Pancreas and Pancreas and hepatobiliary disordershepatobiliary disorders

Feb 12 2004Feb 12 2004

Andrea WilsonAndrea Wilson

Case 1 Case 1 (emedhome.com)(emedhome.com)

28 yo male28 yo male ““ulcer pain acting up”. Has a known peptic ulcer pain acting up”. Has a known peptic

ulcer. ulcer. Epigastric tenderness intermittent x 2 days not Epigastric tenderness intermittent x 2 days not

relieved with antacidsrelieved with antacids No rebound or guarding. Normal rectal.No rebound or guarding. Normal rectal. Busy shiftBusy shift Pt felt better after demerol and wanted to go Pt felt better after demerol and wanted to go

home.home.

Grey-Turner’s signGrey-Turner’s sign

associated with hemorrhagic pancreatitis. associated with hemorrhagic pancreatitis. However, this sign develops in <3% of patients with However, this sign develops in <3% of patients with

acute pancreatitis acute pancreatitis retroperitoneal hemorrhage, splenic rupture, ruptured retroperitoneal hemorrhage, splenic rupture, ruptured

aortic aneurysm, and ectopic pregnancy. aortic aneurysm, and ectopic pregnancy. blood along fascial planes and cause ecchymoses blood along fascial planes and cause ecchymoses

over the flanks. over the flanks. (lateral edge of the quadratus lumbrum muscle)(lateral edge of the quadratus lumbrum muscle)

Acute PancreatitisAcute Pancreatitis

Up to 80% of pts will have uneventful Up to 80% of pts will have uneventful recoveryrecovery

Ranson’s criteria correlate with risk of major Ranson’s criteria correlate with risk of major complications and deathcomplications and death

Overall mortality ranges from 7-20%Overall mortality ranges from 7-20%

Ranson’s criteriaRanson’s criteria

At admission or diagnosisAt admission or diagnosis Age > 55 yearsAge > 55 years WBC > 16,000/mm3WBC > 16,000/mm3 Blood glucose > 200mg/dlBlood glucose > 200mg/dl Serum LDH > 350 IU/mlSerum LDH > 350 IU/ml SGOT > 250 Sigma-Frankel SGOT > 250 Sigma-Frankel

units/dlunits/dl

During initial 48 hoursDuring initial 48 hours Hematocrit fall > 10%Hematocrit fall > 10% BUN rise > 5 mg/dlBUN rise > 5 mg/dl Serum calcium level < 8.0Serum calcium level < 8.0

Arterial oxygen pressure < Arterial oxygen pressure < 60 mm Hg60 mm Hg

Base deficit > 4 mEq/LBase deficit > 4 mEq/L Estimated fluid Estimated fluid

sequestration > 6,000 mlsequestration > 6,000 ml

So…So…

Hypotension, Hypotension, tachycardia >130, tachycardia >130, PO2 <60, PO2 <60, oliguria, oliguria, increasing BUN/Cr increasing BUN/Cr and hypocalcemia and hypocalcemia

= BAD= BAD

PancreatitisPancreatitis

Obstruction of ampulla with reflux of bile into Obstruction of ampulla with reflux of bile into pancreatic duct then activation of digestive pancreatic duct then activation of digestive enzymes and autodigestion of the pancreasenzymes and autodigestion of the pancreas

Gallstones + Etoh = >70%Gallstones + Etoh = >70%

Other causesOther causes

GET SMASHEDGET SMASHED Gallstones, ethanol, tumors, scorpion bite?, Gallstones, ethanol, tumors, scorpion bite?,

microbiology (bacteria, virus, parasites), microbiology (bacteria, virus, parasites), autoimmune (SLE, PAN, Crohn’s), autoimmune (SLE, PAN, Crohn’s), surgery/trauma, hyperlipidemia/ surgery/trauma, hyperlipidemia/ hypercalcemia, emboli/ischemia, drugshypercalcemia, emboli/ischemia, drugs

Also: pregnancy, liver disease, DKAAlso: pregnancy, liver disease, DKA

Acute pancreatitisAcute pancreatitis

SymptomsSymptoms Sharp epigastric painSharp epigastric pain Radiates to backRadiates to back Improves leaning frwdImproves leaning frwd N&VN&V Pain referred to RUQ or Pain referred to RUQ or

LUQLUQ Aggravated by eatingAggravated by eating

SignsSigns JaundiceJaundice Tachycardia (pain or Tachycardia (pain or

volume depletion)volume depletion) FeverFever Grey Turner’s -flankGrey Turner’s -flank Cullen’s – umbil Cullen’s – umbil

