1. Gallstones/Pancreatitis for Finals
Simon Bloomfield, FY1 General Surgery, SWFT

2. 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 work

3. 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 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 normal

4. 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)

5. 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)

6. Management Conservative Medical Surgical
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 chole

7. 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 cholangitis
Obstructive jaundice
Acute Pancreatitis
Bowel
Gallstone ileus
(Perf)

8. 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)

9. 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...

10. 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...)

11. 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 chole

12. Charcot’s triad (cholangitis) – 50-70%
RUQ pain
Jaundice
Fever

13. 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 way

14. 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 pancreatitis

15. 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/L
Sugar - Glucose > 10 mmol/L
+ CRP (>150)
+ Lactate
(APACHE II)

16. 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)

17. Wait. I thought acute pancreatitis was a surgical condition
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 SURGERY
Acute cholecystitis – Abx, SURGERY
(Also: pulmonary oedema, pleural effusions, ARDS, hypovolaemia, shock, DIC, AKI, sepsis, metabolic – low Ca, low Mg, high glucose)

18. 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)

19. 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, diuretics

20. 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)

21. 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 RUQ
Breath halted on inspiration when palpating RUQ (not LUQ)

22. 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 CXR
USS abdo + pancreas mane (good luck getting it overnight)
Special test
MRCP (if CBD dilated) – Why?

23. Management Conservative Medical Surgical NBM, IVI
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 case

24. 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 website

25. end
Thanks