trappied in the gut, peritoenum and retroperitoneum

Question 16

What is the classical presentation of a patient with acute pancreatitis?

Answer 16

Severe, acute, constant epigastric pain that may radiate through to the back - pain may be relieved bby sitting forward Nausea and vomiting is common Fever and jaundice are sometimes present

Question 17

What are the different signs of acute pancreatitis? What are the two rare, but classic signs on the abdomen? - why do they occur

Answer 17

Diffuse upper abdominal tenderness - can present like peritonitis sometimes Shock (low BP and high HR) Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare - form due to blood vessel autodigestion and retroperitoneal haemorrhage

Question 18

What is the immediate management / investigation of a patient suspected of acute pancreatitis?

Answer 18

Immediate management * IV access and fluids * ABG to monitor oxygenation and acid base status Immediate investigations Raised serum amylase - 3-fold upper limit of normal - degree of elevation not related to severity AXXR USS for all patients with acute pancreatitis - detects gallstones, CBD size, cholecystiits

Question 19

Does a normal serum amylase rule out a diagnosis of acute pancreatitis? What enzyme is starting to be measured more in patients with pancreatitis and why?

Answer 19

Normal serum amylase levels do not rule out a diagnosis - levels take a couple of hours to begin to rise and start to fall within 24-48 hours. Presentation outwith these times may not have the 3fold elevation Serum lipase is more sensitive and specific for pancreatitis (especially alcohol related), rises earlier and falls later

Question 20

What is the modified Atalanta criteria for diagnosing acute pancreatitis? (3 factors)

Answer 20

The revised Atlanta classification requires that two or more of the following criteria be met for the diagnosis of acute pancreatitis: * (a) abdominal pain suggestive of pancreatitis, * (b) serum amylase or lipase level greater than three times the upper normal value, or * (c) characteristic imaging findings

Question 21

What investigation is carried out to assess the severity of pancreatitis, assess for complications and when is this carried out?

Answer 21

CT scan is carried out at day 5 from the onset of symptoms in pancreatitis Asses the severity of the disease, looks for potential complications as well

Question 22

Name the main scoring system that is now used to score the severity of pancreatitis?

Answer 22

Modified (revised) Atlanta criteria

Question 23

What is the difference between mild, moderate and severe acute pancreatitis according to the modified Atlanta criteria?

Answer 23

Mild has local complications Moderate has organ failure that resolves within 48 hours (transient organ failure) +/- local complications in the absence of persistent organ failure Severe is characterized by single or multiple organ failure that persists for more than 48 hours

Question 24

What is the CRP level to diagnose severe acute pancreatitis? (used in ninewells)

Answer 24

CRP >150

Question 25

What are some of the potential complications of acute pancreatitis?

Answer 25

Death Local complications * Pseudocyst formation * Abscess formation * Pancreatic necrosis * Ascites Systemic * Hypocalcaemia * Hyperglycaemia * Pulmonary failure / ARDS * Meatbolic acidosis

Question 26

What are the principles of management of acute pancreatitis?

Answer 26

* Fluid resuscitation * Correct electrolyes * Careful fluid balance * Oxygen * IV antibiotics may help if severe disease

Question 27

If the person has acute pancreatitis caused by suspected or proven gallstones, what may management include?

Answer 27

Endoscopic retrograde cholangiopancreatography to relieve the obstruction, within 72 hours of the onset of pain, for those with cholangitis. Cholecystectomy during the same admission.

Question 28

* Local complications * Pseudocyst formation * Abscess formation * Pancreatic necrosis * Ascites Let’s discuss the management of some of the local complications of acute pancreatitis What causes pancreatitc pseudocyst formation?

Answer 28

Pseudocysts in acute pancreatitis result from organisation of peripancreatic fluid collection. The collection is walled by fibrous or granulation tissue and typically occurs 4 weeks or more after an attack of acute pancreatitis

Question 29

How does a pancreatic pseudocyst present and what is used to diagnose it?

Answer 29

Patient typically presents: Fever A mass +/- peristent mildy elevated amylase / LFts (can obstruct biliary tract), jaundice and weight loss May coomunicate with pancreatic duct Suspect when patient not responding to treatment CT scan is the diagnostic study of choice

Question 30

What is the treatment of a pancreatic pseudocyst?

Answer 30

Treatment options include * Symptomatic cases may be observed for 12 weeks as up to 50% resolve * Endoscopic drainage of the cyst * Radiological drainage of the cyst * or * Surgical drainage of the cyst

Question 31

How is a pancreatic abscess diagnose and what is the treatment?

Answer 31

Pancreatic abscess typically develop as the result of an infected pancreatic cyst * Intraabdominal collection of pus associated with pancreas but in the absence of necrosis * Diagnosed on CT They require drainage to prevent sepsis

Question 32

Pancreatic necrosis Pancreatic necrosis may involve both the pancreatic parenchyma and surrounding fat and is also diagnosed on CT scan Why does it occur? How is it treated?

Answer 32

Inflammatory mediators released in acute pancreatitis induce thrombosis and haemorrhage, leading to pancreatic necrosis. The necrotic area is initially sterile, but becomes infected with bacteria of gut origin in 40–70% of cases. Treatment is difficult Treatment may require antibiotcs and surgery