Gallstones/Pancreatitis for Finals - PowerPoint Presentation

Slide1

Gallstones/Pancreatitis for Finals

Simon Bloomfield, FY1 General Surgery, SWFTSlide2

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 workSlide3

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 normalSlide4

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)Slide5

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)Slide6

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

choleSlide7

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

cholangitisObstructive jaundiceAcute PancreatitisBowelGallstone ileus(Perf)Slide8

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)Slide9

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...Slide10

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...)Slide11

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 choleSlide12

Charcot’s triad (cholangitis) – 50-70%

RUQ pain

Fever

JaundiceSlide13

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 waySlide14

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 pancreatitisSlide15

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/LSugar - Glucose > 10 mmol/L+ CRP (>150)+ Lactate(APACHE II)Slide16

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

)Slide17

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 SURGERYAcute cholecystitis – Abx, SURGERY(Also: pulmonary oedema, pleural effusions, ARDS, hypovolaemia, shock, DIC, AKI, sepsis, metabolic – low Ca, low Mg, high glucose)Slide18

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)Slide19

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, diureticsSlide20

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)Slide21

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 RUQBreath halted on inspiration when palpating RUQ (not LUQ)Slide22

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 CXRUSS abdo + pancreas mane (good luck getting it overnight)

Special test

MRCP (if CBD dilated) – Why?Slide23

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 caseSlide24

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 websiteSlide25

end

Thanks