29/01/2013 Gallbladder & Bile Ducts Anatomy Biliary Disease and Pancreatitis Mr Panagiotis Georgiou MD, MRCS Academic Clinical Fellow in General Surgery Date: 29/01/2013 Physiology Congenital Abnormalities ✤ Bile Salts ✤ Liver ✤ Gallbladder ✤ Biliary atresia 50 mls ✤ Concentrate 10-fold ✤ ✤ Choledochal cysts ✤ Miceles ✤ Enterohepatic circulation ✤ Reabsorbed 95%at distal ileum 1
29/01/2013 Gallstones Complications of Gallstones ✤ Common ✤ Biliary Colic ✤ Acute/Chronic Cholecystitis ✤ Age ✤ Pancreatitis ✤ F-emale, F-at, F-orty (40), F-ertile ✤ Cholangitis ✤ Mucocoele ✤ Cholesterol ✤ Choledocholithiasis ✤ Bile is supersaturated with cholesterol ✤ Pigment ✤ Gallstone ileus ✤ Haemolytic blood disorders ✤ Cancer Management Biliary Colic ? ✤ RUQ & Epigastric Pain ✤ Colicky ✤ Analgesia ✤ Radiating at the back ✤ Light diet ✤ Worse with fatty meals ✤ OP Surgery ✤ No Signs of Sepsis 2
29/01/2013 Acute Cholecystitis Management ✤ A, B, C ✤ Obstruction and Infection ✤ Bloods & Blood Cultures ✤ Systemic illness ✤ IV Fluids, Analgesia and Abx ✤ Usually associated with GS ✤ eCXR ✤ RUQ pain and tenderness ✤ USS ✤ Murphy’s sign ✤ MRCP/ERCP Complications Ascending Cholangitis ✤ Infection of the Bile Ducts ✤ Empyema ✤ Ascending Bacteria ✤ Associated with GS ✤ Gangrenous Gallbladder ç ✤ Perforation ✤ Pancreatitis ✤ Charcot’s triad ✤ Pain, Jaundice, Temperature/Rigors 3
29/01/2013 Management? Pancreatitis ✤ Inflammation if the pancreas ✤ A, B, C ✤ G- allstones ✤ Blood Cultures ✤ E- thanol ✤ IV Fluids & Abx ✤ T- rauma ✤ S- teroids ✤ Analgesia ✤ M- umps ✤ A- utoimmune (PAN) ✤ eCXR ✤ S- corpion stings ✤ H- yperlipidemia/ H ypercalcemia ✤ USS ✤ E- RCP ✤ MRCP/ERCP ✤ D- rugs (including azathioprine and diuretics) Presentation Management ✤ A, B, C ✤ Bloods & ABG ✤ Epigastric/RUQ Pain ✤ Score ✤ Radiating at the back ✤ IV Fluids , Catheter ✤ N+V ✤ Urine Output ✤ ?Diarrhoea ✤ eCXR, AXR ✤ Malaise ✤ USS ✤ CT 4
29/01/2013 Score Complications ✤ On admission and within 48h ✤ Systemic ✤ P-O2 < 8 Score > 3 ✤ Local Severe Pancreatitis ✤ A-ge >55 ✤ Respiratory Consider ITU ✤ Necrosis ✤ N-eutrophils (WCC >15) High Mortality ✤ Cardiovascular ✤ Infected Necrosis ✤ C-alcium <2mmol/L ✤ Renal ✤ R-enal (Urea>16mmol/L) ✤ Abscess ✤ Metabolic ✤ E-nzymes (LDH>600units/L) ✤ Pseudocyst ✤ A-lbumin<32 g/L ✤ GI ✤ S-ugar >10 mmol/L Scenario 1 Investigate? ✤ 1/7 history of Abdominal pain Bloods NAD ✤ Epigastric ✤ A, B, C Differential Diagnosis XRs NAD Biliary Colic ✤ Colicky ✤ Clinical examination Heartburn/Gastritis Ulcer ✤ Radiating at the back Cholecystitis ✤ Burning ✤ Bloods? Discharge with OP USS ✤ Worse with meals 5
29/01/2013 Scenario 2 Investigate? ✤ 1/7 history of Abdominal pain Bloods Differential Diagnosis Elevated WCC and CRP ✤ Epigastric ✤ A, B, C Cholecystitis LFTs Normal Pancreatits XRs NAD ✤ Colicky now constant ✤ Clinical examination Heartburn/Gastritis Ulcer ✤ Radiating at the back Admit for IV Abx and Analgesia ✤ Burning ✤ Bloods USS ✤ Worse with movement Scenario 3 Investigate? ✤ 1/7 history of Abdominal pain Bloods ✤ Epigastric Differential Diagnosis Elevated WCC and Amylase ✤ A, B, C Cholecystitis Bil 30 ✤ Colicky now constant Pancreatitis CXR Right pleural effusion ✤ Clinical examination Heartburn/Gastritis ✤ Radiating at the back Ulcer ✤ Burning Admit for IV Fluids and Analgesia ✤ Bloods Monitor Urine Output ✤ Worse with movement USS ✤ Vomiting 6
29/01/2013 Further Management Questions USS + - + MRCP GB CBD - ERCP OP Surgery 7
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