Gall Bladder & Pancreatitc Disorders

 

• Background

  Pathophysiology and epidemiology

  • Gallstones are made up of cholesterol (80% of stones), bile pigments, or a mix.
  • Around 10% of men and 20% of women have gallstones.
  • Usually asymptomatic, but 2% become symptomatic annually.
  • Clinical manifestation depends on location.

  Anatomical locations

  Cholelithiasis

  • Gallstones in the gallbladder.
  • Presentation: acute and chronic cholecystitis, biliary colic.
  • Mirizzi's syndrome is a rare complication where stones in the gallbladder or cystic duct cause obstructive jaundice via extrinsic compression of the CBD.

  Choledocholithiasis

  • Gallstones in the common bile duct (CBD).
  • Presentation: obstructive jaundice, acute cholangitis, or acute pancreatitis.

  Gallstone ileus

  • Gallstones obstructing small bowel.

• Risk factors

  The 5 Fs:

  • Fat or rapid weight loss.
  • Female
  • Forty (age): due to premenopausal estrogen increase.
  • Fair: white ethnicity.
  • Fertile: multiparity.

  Others, FOOD:

  • Family history.
  • Oral contraception.
  • Older age.
  • Diabetes

• Biliary colic

  Definition

  • Biliary obstruction without infection, causing pain as gallbladder contracts against it.
  • Due to stone impaction in the gallbladder neck or cystic duct.

  Signs and symptoms

  • Continuous RUQ or epigastric pain i.e. not 'colicky'. May radiate to back (below the right scapula). Worse after fatty meal. Can be severe, with patients writhing in pain.
  • Nausea and vomiting may occur.
  • Usually resolve <6 hrs.
  • No fever, peritonism, or ↑WBC.

  Investigations

  • Initial: abdo US and LFTs.
  • Consider MRCP if there is duct dilatation on US and/or abnormal LFTs, then endoscopic ultrasound if MRCP not conclusive.
  • Most gallstones (90%) are radiolucent on XR, unlike renal stones, so abdo XR is not useful.

  Management

  Non-operative:

  • Analgesia. For severe pain, give parenteral opioid or PR diclofenac.
  • Avoid triggering foods and drinks i.e. low fat diet.

  Operative:

  • Laparoscopic cholecystectomy. Can be done as a day case. Offer early (<1 week) in an acute presentation requiring hospitalisation.
  • If there are CBD stones → remove via ERCP, or CBD clearance during cholecystectomy. This can be offered even to asymptomatic individuals with CBD stones.
  • Afterwards should be able to consume normal diet, including previously triggering foods and drinks.

• Acute cholecystitis

  Definition and pathophysiology

  • Acute gallbladder inflammation due to stone impaction in the cystic duct or gallbladder neck.
  • May initially look like, or be a complication of, biliary colic.
  • Usually sterile chemical inflammation – at least initially – but becomes infective in ⅓. Pathogens include E. coli and Klebsiella.

  Signs and symptoms

  • Continuous RUQ or epigastric pain, which may radiate to back (below right scapula), as in biliary colic. Tenderness in the area of back pain (Boas' sign).
  • Fever and local peritonism, with the patient lying still instead of the writhing of biliary colic.
  • Murphy's sign: with 2 fingers pressed on RUQ, there is pain on inspiration (but no pain when in LUQ).
  • There may be a palpable RUQ mass: phlegmon (inflamed omentum and bowel around gallbladder), or gallbladder itself (less common).
  • Vomiting
  • Jaundice (10% of patients): due to compression, inflammation, or stone impaction in the CBD. If there is infection of the CBD, it is cholangitis.

  Investigations

  Bloods:

  • FBC: ↑WBC
  • ↑CRP
  • LFT: around 1/3 have ↑alk phos, ↑BR, and/or ↑GGT.

  Imaging:

  • Abdo US. 4 hrs nil by mouth before as this will distend gallbladder. May show stones, thick-walled gallbladder, and/or shrunken gallbladder (if chronic). +ve Murphy's sign is pain on compressing GB with probe. Dilated CBD if there are stones there, but stones lower down may not be visualised.
  • MRCP indications: US showing dilated CBD, obstructive LFTs which are failing to improve. Endoscopic ultrasound (EUS) if MRCP not conclusive.
  • Other options: HIDA cholescintigraphy (nuclear medicine) can show cystic duct obstruction, CT abdo for differentials or complications (but most gallstones are not radiopaque).