(neither specific)(neither specific)

Diagnostic evaluationDiagnostic evaluation

Amylase –Amylase – If 3x N then 80-90%sens , If 3x N then 80-90%sens ,

75% spec75% spec may return to normal within may return to normal within

24 hrs of pain onset24 hrs of pain onset Fallopian tubes, ovaries, Fallopian tubes, ovaries,

testes, adipose tissue, small testes, adipose tissue, small bowel, lung, thyroid, sk bowel, lung, thyroid, sk muscle, neoplasmsmuscle, neoplasms

LipaseLipase 90% sens and specific90% sens and specific Remain elevated for several Remain elevated for several

days after pain onset (7-14 )days after pain onset (7-14 )

What else would you order?What else would you order?

AXR – calcification of the pancreas or AXR – calcification of the pancreas or gallstones if calcified, free air, ileus, colon gallstones if calcified, free air, ileus, colon “cut-off” if transverse colon involved“cut-off” if transverse colon involved

CXR – atelectasis, effusionCXR – atelectasis, effusion U/S and CT if further evaluation needed – U/S and CT if further evaluation needed –

diffusely enlarged pancreas, dilated CBDdiffusely enlarged pancreas, dilated CBD CT negative in 30% of mild pancreatitisCT negative in 30% of mild pancreatitis

ComplicationsComplications

Phlegmon 18% - Phlegmon 18% - Pancreatic abscess 3%Pancreatic abscess 3% Pancreatic pseudocyst 10%Pancreatic pseudocyst 10% AscitesAscites Thrombosis of the central portal systemThrombosis of the central portal system Shock, ARDS and MSOFShock, ARDS and MSOF Profound metabolic disturbances including Profound metabolic disturbances including

hyperglycemia and hypocalcemiahyperglycemia and hypocalcemia

ManagementManagement

1) hemodyanmic stabilization1) hemodyanmic stabilization 2) allevation of pain2) allevation of pain 3) stop progression of damage3) stop progression of damage 4) tx of local and systemic complications4) tx of local and systemic complications

AdmitAdmit NPO, IV analgesics, NG if emesis/ileusNPO, IV analgesics, NG if emesis/ileus Aminoglycoside or cephalosporin if deterioration Aminoglycoside or cephalosporin if deterioration

suggests abscesssuggests abscess

Chronic PancreatitisChronic Pancreatitis

Fibrosis, ductal abnormality, calcification and Fibrosis, ductal abnormality, calcification and cellular atrophycellular atrophy

Leads to chronic pancreatic insufficiency and Leads to chronic pancreatic insufficiency and chronic pain.chronic pain.

Autodigestion from pancreatic digestive Autodigestion from pancreatic digestive enzymes + other vasoactive substances enzymes + other vasoactive substances causing chemical irritation ->edema – causing chemical irritation ->edema – hemorrhage/necrosishemorrhage/necrosis

Chronic pancreatitisChronic pancreatitis

ALCOHOLALCOHOL DM, protein-calorie malnutrition, hereditary DM, protein-calorie malnutrition, hereditary

pancreatitis, cystic fibrosis, hyperparathyroidism, pancreatitis, cystic fibrosis, hyperparathyroidism, pancreas divisumpancreas divisum

Pseudocyst, ascites, CBD stricturePseudocyst, ascites, CBD stricture If>90% exocrine function lost then trouble!If>90% exocrine function lost then trouble!

Steatorrhea (fat), azotorrhea (protein), progressive Steatorrhea (fat), azotorrhea (protein), progressive weight loss.weight loss.

Case 2Case 2

56 yo male56 yo male new onset diabetesnew onset diabetes Dull epigastric pain worse at hsDull epigastric pain worse at hs 10 lb weight loss in past 6 months10 lb weight loss in past 6 months Mildly jaundicedMildly jaundiced ?palpable gallbladder?palpable gallbladder No Murphy’sNo Murphy’s

Pancreatic cancerPancreatic cancer

Males: females 2:1Males: females 2:1 6 month survival6 month survival Usually ductal cell adenocarcinoma and Usually ductal cell adenocarcinoma and

usually in the head of the pancreasusually in the head of the pancreas Smoking, high fat/protein diet, DM, DDT Smoking, high fat/protein diet, DM, DDT

exposureexposure Courvoisier’s lawCourvoisier’s law

4 main gallstone problems4 main gallstone problems

Symptomatic cholelithiasis (biliary colic)Symptomatic cholelithiasis (biliary colic) CholecystitisCholecystitis CholangitisCholangitis PancreatitisPancreatitis

