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Gallstones

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Gallstones

  1. 1. Gallstones & Pancreatitis Dr Alistair Brown Alistair.brown4@nhs.net
  2. 2. • • • • What are gallstones? Risk factors The anatomy Where the stones get stuck and how the patient presents.
  3. 3. What are gallstones? • Cholesterol 20% • Bile Pigment 5% (excess bilirubin – eg. haemolytic anaemia) • Mixed 75%
  4. 4. Risk Factors Cholesterol stones: – – – – – – – – 6F’s FAIR, FAT, FEMALE, FORTY, FERTILE, FHx Female:Male 2:1 Obesity OCP Fhx Pregnancy Hyperlipidaemia Crohns Bile pigment: – Red cell breakdown (eg. haemolytic anaemia) – Infection – cirrhosis
  5. 5. Asymtomatic
  6. 6. Biliary Colic Presentation: – – – – – RUQ pain No Fever, No Jaundice 2-3hrs after eating Continuous May radiate to inferior angle right scapula Complications: – infection Inx: – Bloods, USS Mx: – Analgesia – Cholecystectomy
  7. 7. Acute cholecystitis Presentation: – – – – RUQ pain Fever No Jaundice Murphy’s positive Complications: – Rarely empyema Inx: – Bloods, USS Mx: – Analgesia – Abx – Cholecystectomy or Cholecystostomy – If duct dilated on USS will need on table cholangiogram or preop MRCP
  8. 8. Choledocholithiasis Presentation: – – – – – – RUQ pain Jaundice No Fever Pale stools Dark urine Pruritus Complications: – Ascending cholangitis – Vit A,D,E, K malabsorption Inx: – Bloods, USS, MRCP or ERCP NB: – ERCP 5-20% of cases rise in AMY after procedure – 0.5-5% risk of causing pancreatitis Mx: – – – – Analgesia Abx ERCP + sphincterotomy Cholecystectomy
  9. 9. Ascending Cholangitis Presentation: – – – – – – – Charcot’s Triad RUQ pain Jaundice Fever Pale stools Dark urine Pruritus Inx: – Bloods, USS, MRCP or ERCP Mx: – – – – Analgesia Abx ERCP + sphincterotomy Cholecystectomy
  10. 10. Gallstone ileus Presentation: – Small bowel obx Inx: – AXR – CT scan Mx: – Laparoscopy +enterotomy +removal
  11. 11. Pancreatitis
  12. 12. Other diseases of the gallbladder are rare, so don’t worry about them! – Cholangiocarcinoma – Acalculus cholecystitis (probably vascular in origin)
  13. 13. Summary – think where can the stone get stuck! • • Asymptomatic Biliary colic – RUQ pain – No fever – No jaundice • Cholecystitis – RUQ pain – Fever – No Jaundice • Choledocholithiasis – RUQ pain – No Fever – Jaundice • Ascending cholangitis – RUQ pain – Fever – Jaundice • • Gallstone ileus Pancreatitis
  14. 14. The Pancreas
  15. 15. • Acute Pancreatitis – Causes – Presentation – Scoring – Management • A word on chronic pancreatitis • Pancreatic cancer
  16. 16. Causes • Learn the top three and a few more! – Gallstones 45-55% – Alcohol 20-30% – Idiopathic ?statin 15-20%
  17. 17. IGETSMASHED Idiopathic ?statin related Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion Sting Hypercalcaemia, Hyperlipidaemia, Hypothermia ERCP Drugs : Sulphonamydes, AZT, NSAIDS, diuretics
  18. 18. Acute pancreatitis • • • • Epigastric or RUQ pain Radiates through to the back +/-jaundice N/V Other signs & sx: – – – – Paralytic ileus Respiratory distress Grey Turner & Cullens sign (blood stained peritoneal exudate) Oliguria Diagnosis – Amylase 3x upper limit of normal Severe pancreatitis can lead to multi-system organ failure (cytokines, toxic enzymes, haemolysis, DIC, fat necrosis)
