clin med exam 1: pancreas and biliary tract disorders

chronic pancreatitis patho

irreversible damage from inflammation of the pancreas with destruction of exocrine parenchyma and fibrosis

in late stage pancreatitis the endocrine parenchyma is also destroyed

risk factors of chronic pancreatitis

- alcoholism

- smoking

- genetic risk factors

- 10-20% is idiopathic (no known cause)

signs and symptoms of chronic pancreatitis

- persistent or recurrent episodes of epigastric and LUQ pain

- anorexia

- N+V

- constipation

- flatulence

- weight loss

- steatorrhea

tests for chronic pancreatitis

- labs

- imagining studies

tests for chronic pancreatitis: labs (and what they show)

lab finding:

- elevated serum amylase and lipase (elevated during an attack but low on a day to day basis)

- elevated serum alkaline phosphatase/ alk phos and bilirubin

- glycosuria

- hyperglycemia

- hypoglycemia

- steatorrhea

tests for chronic pancreatitis: imagining studies (and what they show)

x rays: show calcifications

CT of abdomen: shows atrophy and calcifications

ERCP (done if calcifications are seen on x ray or CT because this will be able to image and remove any gallstones)

treatment of chronic pancreatitis

- low fat diet

- alc cessation

- pain control (but avoid opioids b/c of addiction)

- pancreatic enzyme supplements (especially for steatorrhea)

- treat diabetes or hyperlipidemia

- monitor for pancreatic cancer (due to their increased risk)

etiology of pancreatic cancer

carcinoma in the head (75%) or tail (25%) of pancreas

risk factors for pancreatic cancer

- old age

- men (only slightly higher)

- tobacco use

- alcohol

- obesity

- chronic pancreatitis

- prior radiation

- family history

signs and symptoms of pancreatic cancer

- vague epigastric pain with radiation to the back and improved with sitting up or leading forward

- indigestion

- diarrhea

- weight loss

- jaundice (if tumor is obstructing bile flow)

- preumbilical nodule (sister mary joseph nodule) indicates Mets

test for pancreatic cancer (and what they show)

labs:

- elevated Ca 19-9

- mild anemia

- hyperglycemia

- elevated amylase and lipase

CT of abdomen/pelvis with contrast

endoscopic ultrasound (to r/o cancer)

treatment for pancreatic cancer

- TNM staging (to determine extent of the tumor)

- radical pancreaticoduodenal resection (Whipple dissection) for lesions in the head of the pancreas

- chemo + radiation

- endoscopic stenting of the bile duct to relieve jaundice (if Whipple is not feasible)

- prophylaxis with EUS, CT, or MRI/MRCP for people with a family history

etiology of cholelithiasis

stones present in the gallbladder; stones are either classified as: cholesterol (90%) or pigmented (common in chronic hemolysis)

risk factors of cholelithiasis

- sickle cell disease

- rapid weight loss after bariatric surgery

- diabetes

- insulin resistance

- glucose intolerance

- hypertriglyceridemia

- men with cirrhosis and Hep C

- prolonged fasting (it creates biliary sludge that could turn into stones)

- hormonal therapy (estrogen)

six F's:

- Female

- Fertile (pregnancy)

- Fat

- Forty

- Family

- Farmacology (pharmacology: octreotide, ceftriaxone)

symptoms of cholelithiasis

* frequently asymptomatic or biliary colic *

- biliary or episodic gallbladder pain in the RUQ

- pain is intermittent and lasts less than 6 hours

- no fever or elevated WBCs

diagnosis of cholelithiasis

ultrasound

treatment of cholelithiasis

- NSAIDs (diclofenac 50-75 mg IM)

- laparoscopic cholecystectomy followed by pain relief

- open cholecystectomy (if necessary)

- prophylactic cholecystectomy (if gallbladder is calcified, gallstones are > 3cm in diameter, native american pt, or candidate for bariatric or cardiac transplant surgery)

- oral ursodeoxycholic acid (if surgery is not an option)

for pregnant patients:

- cholecystectomy in second trimester

- oral ursodeoxycholic acid

etiology of choledocholithiasis

obstruction of the biliary tract caused by gallstones in the common bile duct

risk factors of choledocholithiasis

- gallstones

- old age

- cholecystectomy

signs and symptoms of choledocholithiasis

- frequently recurring attacks of RUQ pain that is severe and persists for hours

- biliary pain

- chills + fever

- jaundice

testing for choledocholithiasis

- ultrasound (USN)

- measure common bile duct to detect obstruction (if stones don't show up on USN)

treatment for choledocholithiasis

- ECRP + sphincterotomy and stone removal

- laparoscopic cholecystectomy (if needed)

etiology of cholangitis

infection of biliary tract due to an obstruction that leads to biliary stasis and bacterial overgrowth

signs and symptoms of cholangitis

- Charcot triad: RUQ pain, jaundice and fever

- Reynold's pentad: Charcot triad, septic shock and altered mental status

- hyperbilirubinemia

- leukocytosis

- mildly elevated serum transaminases

- hepatomegaly (present in calculous biliary obstruction_

- hepatic failure with portal hypertension (if left untreated)

risk factors of cholangitis

untreated choledocholithiasis

tests for cholangitis

diagnostic criteria

test for cholangitis: diagnostic criteria (and what they show)

diagnosis based on:

- Charcot triad

or...

