Gallstones/Pancreatitis for Finals

1. Gallstones/Pancreatitis for Finals Simon Bloomfield, FY1 General Surgery, SWFT

2. Foreword • The key to passing finals is both knowledge and technique • Clinicals 50/50 • Written SAQ 70/30 • Written EMQ/SBA 60/40 • I had to do further writtens because I did not prepare correctly • I don’t want you to repeat my mistakes • Practice, practice, practice...please • So tonight, you will be doing all the hard work

3. A&E – You are the RSO (with a Med Stud) • Mrs R V Cake, 45 Y/O lady – abdo pain • RUQ pain • Dull ache, 10/10, shortly after food, sudden onset, constant - 15 mins to 24 hours then goes away • Radiating to interscapular region, morphine helps • Many episodes before, N&V • Otherwise well • PMH – Recent bariatric surgery • Examination – High BMI, mild RUQ tenderness, otherwise normal

4. What do you think is going on? • DDx • Most likely – Biliary colic • R/O • Acute pancreatitis • Acute cholecystitis • Ascending cholangitis • (Peptic ulcers, reflux) • (Malignancy unlikely)

5. How would you manage this patient • “Following a full history and examination, I would like to perform some investigations” • Bedside • Urinalysis, ECG may help exclude other causes, VBG (lactate) • Bloods • FBC, U&E’s, LFTs, amylase, CRP, (clotting) • Imaging • AXR, Erect CXR, (USS OPD if other Ix normal or shunt to medics) • (MRCP)

6. Management • Conservative • Home with OPD appointment if well and Ix normal • (Admit, NBM, IVI if unwell) • Advice re: low fat diet • Medical • Analgesia • Anti-emetics • Ursodeoxycholic acid (yeah right, they come back once you stop!) • ERCP if obs jaundice • Surgical • Waiting list for lap chole

7. Please name 8 complications of gallstones • Gall bladder: • Biliary colic • Acute cholecystitis • (Chronic cholecystitis) • GB mucocele • Empyema of the GB • Cancer of the GB • CBD • Ascending cholangitis • Obstructive jaundice • Acute Pancreatitis • Bowel • Gallstone ileus • (Perf)

8. Risk factors for gallstones • Age • FHx • Sudden weight loss • Loss of bile salts – ileal resection, terminal ileitis • Diabetes • Oral contraception (particularly in young) (F) • Obesity (F)

9. The next night you are bleeped by A&E • Mrs R V Cake has returned (oops) • She’s about to breech • Pain – same as before • Now fever (+ rigors), jaundice • HR 91, Temp 38...

10. What have you done for her? • She’s got bloody SEPSIS! • Give 3: • Administer high flow oxygen. • Give broad spectrum antibiotics • Give intravenous fluid challenges • Take 3: • Take blood cultures • Measure serum lactate and haemoglobin (ABG/VBG) • Measure accurate hourly urine output (may need a catheter) • (Using an A-E approach...)

11. So...you’ve saved Mrs Cake’s life (after sending her home for biliary colic...shhh) • Now what...is this medical or surgical? • Obstructive jaundice is managed by medics • You bump to medics for ERCP (don’t forget to do a clotting) ...and you hope that’s the last you see of her until she becomes another abdomen on the table for lap chole

12. Charcot’s triad (cholangitis) – 50-70% RUQ pain Jaundice Fever

13. The next night... • You get a call from NIC on Castle ward (gastro) • Mrs R V Cake is post ERCP • Severe epigastric pain ,radiating through to the back • Vomiting ++ • Med reg, med SHO & ITU reg busy dealing with massive GI haemorrhage • She looks bloody unwell doctor • Pulse 120, BP 80/40... • Does she have a cannula? (She better bloody have one I whacked 2 greys in last night) • Squeeze a bag of n.saline/hartmanns through, I’m on my way

14. What do you do when you arrive? • A – Patent, O2 • B – Sats, RR, resp distress (sweating, cyanosis), auscultate • C – Pulse, BP, Cap refill (central and peripheral), IVI, ABG, feel her hands, look at their colour, auscultate • D – Review ABC, AVPU, glucose • E – Full examination/history, review any Ix you may have, urinary catheter/measure u/o • You successfully resuscitate her (saved her life AGAIN!) • Dx? • Acute pancreatitis