Back to med school…Back to med school…

Bile needed for absorption of fats and fat Bile needed for absorption of fats and fat soluble nutrients from small intestinesoluble nutrients from small intestine

Imbalance of chol + solubilizing agentsImbalance of chol + solubilizing agents 70% of gallstones are >70% cholesterol 70% of gallstones are >70% cholesterol

(radiolucent)(radiolucent) 20% are pigment stones bc of abnormal 20% are pigment stones bc of abnormal

solubility of unconjugated bilirubin with the solubility of unconjugated bilirubin with the precipitation of calcium saltsprecipitation of calcium salts

10% mixed10% mixed

Gallstone risk factorsGallstone risk factors

Cholesterol – female, 20-40, pregnant/OCP, parity, Cholesterol – female, 20-40, pregnant/OCP, parity, obsesity/ profound weight loss, TPN, fam hx, C.F., obsesity/ profound weight loss, TPN, fam hx, C.F., Crohn’s, clofibrate, ceftriaxone, Pima indiansCrohn’s, clofibrate, ceftriaxone, Pima indians

(fat, female, forty, fertile, ethnic, estrogen, diet, (fat, female, forty, fertile, ethnic, estrogen, diet, drugs)drugs)

Pigment stones – Asian, chronic biliary tract Pigment stones – Asian, chronic biliary tract infection, chronic liver disease, intravasc hemolysis infection, chronic liver disease, intravasc hemolysis (sickle cell or spherocytosis)(sickle cell or spherocytosis)

Protective factorsProtective factors

ascorbic acid (?increased cholesterol catabolism) ascorbic acid (?increased cholesterol catabolism) coffee (3-4 cups/day 40% less likely to develop coffee (3-4 cups/day 40% less likely to develop

gallstones) Yeah!gallstones) Yeah!

Biliary colicBiliary colic

Stone lodged in cystic or CBD -> inc in Stone lodged in cystic or CBD -> inc in intraluminal pressure/ distention -> N&V& intraluminal pressure/ distention -> N&V& pain (15%)pain (15%)

Usually constant (not colic) but <6 hrsUsually constant (not colic) but <6 hrs Epig or RUQ dull/visceral pain with radiation Epig or RUQ dull/visceral pain with radiation

to R post shoulder + N&Vto R post shoulder + N&V Eating after fasting or fatty mealEating after fasting or fatty meal May have post-attack soreness for 1-2 daysMay have post-attack soreness for 1-2 days

CholecystitisCholecystitis

If obstruction persists – inflammation +/- If obstruction persists – inflammation +/- infection of gallbladder wallinfection of gallbladder wall

May develop gangrene +/- perf -> more May develop gangrene +/- perf -> more localized pain/ peritonitislocalized pain/ peritonitis

More parietal painMore parietal pain Murphy’s sign (97% sens, only 48% in Murphy’s sign (97% sens, only 48% in

elderly)elderly) May have fever/chillsMay have fever/chills

Acalculous cholecystitisAcalculous cholecystitis

5-10% of cholecystitis5-10% of cholecystitis Elderly + DM + immunosuppressed ( trauma, Elderly + DM + immunosuppressed ( trauma,

burn, labor, surgery, vasculitis, gallbladder burn, labor, surgery, vasculitis, gallbladder torsion, parasitic or bacterial infections of the torsion, parasitic or bacterial infections of the biliary tract.)biliary tract.)

Do worseDo worse

InvestigationsInvestigations

CBC (but WBC may be Normal) ? Low HbCBC (but WBC may be Normal) ? Low Hb Lipase +/- liver function tests (may be normal)Lipase +/- liver function tests (may be normal) U/S sensitivity >95% for stones > 2mm, spec 78%U/S sensitivity >95% for stones > 2mm, spec 78% False neg and pos rates 2-4% may miss cholecystitisFalse neg and pos rates 2-4% may miss cholecystitis Emergency physician U/SEmergency physician U/S HIDA/DISIDA best for cholecystitis sensitivity HIDA/DISIDA best for cholecystitis sensitivity

almost 100%, spec 90% but start with U/Salmost 100%, spec 90% but start with U/S 12 lead ECG, U/A, preg test, AXR, CXR12 lead ECG, U/A, preg test, AXR, CXR