- 2 elements and laboratory evidence of inflammation: elevated white count or C-reactive protein

test for cholangitis: labs (and what they show)

lab findings:

- huge increase in serum aminotransferase levels ( >1000 units/L)

- bilirubinuria and elevation of serum bilirubin

- serum alkaline phosphatase (alk phos) rises slowly

- elevation of serum amylase

- leukocytosis

test for cholangitis: imaging (and what they show)

- ERCP (sometimes with intraductal ultrasonography or PTC): to determine cause, location and extent of obstruction

- initial cholecystectomy with intraoperative cholangiography

treatment for cholangitis

- broad spectrum IV antibiotics

- ERCP: endoscopic sphincterotomy and stone extraction

- followed by laparoscopic cholescystectomy

- laparoscopic cholecystectomy and bile duct exploration

etiology of primary biliary cirrhosis

autoimmune condition in which the immune system attacks the intrahepatic bile ducts in the liver resulting in bile outflow obstruction, fibrosis, cirrhosis and liver failure

risk factors for primary biliary cirrhosis

- middle aged women

- Northern Europe and North America

- genetic predisposition

signs and symptoms of primary biliary cirrhosis

* many are asymptomatic *

- fatigue

- itching

- dry eyes and mouth

- RUQ discomfort

- liver cirrhosis symptoms: jaundice, abdominal and lower extremity edema, and easy bruising

test for primary biliary cirrhosis (and what they show)

liver biopsy: assess stage of progression

lab values:

- anti-mitochondrial antibodies

- anti-nuclear antibodies (in 35% of pts)

treatment for primary biliary cirrhosis

ursodeoxycholic acid/ UDCA (only slows disease progression, not curative)

etiology of primary sclerosing cholangitis

condition in which the intrahepatic or extrahepatic ducts become sclerosed (stiffened and hardened), fibrotic and inflamed

the cause is unknown but it is thought to be a combo of genetic, autoimmune, intestinal microbiome and environmental factors

risk factors of primary sclerosis cholangitis

- ulcerative colitis

- males

- 20-50 yrs old

(decreased risk with smoking and caffeine)

signs and symptoms of primary sclerosing cholangitis

- progressive jaundice

- fatigue

- itchiness

- anorexia

- indigestion

- progression to liver failure

- complications of chronic cholestasis (osteoporosis, malabsorption, malnutrition)

test for primary sclerosing cholangitis (and what they show)

ERCP: shows bead like dilations of intrahepatic and extrahepatic ducts

MCRP: shows segmental fibrosis of bile ducts with saccular dilations between strictures

labs:

- elevated or normal LFTs

- elevated CA 19-9 levels (test for cholangiocarcinoma/ pancreatic cancer)

treatment for primary sclerosis cholangitis

* no cure *

treatment revolves around managing symptoms and complications:

- antibiotic therapy

- dilation of strictures for symptom relief

- meds for underlying condition

- liver transplant (if it progresses)

Q: a 46 year old male is brought into the emergency department by his worried wife. "It's this pain; I can't take it anymore," he says while holding his epigastric region. "I feel it in my back too. I tried to eat and it just got worse." KG's heart rate is 102/min and blood pressure 144/92 mmHg. On exam, he is curled in the fetal position. His abdomen is tender in the epigastrium and left upper quadrant. As KG is getting his bloodwork, his wife pulls you aside to tell you that he drinks 6-8 beers daily and today was no different.

1. what tests will help you determine the diagnosis?

2. what is the diagnosis?

3. what treatment will you recommend?

1. labwork (specifically looking for elevated serum lipase and amylase, and AST: ALT ratio)

- CT of the abdomen could also be done if the labwork is inconclusive

- could also do an abdominal USN to r/o gallstones as the cause and confirm alcohol (but if AST:ALT ratio is 2:1 than gallstones can probably be ruled out with labs and history alone)

- ranson criteria test (to assess severity)

2. acute pancreatitis (most likely acute alcoholic pancreatitis)

3. pancreatic rest:

- NPO --> clear liquids --> soft --> low fat --> regular diet

- bed rest

- IV fluids

(also encourage patient to stop drinking)