15. What Ix do you perform to assess severity? • Glasgow Prognostic Score - PANCREAS: • PO2 <8 kPa (60 mmHg) • Age > 55 • Neuts - WCC > 15 • Calcium < 2 mmol/L • Renal - Urea > 16 mmol/L • Enzymes - (LDH) > 600iu/L & (AST) > 200iu/L • Albumin < 32g/L • Sugar - Glucose > 10 mmol/L • + CRP (>150) • + Lactate • (APACHE II)

16. Management of acute pancreatitis(Surgical condition) • Conservative • Drip & Suck (NBM) • ITU Referral if Glasgow score > 3 or APACHE II > 8 • They may not take over care – think of why they score so high and look at the overall patient • Or transfer to Willoughby ward (where the surgical nurses are AMAZING) • Monitor closely including urine output • Medical • Analgesia, anti-emetics • Antibiotics? (Controversial subject in acute pancreatits)

17. Wait...I thought acute pancreatitis was a surgical condition? (Sorry for the busy slide) • Complications: • Pancreatic necrosis – SURGICAL debridement • Infected necrosis – Abx, drain, SURGICAL debridement • Acute fluids collections – look cool on CT • Pancreatic abscess – SURGERY • Pseudo-cysts – also look cool on CT, can rupture or haemorrhage, may need SURGERY • Occur in the lesser sac NOT the pancreas – remember your anatomy • Pancreatic ascites – pseudocyst collapses into peritoneal cavity • May require SURGERY • Acute cholecystitis – Abx, SURGERY • (Also: pulmonary oedema, pleural effusions, ARDS, hypovolaemia, shock, DIC, AKI, sepsis, metabolic – low Ca, low Mg, high glucose)

18. Outcome • So you’ve saved Mrs R V Cake’s life twice now • She forgives you for sending her home now • Lovely • She turns up a couple of months later on Mr Younan’s lap chole list • And will never darken your door with gallstone related disease again (unless she has retained stones or something)

19. Causes of pancreatitis • I – Idiopathic • G - Gallstones • E - Ethanol (alcohol!) • T – Trauma • S - Steroids • M - Mumps • A - Autoimmune - e.g. Good old lupus • S - Scorpion bites (rare, don’t say this in finals...please!) • H - Hypercalcaemia, hypothermia, hyperlipiaemia • E - ERCP • D - Drugs - e.g. Azathioprine, NSAIDs, diuretics

20. Tangent: Pink and fluffy finals question: • Patient with alcohol induced pancreatitis: • How can you help them quit? • Local alcohol quitting services (Open hands, AA, addaction)

21. The home stretch • Last night as RSO on call • Mrs M Battenburg (47) is admitted with • RUQ pain (sounds like biliary colic pain) • Fever • Vomiting • O/E • Abdo soft • Tender in RUQ • Breath halted on inspiration when palpating RUQ (not LUQ)

22. It’s gallstone week! • Acute cholecystitis • Ix: • Bedside – ECG, urine dip, ABG (lactate) • Bloods – FBC, CRP, LFT, U&E, amylase • What other bloods? That’s right • G&S, clotting – surgical patient • Imaging • Initially AXR , erect CXR • USS abdo + pancreas mane (good luck getting it overnight) • Special test • MRCP (if CBD dilated) – Why?

23. Management • Conservative • NBM, IVI • Medical • Analgesia, anti-emetics • Abx (Tazocin in this trust) • ERCP for impacted stone • Surgical • <72 hours from onset – lap chole on CEPOD • >72 hours bring back in a few weeks as day case

24. Things I haven’t told you • Types of gallstones (boring) • Pathophysiology of gallstones (boring) • Imaging in acute pancreatitis (USS, CT) • Chronic pancreatitis (faecal elastase) • Courvoisier’s law: • “In the presence of jaundice, an enlarged gallbladder is unlikely to be due to gallstones; rather carcinoma of the pancreas or the lower biliary tree is more likely.” • These will be included in the handout on the SLIME website

25. end Thanks