DDxDDx

Gastritis, PUD, hepatitis, hepatic abscess, Gastritis, PUD, hepatitis, hepatic abscess, intraabd abscess, ischemic gut, Fitz-Hugh-intraabd abscess, ischemic gut, Fitz-Hugh-Curtis syndrome (GC or Chlamydial Curtis syndrome (GC or Chlamydial perihepatitis), pancreatitis, GERD, perihepatitis), pancreatitis, GERD, AppendicitisAppendicitis

Renal colic, pyelonephritisRenal colic, pyelonephritis Pneumonia, acute MI, Pneumonia, acute MI, PID +/- TOA, ectopic pregnancyPID +/- TOA, ectopic pregnancy

BactobiliaBactobilia

35-65% of pts with cholecystitis 35-65% of pts with cholecystitis E. coli or Klebsiella in 70%E. coli or Klebsiella in 70% Also Enterococcus, Bacteroides, Clostridium, Also Enterococcus, Bacteroides, Clostridium,

GDS, StaphGDS, Staph For non-septic: third generation cephalosporinFor non-septic: third generation cephalosporin Septic: amp, gent and clindaSeptic: amp, gent and clinda

CholangitisCholangitis

Complete obstruction + bacteria = cholangitisComplete obstruction + bacteria = cholangitis Backup into lymphatic vessels and hepatic Backup into lymphatic vessels and hepatic

veinsveins High mortality rateHigh mortality rate Stone, stricture, Ca Stone, stricture, Ca Increased ALP, GGT, bili (late) +/- AST, ALTIncreased ALP, GGT, bili (late) +/- AST, ALT E. coli, Klebsiella, PseudomonasE. coli, Klebsiella, Pseudomonas

Triads and pentadsTriads and pentads

25% Charcot’s triad25% Charcot’s triad Fever jaundice, RUQ painFever jaundice, RUQ pain Reynold’s pentadReynold’s pentad Altered LOC, distributive shock Altered LOC, distributive shock

Cholangitis management Cholangitis management EMR Aug 12 , 2002EMR Aug 12 , 2002

Volume resuscitation +/- vasopressorsVolume resuscitation +/- vasopressors Broad-spectrum antibioticsBroad-spectrum antibiotics Surgery or endoscopic decompressionSurgery or endoscopic decompression

Weird and wonderfulWeird and wonderful

Gallbladder empyemaGallbladder empyema Emphysematous (gangrenous) cholecystitis (1% of Emphysematous (gangrenous) cholecystitis (1% of

cholecystitis)cholecystitis) Hydrops= mucous accumulation in gallbladder due to Hydrops= mucous accumulation in gallbladder due to

cystic duct obstructioncystic duct obstruction Gangrene perforationGangrene perforation Cholecystoenteric fistula (repeated attacks)Cholecystoenteric fistula (repeated attacks) Gallstone ileus – cholecystoenteric connection with Gallstone ileus – cholecystoenteric connection with

impacted stone at ileocecal valve, pneumobiliaimpacted stone at ileocecal valve, pneumobilia

ManagementManagement

Urgent biliary decompression for pts in Urgent biliary decompression for pts in extremis or with clinical deteriorationextremis or with clinical deterioration

Consider operating if porcelain gallbladder Consider operating if porcelain gallbladder (15-20% assoc Ca) , DM, hx of biliary (15-20% assoc Ca) , DM, hx of biliary pancreatitispancreatitis

Demerol vs morphine, antiemeticsDemerol vs morphine, antiemetics Admit, hydrate, antibiotics (even though Admit, hydrate, antibiotics (even though

questionable in cholecystitis)questionable in cholecystitis)

What about ERCP?What about ERCP?

Severe pancreatitis, continuing biliary colic, Severe pancreatitis, continuing biliary colic, cholangitis, obstructive jaundice, stones in cholangitis, obstructive jaundice, stones in CBD or CBD dilationCBD or CBD dilation

Ultimately endoscopic sphincterotomy and Ultimately endoscopic sphincterotomy and stone extraction followed by laparoscopic stone extraction followed by laparoscopic cholecystectomy is preferred tx for cholecystectomy is preferred tx for choledocholithiasis.choledocholithiasis.

CholecystectomyCholecystectomy

Best management for Best management for Frequent or severe attacksFrequent or severe attacks Hx of gallstone complicationsHx of gallstone complications Stones over 2 cmStones over 2 cm Congenitally abnormal hepatobiliary system, Congenitally abnormal hepatobiliary system, +/- DM+/- DM

Discharge home if:Discharge home if:

Resolution of symptoms (4-6 hrs)Resolution of symptoms (4-6 hrs) Correction of intravascular volume deficitsCorrection of intravascular volume deficits Restored ability to drinkRestored ability to drink Give them analgesicsGive them analgesics

Keep if high risk with CBD stones or if Keep if high risk with CBD stones or if pregnantpregnant

Then what?Then what?

