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

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

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 normal

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)

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)

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

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)

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)

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...

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...)

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

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

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

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

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)

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)

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)

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)

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

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)

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)

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?

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

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

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