  Management

  Non-operative:

  • Supportive treatment, including fluids and analgesia (as for biliary colic). ITU if there is perforation.
  • Antibiotics IV.

  Operative:

  • Although 90% resolve with non-operative management, recurrences are common so this is offered to most patients.
  • Early (<1 week) laparoscopic cholecystectomy. Doing it <1 week prevents re-admission and second 'illness' episode.
  • If there are CBD stones: ERCP pre-op or intra-operative bile duct clearance.
  • Percutaneous cholecystotomy tube (PCT) for drainage can be used as an urgent treatment in perforation, or in patients not fit for surgery.

  Complications

  • Infarction (gangrenous cholecystitis) or perforation. Can lead to peritonitis, with high mortality risk.
  • Gallbladder empyema (aka suppurative cholecystitis).
  • Chronic cholecystitis: repeated episodes lead to fibrosed and shrunken gallbladder.

• Acute cholangitis

  Definition and pathophysiology

  • Infection of the bile duct, usually with Klebsiella, E. coli, or Enterobacter.
  • Risk factors: ERCP, biliary malignancy.
  • Aka ascending cholangitis.

  Clinical features

  Charcot's triad (all 3 present in 60%):

  • RUQ pain.
  • Obstructive jaundice.
  • Rigors

  Investigations

  • Bloods: ↑WBC, LFTs (↑BR, ↑alk phos, ↑GGT).
  • Imaging: US, MRCP.

  Management

  • Antibiotics IV and fluids.
  • ERCP once stable. Involves sphincterotomy and stone clearance, or stenting if stones cannot be retrieved.
  • Consider cholecystectomy and CBD clearance as an alternative.

• Gallstone ileus

  • Large gallstone that erodes through gallbladder and into duodenum, causing small bowel obstruction.
  • Stones that are small enough to pass through the sphincter of Oddi are unlikely to cause obstruction.
  • Usually impacts at narrowest point in small bowel, 2 feet proximal to the ileocecal valve.
  • Abdo XR shows dilated loops of bowel and air in the biliary tree (entered through the fistula).

• Acute pancreatitis

  Pathophysiology

  • Involves intra-pancreatic activation of pancreatic enzymes and auto-digestion.
  • Inflammation leads to oedema, fluid shifts, and hypovolaemia.
  • In severe disease, there is erosion of vessel walls and intra-abdominal bleeding.

  Causes

  I GET SMASHED:

  • Idiopathic (20%)
  • Gallstones (50%). Commoner in women.
  • Ethanol (20%). Commoner in men.
  • Trauma
  • Steroids
  • Mumps and Malignancy.
  • Autoimmune
  • Scorpion sting.
  • Hyperlipidaemia and Hypercalcaemia.
  • ERCP
  • Drugs e.g. valproate, azathioprine, thiazides.

  Signs and symptoms

  • Sudden-onset epigastric or LUQ pain and tenderness. Radiates to back.
  • Nausea, anorexia, and vomiting.
  • SIRS
  • May be jaundiced if due to gallstones.
  • Pleural effusions and ascites if severe.
  • In haemorrhagic pancreatitis, bruising over both flanks (Grey-Turner's sign) and/or peri-umbilicus (Cullen's sign).

  Diagnosis and investigations

  Diagnosis requires 2 out of 3 of:

  • Compatible history/exam i.e. acute epigastric pain.
  • ↑Amylase or ↑lipase (≥3 times upper limit). Lipase is slightly more sensitive and specific, and elevated for longer.
  • Compatible CT, MRI, or US findings.

  Other bloods:

  • FBC: ↑WBC, ↑RBC (dehydration) or ↓RBC (haemorrhage).
  • ↑CRP
  • ↑LFTs, especially in gallstones.
  • ABG: may show lactic acidosis or ↓O2.
  • ↓Ca2+ is common in severe pancreatitis.

  Imaging:

  • Abdo XR: dilated gut ('sentinel loop') next to pancreas.
  • CXR: pleural effusions.
  • Ultrasound: may show pancreatic inflammation, but mainly done to find gallstones. Repeat after acute phase if gallstones found.
  • Abdo CT with contrast or MRCP are the gold standards, but only needed if the diagnosis is uncertain.

