082. Pancreatitis and Cholecystitis

Pancreatitis

Gallstones MCC – 60%. Alcohol second MCC. Other causes: I GET SMASHED: Idiopathic, Gallstones, Trauma, Steroids, Mumps, Autoimmune, Scorpion stings, Hypertriglyceridemia (3rd MC, 10%, probably need to check level on most patients) calcium/parathyroid, ERCP, Drugs. Parasites is MCC worldwide.

Trypsin activation within the pancreas with autodigestion, inflammatory markers initiated.

Epigastric pain, radiating into upper quadrants, back. Usually pain increases over 30 minutes until its constant. Pain worse with laying flat. Nausea/vomiting. Fever is severe cases. Cullen sign: periumbilical ecchymoses and Turner sign: ecchymoses in the flanks – indicate retroperitoneal/intraabdominal hemorrhage – severe necrotizing pancreatitis. ARDS can occur with severe pancreatitis. Large pleural effusions can be related to pancreaticopleural fistula with pseudocyst. Pleural effusion good indicator of severe pancreatitis.

Lipase 3x upper limit of normal. Lipase stays elevated longer than amylase – better sensitivity for delayed presentations. Recurrent disease can have normal levels. Level does not predict severity either. Need 2 of the 3: HPI/exam consistent with pancreatitis, lipase > 3x upper limit, and CT findings. Need to check all first time pancreatitis for upper abdominal ultrasound for GS pancreatitis – even the alcoholics.

Colon cutoff sign: colonic gas stops at splenic flexure due to spasm from pancreatic exudate. CT best test for diagnosis. Abscess don’t usually form until >15 days after initial event.

Ranson criteria: terms severity of pancreatitis. 5 points determined on admission (age>55, WBC>16k, Glucose >200, LDH>350, AST>250) and 6 obtained 48 hours after (Decrease in hemocrit by 10%, fluid sequestration >6L, calcium level <8, PaO2 <60, BUN>5 after hydration, base deficit >4). APACHEII used as well for severity. CT Severity Index is better predictor of severity than Ranson.

Treatment: supportive/conservative. Hydration (start at 2L, need 4L likely by the 6-12 hour mark, can check with serial hemocrits – LR > NS), pain control (ok to do oral over IV). Newer recommendations are to start fluids/food early, recommend low-fat food – NPO no longer recommended unless unable to. If elevated bili, GI consult for urgent ERCP in the next day or so. Pseudocysts that are large, symptomatic or complicated can be treated by endoscopic ultrasound (usually GI service).

Cholecystitis

Inflammation of the gallbladder. Acute cholecystitis is bacterial invasion. Biliary colic is constant RUQ lasting 2-6 hrs and then resolving.  Acute calculus cholecystitis occurs with absence of gallstones (RF: elderly, critical ill, burns, trauma, major surgery, TPN, DM, immunosuppression, childbirth). Silent gallstones: 1-4% per year of causing symptoms, 10% by 5 years, 20% by year 20. Sludge can form into gallstones or can completely resolve Рno methods to prevent sludge.

Cholangitis is ascending infection due to obstructing stone.

Generally RUQ pain with radiation into back, shoulder. Can also cause pain in LUQ. Some symptoms develop at night with peak in symptoms at midnight to 1am. Not necessarily with meals. Colic should only last about 5 hours. If >, consider cholecystitis/pancreatitis. Murphy sign has highest sensitivity for diagnosing acute cholecystitis. WBC > 10k is 63% sensitive, CRP sensitive in 97%. Mirizzi syndrome (compression of common hepatic duct from impacted stone on cystic duct – external squeeze). US only 94% sensitive for cholecystitis.

Ultrasound findings: gallbladder wall >3mm, pericholecystic fluid. >5 is more predictive of cholecystitis. Consider ascites, pancreatitis, heart failure, alcoholic hepatitis as causes for incidental wall thickening.

HIDA (hepatobiliary imilodiacetic acid cholescintigraphy) looks at GB function. Looks for biliary dyskinesia (<35% EF). Morphine can interfere with result.

Treatment: biliary colic can be outpatient surgery. Acute cholecystitis require laparoscopic cholecystectomy. ERCP for CBD stones. All narcotics can increase biliary pressure and induce spasm of Oddi. Antibiotics: third generation cephalosporin + flagyl or fluoroquinolone + flagyl. Zosyn for severe cases.

Acute Cholangitis

Obstruction + Infection. Causes: choledocholithiasis, biliary stricture, compression caused by malignant. Charcot triad: fever, jaundice, RUQ pain. Reynolds pentad: AMS, shock, fever, jaundice, and pain. Tx: Abx, hydration, GI/surgery consult.

Chronic Cholecystitis

Longer milder symptoms. US can show porcelain gallbladder.

Gallstone Ileus

SBO due to impaction from large gallstone at terminal ileum. Gallstone usually enters from biliary-duodenal fistula. Usually pneumobilia. Morbidity/mortality high.

References

Tintinalli, Seventh Edition, Chapter 82: Pancreatitis and Cholecystitis

CrashingPatient, Scott Weingart, Pancreas, Reviewed 6/17/17

EMRAP, December 2017

082. Pancreatitis and Cholecystitis