biliary disease + pancreatitis for finals (and beyond) …the story of mrs harvey-henry
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Biliary disease + pancreatitis for finals (and beyond) …the story of Mrs Harvey-Henry. Dr Julian Dickmann General Surgery. By the end of this session…. You will be able To recognise the common complications of gallstone disease Understand the underlying pathophysiology - PowerPoint PPT PresentationTRANSCRIPT
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Biliary disease + pancreatitisfor finals (and beyond)
…the story of Mrs Harvey-Henry
Dr Julian DickmannGeneral Surgery
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By the end of this session…You will be able- To recognise the common complications of gallstone disease - Understand the underlying pathophysiology- Start initial management and investigations- To initiate treatment.
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First doctor
You are the F2 in general practice – Mrs Harvey-Henry, a 44 year old restaurant critic comes to you with her private ultrasound report after a visit to the well woman clinic which showed “numerous gallstones”. She does not complain of any symptoms. She is very worried – what do you advise?
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Gallstones
The commonest cause of emergency hospital admission with abdominal pain1
1- Kettunen et al. Emergency abdominal surgery in the elderly. Hepatogastroenterology. 1995;42:106–8.Pictures from BMJ Review (Gallstones)
= common in exams
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“Pathological” effects of gallstones
Silent90% asymptomatic
WITHIN THE GALLBLADDER
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Second doctor
You are the F1 in A+E – Mrs Harvey-Henry, presents to the emergency department with a 1h history of RUQ pain after dining at the Fat Duck. The pain has now subsided and she is very worried. What do you advise (examination unremarkable)?
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“Pathological” effects of gallstones
Biliary colic
WITHIN THE GALLBLADDER
INTERMITTENT PAIN NOT SYSTEMICALLY
UNWELL
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Clinical management & investigationsDo not admit. Ultrasound as an outpatient.• Conservative– Analgesia– Anti-emetics
• Medical– Ursodesoxycholic acid (not effective)
• Surgical– Cholecystectomy (laparoscopic)
Biliary colic
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Third doctor
You are the F1 in A+E – Mrs Harvey-Henry, now complains of a 2 day history of RUQ pain, vomiting and feeling unwell.
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“Pathological” effects of gallstones
Acute cholecystitis
WITHIN THE GALLBLADDER
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Acute cholecystitis – pathogenesis
obstruction of the cystic duct (gallstones / sludge)
↑ Intraluminal pressure
supersaturation of cholesterol
Inflammatory response(PG-I2/E2)
± secondary bacterial infection (E Coli, Klebsiella) in 20%
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Acute cholecystitis – diagnosis
Murphy’s sign positive: inspiratory arrest by pain on palpation AND the absence of left sided arrest of inspiration
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Acute cholecystitis – investigations
UltrasoundDistended “thick walled” gallbladderGallstones / SludgeMurphy’s sign – elicited with probe
Preparation for ultrasound abdomen:Fasting for 6h.Clear fluids until 2h.(+ full bladder for renal/gynae)
Blood tests
CT(CXR) Δ RLL Pneumonia
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• Conservative– Analgesia– Anti-emetics
• Medical– IV Antibiotics (Tazocin ± Gentamicin)
• Surgical – definite treatment– Laparoscopic / open cholecystectomy– High surgical risk + sepsis: percutaneous
cholecystostomy
Acute cholecystitis – managementAcute cholecystitis – management II
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Timing of surgery?28.5% readmission rate (gallstone-related complications) on NHS waiting list (1)
Either:Early urgent (<72h) or delayed-interval LC– Introduction of an “urgent cholecystectomy
service” of readmission rate 19% to 3.6% (2)
– Optimal time: 6-12 weeks after initial admission (3)
Acute cholecystitis – managementAcute cholecystitis – management I
(1) Cheruvu et al. Ann R Coll Surg Engl 2002(2) Mercer et al. Br J Surg 2004
(3) Gurusamy et al. Br J Surg. 2010
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Complications
• Anaesthetic risk (PE, Pneunomia, MI)• Procedure-specific risks: – Conversion to open– Injury to CBD– Biliary leak causing biliary peritonitis– Post-op haemorrhage– Intra-abdominal abscess
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4th doctor
Mrs Harvey-Henry responds well to analgesia and antibiotics but a day you as the F1 notice that she is appears jaundiced (obviously you noticed this without looking at the bilirubin…).
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“Pathological” effects of gallstones
Obstructive jaundice
Choledocolithiasis=stone in CBD
Oedema around the biliary tract
Mirizzi’s syndrome(stone in Hartmann’s pouch
compressing common hepatic duct)
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CholedocolithiasisSuspect if: JAUNDICE ± deranged liver function ± dilated CBD
Management1st – MRCP2nd – Endoscopic retrograde cholangiopancreatography (ERCP)NB: no diagnostic test, treatment only (>90% success rate)
(operative CBD exploration during cholecystecomy)
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Normal CBD diameter< 50 years – 6mm > 50 years – 8mmpost-cholecystectomy >10mm
Senturk et al. Eur J Radiol. 2012 Jan;81(1):39-42.
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5th doctor
On your on-call night shift, the a nurse on Willoughby ward bleeps you: Mrs Harvey-Henry’s MEWS is 8 (systolic BP of 85, HR 120, RR 24, T 39.2). They are apologetic, but as she was in a side-room, they only noticed this at midnight. So you make your way up to the ward…
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Ascending cholangitisBacterial infection (E. Coli) of the biliary tree
Management:IV Fluids, Abx + urgent removal of obstruction (ERCP)
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6th doctorMrs Harvey-Henry is successfully resuscitated by yourself (ABC!) and there was a slot for an ERCP available first thing in the morning.
Anything to consider?
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7th doctorYou get bleeped at 11pm. The nurses tell you that Mrs Harvey Henry needs more pain relief. Her pain is not adequately controlled on paracetamol, tramadol and hourly oramorph. Could you come and assess her?
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post-ERCP Pancreatis (PEP)5% risk esp. multiple injections of contrast into pancreatic duct
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Acute Pancreatitis
Aetiology
Gallstones (50%)Alcohol (35%)Post-ERCP (5%)(the rest = 5%)
Painsevere epigastric
central abdominal radiation to the back
Vomiting
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8th doctorYour SHO and registrar are busy in theatres. You are on your own.Start initial investigations and management.
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Management
• Nil by mouth• IV Access (green cannula)• Bloods – FBC/U+Es/Amylase/CRP/G+S/Clotting• Aggressive fluid replacement– 1000ml Hartmann’s stat– 1000ml Hartmann’s 2h / 4h / 6h
• Catheterise – strict fluid balance• Hourly observations• Analgesia• ABG
For ANY surgical admission
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ABGs…
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Investigations
LOOK FOR SIGNS OF (MULTI-) ORGAN FAILURE
Modified Glasgow criteria – prognostic criteria Predicts severity of severe pancreatitis: ≥3 factors are over the
first 48h indicate severe pancreatitis ITU involvementPaO2 <8kPA [ARDS]Age >55yNeutrophils WBC>15Calcium <2mmol/l [lipid saponification]Renal functionUrea >16 [hypovoloaemia]Enzymes LDH >600, AST>200 [autolysis]Albumin <32gSugar BM >10mmol/l [endocrine disturbance]
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Questions?
Covered in the handout:– Biliary malignancies (cholangiocarcinoma)– Chronic pancreatitis