  19. 19. When to call ITU? • Scoring – Modified Glasgow score – – – – – – – – PaO2 <8 Age >55 Neutophils WCC>15 Calcium <2 Renal urea >16 Enzymes LDH>600 AST>200 Albumin <32 Sugar >10 Score greater or equal to 3 d/w ITU
  20. 20. Management Supportive: ABC approach – Early: • • • • • • • • 1 Oxygen 2 Access – central line if v. Severe, fluids 3 catheter – monitor urine output 4 Baseline ABG 5 Analgesia 6 NG – prevents vomiting and gastric dilation 8 NBM Anticoagulation – Later: • • • • 9 Consider nutrition NG/NJ/TPN 10 Abx if severe or assoc. with gallstones 11 PPI – prevent gastric erosions 12 CT scan >day 5 to assess for complications
  21. 21. Chronic Pancreatitis • Causes • 70-85% alcohol related • 10-15% idiopathic • Other: drugs, autoimmune • Features • • • • • Recurrent abdominal pain Steatorrhoea Diabetes Weight loss Mildly raised amylase during acute attacks • Management • • • • Abstinence Analgesia Insulin Pancreatic enzyme replacement & nutritional assessment
  22. 22. Pancreatic cancer • Courvoisiers Law – Jaundice in the presence of an enlarged non tender gallbladder is unlikely to be gallstone related. Therefore likely to be pancreatic or GB cancer. • Other features • • • • Weight loss Steatorrhoea N&V New onset diabetes • Most are palliative -5yr survival ~3% • • • • Abx for cholangitis Biliary stent Creon replacement Chemotherapy • 10-15% are surgical candidates – Whipples procedure
  23. 23. EMQ 1 • • • • • • • • Bliary colic Cholangitis Pancreatitis Gallstone ileus Empyema of gallbladder Acute cholecystitis Gallbladder mucocoele Gallbladder perforation/bilairy peritonitis
  24. 24. 1. 30yo female 2day hx constant pain RUQ associated with vomiting. Murphys positive. Febrile. 2. 56yo male 1week severe abdominal pain. Febrile. O/E: RUQ peritonism with a palpable lump. Bloods show increased WCC. 3. 60yo man 6hour hx of constant generalised abdo pain. O/E signs of shock. Abdomen is distended, generalised guarding and tenderness. 4. 38yo female 6hour hx of colicky RUQ pain radiating to back and shoulder. Afebrile, abdomen is soft & nontender.
  25. 25. 5. 40yo female treated for acute cholecystitis with palpable non tender gallbladder. Afebrile and systemically well. 6. 78yo female known gallstones central colicky abdo pain and vomiting. Constipated for a few days. O/E increased bowel sounds and abdominal distension. 7. 42yo male sudden onset severe epigastric pain radiating through to the back. Vomiting and rething. O/E in shock, upper abdo tenderness, some guarding. 8. 60yo male presents with episodic RUQ pain, jaudice, fever and chills.
  26. 26. MCQ 1 • A 56 year old lady presents with pancreatitis. She is saturating 98% on air, BP is 80/50, HR 105, RR 16. BM 6, Calcium is within normal limits, WCC 20.2, albumin 36, Lfts derranged ALT 700, LDH 650. U&Es normal. What is her score? a) 2 b) 3 c) 4 d) 5 c) 6 What should you do?
  27. 27. MCQ 2 • Which of these can cause a raised amylase? a) b) c) d) e) Severe DKA Renal Failure Perforated DU ERCP Chronic pancreatitis
  28. 28. MCQ 3 • Which of the following is diagnostic of pancreatitis? a) a serum amylase >3x upper limit of normal b) a serum amylase >1000 c) a serum amylase >2x upper limit of normal d) jaundice with obx lfts e) RUQ pain and jaundice

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