Asymptomatic gallstones develop Asymptomatic gallstones develop complicationscomplications

10% at 5 yrs10% at 5 yrs 15% at 10 yrs15% at 10 yrs 18% at 15-20 yrs18% at 15-20 yrs Close observation even for most diabetic Close observation even for most diabetic

patientspatients

Primary biliary cirrhosisPrimary biliary cirrhosis

Autoimmune associations Autoimmune associations Antimitochondrial antibody in >90%Antimitochondrial antibody in >90% Not fully understood. Necrotizing inflammation Not fully understood. Necrotizing inflammation

leading to bile duct fibrosisleading to bile duct fibrosis Often detected by elevated ALP on routine screeningOften detected by elevated ALP on routine screening Women, age 35-60, pruritus, fatigue, jaundice, Women, age 35-60, pruritus, fatigue, jaundice,

hyperpigmentation, eventual cirrhosishyperpigmentation, eventual cirrhosis Biopsy, colchicine, methotrexate/cyclosporine, Biopsy, colchicine, methotrexate/cyclosporine,

ursodiol, transplantursodiol, transplant

Secondary biliary cirrhosisSecondary biliary cirrhosis Postop strictures/ gallstonesPostop strictures/ gallstones Usually with superimposed infectious cholangitisUsually with superimposed infectious cholangitis Congenital biliary atresia, CF, choledochal cystsCongenital biliary atresia, CF, choledochal cysts Signs and symptoms like PBC but also intermittent Signs and symptoms like PBC but also intermittent

bouts of colic/cholangitisbouts of colic/cholangitis AMA negativeAMA negative Suspect if bile flow obstruction, especially postopSuspect if bile flow obstruction, especially postop

Sclerosing cholangitisSclerosing cholangitis

Affects extrahepatic +/- intrahepaticAffects extrahepatic +/- intrahepatic On ERCP see thickened ducts with narrow, On ERCP see thickened ducts with narrow,

beaded luminabeaded lumina Often associated with IBD, fibrosing Often associated with IBD, fibrosing

conditions, AIDSconditions, AIDS Cholestyramine for pruritus, transplantCholestyramine for pruritus, transplant Age, bili, histologic stage and splenomegaly Age, bili, histologic stage and splenomegaly

predict survivalpredict survival

What should I rememberWhat should I remember

Pancreatitis – get Pancreatitis – get smashedsmashed

Biliary colic - <6 hrsBiliary colic - <6 hrs Cholecystitis – usually Cholecystitis – usually

antibiotics, consider antibiotics, consider acaculous cholecystitisacaculous cholecystitis

Weird and wonderful Weird and wonderful complicationscomplications

When to discharge colicWhen to discharge colic

ReferencesReferences Cholangiography and PancreatographyCholangiography and Pancreatography, by M. Ohta, et al., Eds. Igaku-, by M. Ohta, et al., Eds. Igaku-

Shoin Ltd., Tokyo, University Park Press, Baltimore, 1978 Shoin Ltd., Tokyo, University Park Press, Baltimore, 1978 Emergency MedicineEmergency Medicine. Tintinalli, Kelen, Stapczynski.. Tintinalli, Kelen, Stapczynski. Emergency Medicine Reports – Presentation and mangement of Acute Emergency Medicine Reports – Presentation and mangement of Acute

biliary Tract Disorders in the Emergency Department – optimizing biliary Tract Disorders in the Emergency Department – optimizing Assessment and Treatment of Cholelithiasis and cholecystitis Aug 12 Assessment and Treatment of Cholelithiasis and cholecystitis Aug 12 20022002

Harrison’s principles of Internal Medicine 14Harrison’s principles of Internal Medicine 14 thth edition 1984 edition 1984 http://http://www.bupa.co.uk/health_information/html/organ/liver.htmlwww.bupa.co.uk/health_information/html/organ/liver.html Presentation by Rob Hall 2002Presentation by Rob Hall 2002 Thomson, A.B.R., Shaffer E.A Thomson, A.B.R., Shaffer E.A First Principles of GastroenterologyFirst Principles of Gastroenterology. 1997. 1997 www.emedhome.comwww.emedhome.com