Biliary disease + pancreatitisfor finals (and beyond)

…the story of Mrs Harvey-Henry

Dr Julian DickmannGeneral Surgery

By the end of this session…You will be able- To recognise the common complications of gallstone disease - Understand the underlying pathophysiology- Start initial management and investigations- To initiate treatment.

First doctor

You are the F2 in general practice – Mrs Harvey-Henry, a 44 year old restaurant critic comes to you with her private ultrasound report after a visit to the well woman clinic which showed “numerous gallstones”. She does not complain of any symptoms. She is very worried – what do you advise?

Gallstones

The commonest cause of emergency hospital admission with abdominal pain1

1- Kettunen et al. Emergency abdominal surgery in the elderly. Hepatogastroenterology. 1995;42:106–8.Pictures from BMJ Review (Gallstones)

= common in exams

“Pathological” effects of gallstones

Silent90% asymptomatic

WITHIN THE GALLBLADDER

Second doctor

You are the F1 in A+E – Mrs Harvey-Henry, presents to the emergency department with a 1h history of RUQ pain after dining at the Fat Duck. The pain has now subsided and she is very worried. What do you advise (examination unremarkable)?

“Pathological” effects of gallstones

Biliary colic

WITHIN THE GALLBLADDER

INTERMITTENT PAIN NOT SYSTEMICALLY

UNWELL

Clinical management & investigationsDo not admit. Ultrasound as an outpatient.• Conservative– Analgesia– Anti-emetics

• Medical– Ursodesoxycholic acid (not effective)

• Surgical– Cholecystectomy (laparoscopic)

Biliary colic

Third doctor

You are the F1 in A+E – Mrs Harvey-Henry, now complains of a 2 day history of RUQ pain, vomiting and feeling unwell.

“Pathological” effects of gallstones

Acute cholecystitis

WITHIN THE GALLBLADDER

Acute cholecystitis – pathogenesis

obstruction of the cystic duct (gallstones / sludge)

↑ Intraluminal pressure

supersaturation of cholesterol

Inflammatory response(PG-I2/E2)

± secondary bacterial infection (E Coli, Klebsiella) in 20%

Acute cholecystitis – diagnosis

Murphy’s sign positive: inspiratory arrest by pain on palpation AND the absence of left sided arrest of inspiration

Acute cholecystitis – investigations

UltrasoundDistended “thick walled” gallbladderGallstones / SludgeMurphy’s sign – elicited with probe

Preparation for ultrasound abdomen:Fasting for 6h.Clear fluids until 2h.(+ full bladder for renal/gynae)

Blood tests

CT(CXR) Δ RLL Pneumonia

• Conservative– Analgesia– Anti-emetics

• Medical– IV Antibiotics (Tazocin ± Gentamicin)

• Surgical – definite treatment– Laparoscopic / open cholecystectomy– High surgical risk + sepsis: percutaneous

cholecystostomy

Acute cholecystitis – managementAcute cholecystitis – management II

Timing of surgery?28.5% readmission rate (gallstone-related complications) on NHS waiting list (1)

Either:Early urgent (<72h) or delayed-interval LC– Introduction of an “urgent cholecystectomy

service” of readmission rate 19% to 3.6% (2)

– Optimal time: 6-12 weeks after initial admission (3)

Acute cholecystitis – managementAcute cholecystitis – management I

(1) Cheruvu et al. Ann R Coll Surg Engl 2002(2) Mercer et al. Br J Surg 2004

(3) Gurusamy et al. Br J Surg. 2010

Complications

• Anaesthetic risk (PE, Pneunomia, MI)• Procedure-specific risks: – Conversion to open– Injury to CBD– Biliary leak causing biliary peritonitis– Post-op haemorrhage– Intra-abdominal abscess

4th doctor

Mrs Harvey-Henry responds well to analgesia and antibiotics but a day you as the F1 notice that she is appears jaundiced (obviously you noticed this without looking at the bilirubin…).

“Pathological” effects of gallstones

Obstructive jaundice

Choledocolithiasis=stone in CBD

Oedema around the biliary tract

Mirizzi’s syndrome(stone in Hartmann’s pouch

compressing common hepatic duct)

CholedocolithiasisSuspect if: JAUNDICE ± deranged liver function ± dilated CBD

Management1st – MRCP2nd – Endoscopic retrograde cholangiopancreatography (ERCP)NB: no diagnostic test, treatment only (>90% success rate)

(operative CBD exploration during cholecystecomy)

Normal CBD diameter< 50 years – 6mm > 50 years – 8mmpost-cholecystectomy >10mm

Senturk et al. Eur J Radiol. 2012 Jan;81(1):39-42.

5th doctor

On your on-call night shift, the a nurse on Willoughby ward bleeps you: Mrs Harvey-Henry’s MEWS is 8 (systolic BP of 85, HR 120, RR 24, T 39.2). They are apologetic, but as she was in a side-room, they only noticed this at midnight. So you make your way up to the ward…

Ascending cholangitisBacterial infection (E. Coli) of the biliary tree

Management:IV Fluids, Abx + urgent removal of obstruction (ERCP)

6th doctorMrs Harvey-Henry is successfully resuscitated by yourself (ABC!) and there was a slot for an ERCP available first thing in the morning.

Anything to consider?

7th doctorYou get bleeped at 11pm. The nurses tell you that Mrs Harvey Henry needs more pain relief. Her pain is not adequately controlled on paracetamol, tramadol and hourly oramorph. Could you come and assess her?

post-ERCP Pancreatis (PEP)5% risk esp. multiple injections of contrast into pancreatic duct

Acute Pancreatitis

Aetiology

Gallstones (50%)Alcohol (35%)Post-ERCP (5%)(the rest = 5%)

Painsevere epigastric

central abdominal radiation to the back

Vomiting

8th doctorYour SHO and registrar are busy in theatres. You are on your own.Start initial investigations and management.

Management

• Nil by mouth• IV Access (green cannula)• Bloods – FBC/U+Es/Amylase/CRP/G+S/Clotting• Aggressive fluid replacement– 1000ml Hartmann’s stat– 1000ml Hartmann’s 2h / 4h / 6h

• Catheterise – strict fluid balance• Hourly observations• Analgesia• ABG

For ANY surgical admission

ABGs…

Investigations

LOOK FOR SIGNS OF (MULTI-) ORGAN FAILURE

Modified Glasgow criteria – prognostic criteria Predicts severity of severe pancreatitis: ≥3 factors are over the

first 48h indicate severe pancreatitis ITU involvementPaO2 <8kPA [ARDS]Age >55yNeutrophils WBC>15Calcium <2mmol/l [lipid saponification]Renal functionUrea >16 [hypovoloaemia]Enzymes LDH >600, AST>200 [autolysis]Albumin <32gSugar BM >10mmol/l [endocrine disturbance]

Questions?

Covered in the handout:– Biliary malignancies (cholangiocarcinoma)– Chronic pancreatitis