  Management

  Initial management:

  • Supportive care, including plentiful fluids (plus catheterisation and fluid balance chart), analgesia, and antiemetics. Antibiotics if there are signs of infection.
  • Risk stratify with Glasgow Prognostic Score, PANCREAS: PaO2 <8 kPa, Age >55, Neutrophilia (WBC >15), Ca2+ <2 mmol/L, Renal impairment (urea >16 mmol/L), Enzymes (↑LDH, ↑AST), Albumin <32 g/L, Sugar (glucose) >10 mmol/L. Score ≥3 = severe. Ranson's Criteria are an alternative.
  • Routine nil by mouth not indicated. NG or NJ tube for nutrition if severe vomiting.
  • Ca2+ replacement if needed.
  • If due to alcohol, give benzodiazepines and micronutrients (thiamine, folate, B12).

  Interventional treatments:

  • Necrosectomy if there is infected necrosis: removal of necrotic tissue and placement of irrigation tubes.
  • Drainage of pseudocyst (endoscopic US-guided or surgical) if symptomatic or infected.
  • If due to gallstones, offer cholecystectomy or ERCP after recovery. Perform ERCP acutely if there is CBD obstruction or cholangitis.

  Complications

  • 20% mortality if severe, but 1% if mild (80% of cases).
  • Pancreatic necrosis and infection. Suggested by rising CRP.
  • Pancreatic abscess, pancreatic insufficiency, or chronic pancreatitis.
  • Pseudocyst: fluid in lesser peritoneal sac.
  • Sepsis and DIC.
  • Multi-organ failure: AKI, ARDS, paralytic ileus.

• Chronic pancreatitis

  Pathophysiology

  • Similar causes to acute pancreatitis, and may follow repeated episodes. Distinguished from repeated acute episodes by presence of exocrine or endocrine dysfunction.
  • Commonest causes: alcohol (75%), idiopathic.

  Clinical features

  • Recurrent or chronic epigastric pain radiating to back.
  • Exocrine pancreatic insufficiency causing steatorrhea and malnutrition.
  • Diabetes

  Investigations

  • Blood glucose.
  • CT (ideally) or US: pancreatic calcifications.

  Management

  • Analgesia
  • Enzyme supplements.
  • Diabetes management.
  • Dietician support.
  • Manage alcohol problems.

• Laparoscopic cholecystectomy

  Procedure

  • First port is placed in umbilicus, abdomen is insufflated, then three other ports are placed.
  • Operative cholangiogram can be performed to check for CBD stones, and removal if found.
  • Gallbladder removed through umbilicus.

  Outcomes vs. open surgery

  • Shorter stay and quicker recovery.
  • No difference in mortality or complications.

  Complications

  General complications of abdominal laparoscopic surgery:

  • Surgical pneumoperitoneum reduces venous return causing cardiorespiratory strain. May be poorly tolerated by patient with heart or lung disease.
  • Technically more difficult than open surgery, so requires longer training and more equipment.
  • May require conversion to open surgery.

  Specific to laparoscopic cholecystectomy:

  • Bleeding. Relative to open surgery, it may be harder to deal with intraoperative bleeding (e.g. cystic or hepatic artery), so a bleeding disorder is a contraindication.
  • Common bile duct injury, though similar risk as open surgery.
  • Missed CBD stones.
  • Sub-hepatic abscess.
  • Bowel injury.
  • Potential seeding of tumour if gallbladder cancer is present. Suspected cancer is therefore a contraindication.

• Endoscopic retrograde cholangiopancreatography (ERCP)

  Procedure

  Upper GI endoscopy with injection of radiocontrast into the biliary tree and pancreas. Can then proceed to biliary or pancreatic sphincterotomy, stone clearance, and biliary or pancreatic stenting.

  Indications and uses

  • Common bile duct stones.
  • Acute cholangitis.
  • Can be used for diagnostic purposes, but given risks, MRCP is better in such cases, with ERCP reserved for therapeutic use.

  Complications

  Inflammatory:

  • Acute pancreatitis.
  • Cholangitis

  Traumatic:

  • Bleeding. If sphincterotomy being performed, minimize bleeding risk by stopping warfarin, clopidogrel, and ticagrelor 5 days before, and DOACs 2 days before. For stenting, continue warfarin (if in range), clopidogrel, and ticagrelor as normal, and omit DOAC on morning of procedure.
  • GI perforation.
  • Bile duct injury.

  Percutaneous transhepatic cholangiography (PTC)

  An alternative to ERCP in those with hilar obstruction.