Biliary disease + pancreatitis
for finals (and beyond)
…the story of Mrs Harvey-Henry
Dr Julian Dickmann
General 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 HarveyHenry, 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 = common in exams
1- Kettunen et al. Emergency abdominal surgery in the elderly. Hepatogastroenterology. 1995;42:106–8.
Pictures from BMJ Review (Gallstones)
“Pathological” effects of gallstones
WITHIN THE
GALLBLADDER
Silent
90% asymptomatic
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
WITHIN THE
GALLBLADDER
Biliary colic
 INTERMITTENT PAIN
 NOT SYSTEMICALLY
UNWELL
Biliary colic
Clinical management & investigations
Do not admit. Ultrasound as an outpatient.
• Conservative
– Analgesia
– Anti-emetics
• Medical
– Ursodesoxycholic acid (not effective)
• Surgical
– Cholecystectomy (laparoscopic)
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
WITHIN THE
GALLBLADDER
Acute
cholecystitis
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
Blood tests
Ultrasound
Distended “thick walled” gallbladder
Gallstones / Sludge
Murphy’s sign – elicited with probe
CT
(CXR) Δ RLL Pneumonia
Preparation for ultrasound abdomen:
Fasting for 6h.
Clear fluids until 2h.
(+ full bladder for renal/gynae)
Acute cholecystitis – management II
• Conservative
– Analgesia
– Anti-emetics
• Medical
– IV Antibiotics (Tazocin ± Gentamicin)
• Surgical – definite treatment
– Laparoscopic / open cholecystectomy
– High surgical risk + sepsis: percutaneous
cholecystostomy
Acute cholecystitis – management I
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)
(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
Oedema around
the biliary tract
Choledocolithiasis
=stone in CBD
Mirizzi’s syndrome
(stone in Hartmann’s pouch
compressing common hepatic
duct)
Choledocolithiasis
Suspect if:
JAUNDICE ± deranged liver function ± dilated CBD
Management
1st – MRCP
2nd – 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 – 8mm
post-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 HarveyHenry’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 cholangitis
Bacterial infection (E. Coli) of the biliary tree
Management:
IV Fluids, Abx + urgent
removal of obstruction
(ERCP)
6th doctor
Mrs 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 doctor
You 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
Pain
severe epigastric
central abdominal
radiation to the back
Aetiology
Gallstones (50%)
Alcohol (35%)
Post-ERCP (5%)
(the rest = 5%)
Vomiting
8th doctor
Your 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
For ANY surgical admission
Aggressive fluid replacement
– 1000ml Hartmann’s stat
– 1000ml Hartmann’s 2h / 4h / 6h
•
•
•
•
Catheterise – strict fluid balance
Hourly observations
Analgesia
ABG
ABGs…
Investigations
Modified Glasgow criteria – prognostic criteria
Predicts severity of severe pancreatitis: ≥3 factors are over the first
48h indicate severe pancreatitis  ITU involvement
PaO2
<8kPA
[ARDS]
Age
>55y
Neutrophils WBC>15
Calcium
<2mmol/l
[lipid saponification]
Renal functionUrea >16
[hypovoloaemia]
Enzymes
LDH >600, AST>200 [autolysis]
Albumin
<32g
Sugar
BM >10mmol/l
[endocrine disturbance]
LOOK FOR SIGNS OF (MULTI-) ORGAN FAILURE
Questions?
Covered in the handout:
– Biliary malignancies (cholangiocarcinoma)
– Chronic pancreatitis