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Gallstones and pancreatitis

Gallstones and pancreatitis. a lex knight. Topics. Case Presentation Bile and LFT’s Gallstones Risk Factors Complications + Presentations. Clinical Scenario.

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Gallstones and pancreatitis

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  1. Gallstones and pancreatitis alex knight

  2. Topics • Case Presentation • Bile and LFT’s • Gallstones • Risk Factors • Complications + Presentations

  3. Clinical Scenario • A 45 year old female presents to A&E with an hour long history of severe RUQ pain, and associated vomiting. She has had this in the past few weeks but now its got worse

  4. She has no significant past medical history, is on no regular medication, and has no allergies. She does not smoke, drinks 14 units of alcohol per week and works as a market analyst.

  5. On examination she is febrile at 38.5, tachycardic at 110bpm and her BP is 135/65. On palpation, her abdomen is soft but tender in the RUQ. Murphy’s sign positive

  6. Investigations • Bedside tests • Observations • Blood tests • LFTs • Serum bilirubin • ALP • FBCs • High WCC • Inflammatory markers • CRP • Imaging • Abdominal Ultrasound scan

  7. Management • Conservative • NBM • IVI fluids • Analagesia • Medical • Antibiotics? • Surgical • Laparascopic +/- open cholecystectomy

  8. Liver Functions • Digestion • processing digested food • breaking down food and turning it into energy • Homeostasis • controlling levels of fats, amino acids and glucose in the blood • storing iron, vitamins and other essential chemicals • manufacturing, breaking down and regulating numerous hormones including sex hormones • Immune • combating infections in the body • clearing the blood of particles and infections including bacteria • neutralising and destroying drugs and toxins • Blood • manufacturing bile • Enzymes and proteins - those involved in blood clotting and tissue repair.

  9. Bile • Water, • Electrolytes, • Bile acids, • Cholesterol, • Phospholipids • Conjugated Bilirubin

  10. Bile Metabolism

  11. Liver Function Tests and Bile • Albumin • General synthetic function + severity of Liver disease • Clotting • Also synthetic - Prothrombin time (INR) • Total Bilirubin • Processing function • Aminotransferases (AST+ALT) • Mitochondrial and cytosolic enzymes – ALT more specific • ALP • Enzyme in the cells lining the biliary ducts of the liver • γGlutamyl-transpeptidase (GGT) • A rough marker of alcohol consumption if ALP is normal

  12. Gallstones • 80% - “Cholesterol” Stones • Cholesterol supersaturation of bile • Proportion to bile salts and phospholipids • Crystallisation-promoting factors • Bile salt loss in terminal Ileum in Crohn’s Disease • Motility of gall bladder • 20% - “Pigment” Stones • Calcium Bilirubinate • Haemolytic Diseases • Cause of recurrent stones post cholecystectomy

  13. Risk Factors • Increasing age • Rapid weight loss • Drugs – OCP • Ileal disease or resection • Diabetes

  14. Presentations/Complications • Asymptomatic – Incidental finding • In the Gall bladder • Chronic Cholecystitis • Biliary Colic • Acute Cholecystitis • Empyema of the gallbladder • Biliary peritonitis • Abcess • Mucocoele • Carcinoma of the gallbladder • In the common bile duct • Obstructive jaundice • Cholangitis • Pancreatitis

  15. Chronic Cholecystitis • Abdominal Pain • Indigestion • Bloating • Burping • Nausea • Important differentials – peptic ulcer and hiatus hernia

  16. Biliary Colic • Spasm pain when the gallbladder contracts against a stone in the Hartmann’s Pouch • Epigastrium or RUQ • Constant, not in waves • Extremely severe – sweaty, writhe around • Important Differentials: Perforated peptic ulcer, pancreatitis, ruptured aneurysm

  17. Acute Cholcystitis • Usually progression of biliary colic • Increased glandular secretion • Distension – possible impeding vascular supply • Chemical Inflammation • Bacterial Infection • Murphy’s sign • Patients lie still • Local Peritonitis • Important Differentials: Basal Pneumonia, Intrahepatic Abcess, Perforated peptic ulcer, pancreatitis, ruptured aneurysm

  18. Investigations • Bedside tests • Observations • Blood tests • LFTs • Serum bilirubin • ALP • FBCs • High WCC • Inflammatory markers • CRP • Imaging • Abdominal Ultrasound scan

  19. Management • Conservative • NBM • IVI fluids • Analagesia • Medical • Antibiotics? • Surgical • Laparascopic +/- open cholecystectomy

  20. Cholecystectomy • Complications • General • Bleeding • Infection • Pneumoperitoneum – vagus nerve – decereased cardiac output • Specific • Bleeding from cystic artery is more difficult to stop haemodynamically • Common Bile Duct Injury or stone movement. • Bowel Perforation

  21. Common Bile Duct RUQ Pain Fever/Rigors Jaundice

  22. Triad only present in minority • Pain is the most common • In comparison to jaundice from malignancy the Jaundice fluctuates • Fever indicates biliary sepsis

  23. Investigations • Bedside tests • Observations • Blood tests • LFTs • Serum bilirubin • ALP • FBCs • High WCC • Inflammatory markers • CRP • Imaging • Abdominal Ultrasound scan • CT • Special Tests • ERCP • MRCP

  24. Management • Conservative • NBM • IVI fluids • Analagesia • Medical • Antibiotics • Surgical • ERCP

  25. Pancreatitis

  26. Pancreatitis • Mild: • Enzymatic spillage • Inflammatory cascade activation and • Localized oedema. Local exudate may also lead to increased serum levels of pancreatic enzymes. • Moderate: • Increasing local inflammation bleeding, fluid collections and spreading local oedema involving the mesentery and retroperitoneum other organs. • Severe: • Necrosis • Profound localized bleeding and fluid collections • Spread to local structures mesenteric infarction, peritonitis and intra- abdominal fat ‘saponification’. • A persisting accumulation of inflammatory fluid, usually in the lesser sac, is a pseudocyst, i.e. does not have an epithelial lining.

  27. At admission: • Age in years > 55 years • White blood cell count > 16x10/l • Blood glucose > 11 • Serum AST > 200 • Serum LDH > 500 • Within 48 hours: • Calcium < 2 • Hematocrit fall > 10% • Oxygen PO2 < 8kPa • BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration • Base deficit (negative base excess) > 4 • Sequestration of fluids > 6 L

  28. ERCP • Endoscopic Retrograde CholangioPancreatography • Diagnostic +/- Therapeutic • Stone extraction • Fogarty balloon • Basket catheters • Sphincterotomy

  29. ERCP Risks • Bleeding – especially if Sphincterotomy is concerned • Infection – cholangitis in the bile duct. • Pancreatitis – 5% • Younger patients, • Previous post-ERCP pancreatitis • Females • Procedures that involve cannulation or injection of the pancreatic duct • Patients with sphincter of Oddidysfunction • Gut perforation • Additional risk if a sphincterotomy is performed. • D2 is anatomically retroperitoneal, perforations due to sphincterotomies are also retroperitoneal. • Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting. • There is also a risk associated with the contrast dye in patients who are allergic to compounds containing iodine.

  30. MRCP Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique that uses magnetic resonance imaging to visualise the biliary and pancreatic ducts in a non-invasive manner

  31. 3 things I want you to take away 1 • Complications/Presentations • Investigations • Ranson’s Criteria 2 3

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