Candyce Cheng 3092019 Learning objectives Basic anatomy of biliary tree Clinical presentations of common biliary pathology Investigations needed for each biliary pathology the pros and cons ID: 926528
Download Presentation The PPT/PDF document "The Gallbladder & its associates" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
The Gallbladder & its associates
Candyce
Cheng
3/09/2019
Slide2Learning objectives
Basic anatomy of biliary tree
Clinical presentations of common biliary pathology
Investigations needed for each biliary pathology (the pros and cons)
TO OPERATE OR NOT TO OPERATE?
Slide3Anatomy
WHERE IS THE BLOCKAGE?
Biliary colic/ cholecystitis
Choledocholithiasis
/ Ascending cholangitis
Pancreatitis
Slide4Ms B ED referral with RUQ pain
29 F, fit and healthy, 2 months postpartum
2 weeks of intermittent upper abdominal pain
What would you want to know?
Slide5Ms B (cont
)
Intermittent epigastric and RUQ pain
Twice a week, usually occurs around 8-9pm, lasting a couple of hours
Some nausea no vomiting
GP has done an ultrasound and told her that she has gallstones
Pain is not too bad at this presenting time
O/E
Clinically well,
obs
stable, afebrile
RUQ mildly tender, Murphy’s negative
What next?
Slide6Ms B (cont
)
Ix:
WCC 9, CRP 2
ALT 13, AST 20, ALP 75, GGT 25, Bili 5
Lipase 30
What is your differential diagnosis?
What would you do?
Slide7Ms B (cont
) – a week later you see her at 3am in ED
Came back with same exact pain this evening
Still in a lot of pain when you see her
Vomited twice in ED
O/EHR 90, SBP 120, RR 20,
Sats
97% RA, T 37.6
Appears in pain
Abdomen soft, murphy’s equivocal
DDX?
Slide8Ms B (Cont
)
Ix:
WCC 13, CRP 50
ALT 20, AST 16, ALP 80, GGT 25, Bili 6
Lipase 25
What do you do?
Slide9Ms B (Cont
) – while waiting for OT
Pre-MET T 38.5 at 7pm, HR 90s, SBP 110, RR 20,
Sats
95% RA
Still in pain, but managing with morphine
Bloods from early that morning
WCC 15, CRP 100
ALT 100, AST 80, ALP 150, GGT 200,
bili
45
Lipase 36
DDX?
What do you do? – what
abx
?
Rush to OT????
Slide10Biliary colic and cholecystitis
Biliary Colic
Gallbladder obstruction
RUQ pain typically lasting a couple of hours
Normal inflammatory markers
Elective lap cholecystectomy
Cholecystitis
Gallbladder obstruction + infection of the gallbladder
Persistent RUQ pain
Raised inflammatory markers
Antibiotics + emergency lap cholecystectomy
What about
choledocholithiasis
?
Slide11Mr A – yellow man in ED 2330pm
87 M from nursing home
PMHx
:
IHD (CABG X 3) on aspirin only
T2DM on insulinHTN
Hypercholesterolaemia
Ex smoker &
presumbed
COPD
CCF
Stage 3 CKD
GORD
Mild cognitive impairment
Obesity
Mobilise with 4WF independently
Slide12Mr A (
Cont
)
Before you walk in,
Obviously
jaundiced man, T 39.1,
HR 110, SBP 109/60, RR
16,
Sats
94% on RA
ECG monitor showing AF
HOPC:
Vague historian
3 weeks of intermittent abdominal pain
Past two days have decreased oral intake and vomiting
He feels fatigue and cold
Nursing staff noticed him having rigors and slightly disoriented
Slide13Mr A (Cont
)
Only thing back is VBG
Ph
7.35, PCO2 36, Bicarb 20, Bili 89
What do you do?
Resuscitation and investigation
ABC
IVT + IV antibiotics (which one?) (do blood cultures prior to antibiotics)
Call your consultant/fellow
Ix – imaging????
Slide14First line imaging – When and what
ULTRASOUND
In hour only and operator dependent
Very sensitive to pick to gallstones & can measure CBD size (
>6 mm + 1 mm per decade above 60 years of
age)
Sonographic features of cholecystitis?
CT
Easy to obtain
Radiation, and only pick radio-opaque stones
Very sensitive to inflammation, and other structure abnormalities
What is fat stranding?
Slide15Slide16Mr A (Cont
)
So you’ve done a non contrast CT due to poor renal function
Slide17Mr A (Cont
)
You’ve called up the lab for blood test results
WCC 20, CRP 309
ALT 230, AST 109, ALP 260, GGT 300, Bili 138
Re-review patient after I.5 l of fluids, tazocin
and 5mg IV morphine
T 35.4, HR 105, SBP 110, RR 22,
Sats
92% 2L
Slide18Endoscopic retrograde cholangiopancreatography
Source control in ascending cholangitis patient!!!
Life saving procedure
Slide19Other options for biliary drainage
Percutaneous
transhepatic
cholangiography
When ERCP fails or not available
Intrahepatic haemorrhoage
and biliary peritonitis as major complications
? Patients who cannot survive GA
Slide20Mr A (Cont
)
D1 Post ERCP, Mr A recovers well on the ward
Pain much settled
Now tolerating some free fluids
Tazocin
continued, and inflammatory markers are down trending
WCC 12, CRP 154,
bili
98
You had a lengthy discussion about lap cholecystectomy, Mr A declined treatment
D 2, nurse tells you that Mr A complains about “bad abdominal pain” returned, and had vomited again on the ward
O/E
HR 90, otherwise unremarkable, afebrile
Tender epigastrium and RUQ, murphy’s negative
Slide21Mr A (Cont
)
Ix:
ECG sinus
tachy
WCC 15, CRP 155,
bili
68,
lipase 3387
What are the causes for pancreatitis, what do you think caused Mr A’s pancreatitis?
Slide22Pancreatitis
Diagnosis
Clinical
Radiological
Biochemical
Severity
Glasgow score
Apache II score
Ranson’s
criteria
Slide23Pancreatitis (Cont
)
Management
Pain control
Nutrition
Fluid Antibiotics ?
Cause for pancreatitis
Complications
Slide24Thank you!
Questions?