Jaundice (Gallstones and Pancreatitis)

Jaundice and Related Conditions

Learning Outcomes

• Describe the initial assessment of a patient with jaundice and pale stools (history and exam).
• Formulate a differential diagnosis list for jaundice and pale stools.
• Choose appropriate investigations for jaundice and pale stools.
• Explain the principles of treatment for obstructive jaundice.
• Use effective strategies as part of a multidisciplinary and interprofessional team.

Clinical Case: Brian O'Malley

• 52-year-old male presenting to ED with severe upper abdominal pain.
  • Sharp RUQ pain, 7/10, radiating to the right shoulder.
  • Pain increases with movement and coughing.
  • Fever since this morning.
  • Vomited stomach contents twice at the onset of pain, ongoing nausea.
  • History of on and off mild upper abdominal pain after food for years.
• Vitals:
  • Blood pressure: 110/60 mmHg
  • Temperature: 37.8 degrees Celsius
  • Heart rate: 98 bpm
  • Oxygen saturation: 98% on room air
  • Respiratory rate: 13 breaths per minute
• On Exam:
  • Yellowish tinge to sclera (jaundice).
  • Tender in the right hypochondrium and epigastrium.
  • Murphy's sign positive.

Causes of Jaundice

• Pre-hepatic:
  • Sickle cell disease
  • Malaria
  • G6PD deficiency
• Hepatic:
  • Gilbert's syndrome
  • Crigler-Najjar syndrome
  • Hepatitis
  • Cirrhosis
  • Hepatocellular carcinoma
  • Alcoholic liver disease
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
• Post-hepatic:
  • Obstruction of bile ducts:
    • Pancreatitis
    • Gallstones
    • Cholangiocarcinoma
    • Cholangitis
    • Pancreatic malignancy
    • Lymphoma
• Bilirubin Conjugation:
  • Bilirubin is conjugated in the liver.
  • Pre-hepatic jaundice: raised unconjugated bilirubin.
  • Post-hepatic jaundice: raised conjugated bilirubin.
  • Hepatic jaundice: mixed picture.

Investigations

• Bedside tests:
  • ECG (rule out cardiac cause of epigastric pain).
  • Urinalysis.
• Bloods:
  • FBC, CRP, U&Es, Amylase, Troponins, coagulation profile, blood cultures, calcium, Ca19-9
• LFTs:
  • Raised GGT and ALP = cholestasis/obstruction.
  • Raised AST/ALT = hepatocellular injury.
• Imaging:
  • Erect chest X-ray.
  • US abdomen.
  • MRCP.

Gallstones

• Definition: Small, hard deposits formed abnormally in the gallbladder or biliary tree from bile pigments, cholesterol, or calcium.
• Types:
  • Pure cholesterol (10%)
  • Pure pigment (10%)
  • Mixed (80%)

Gallstones - Risk Factors

• Age and female sex.
• Family History.
• Pregnancy.
• Diet and lifestyle:
  • Obesity.
  • Rapid weight loss.
• Medical conditions:
  • Diabetes Mellitus.
  • Dyslipidaemia.

Gallstones - Presentation

• Majority are asymptomatic.
• Biliary colic:
  • Gallbladder contracts in response to CCK release.
  • Stone impacted in Hartmann's pouch/cystic duct causes intermittent epigastric pain with GB contraction.
• Acute cholecystitis:
  • Inflammation of the gallbladder due to chemical/bacterial irritation at the site of an impacted stone.
  • Murphy's sign: Pain on inspiration when hand is placed on patient's RUQ.
• Ascending Cholangitis:
  • Stone obstructs the common bile duct, causing infection.
  • Charcot's Triad: RUQ pain + jaundice + fever.
  • Reynold's Pentad: Charcot's Triad + confusion + hypotension.

Communication Task: ERCP Explanation

• ERCP (Endoscopic Retrograde Cholangiopancreatography):
  • Camera passed into the biliary tree.
  • Benefit: Diagnostic and therapeutic intervention that allows direct visualization of the biliary system. It is also possible to remove gallstones/sludge or perform sphincterotomy.
  • Risks: Bleeding, infection, perforation, pancreatitis (5-10%), cholangitis.

Clinical Case Continued

• Brian undergoes laparoscopic cholecystectomy following his ERCP.
• Develops severe upper abdominal pain that night.
• Vitals:
  • Temperature: 38.6 degrees Celsius
  • Heart rate: 108 bpm
  • Blood pressure: 100/50 mmHg
  • Respiratory rate: 16
  • Oxygen saturation: 95% on room air
• On review:
  • 10/10 upper abdominal pain radiating to the back with associated vomiting.
  • Surgical sites: no swelling / bleeding / discharge / bruising.

Acute Pancreatitis

• A possible complication post ERCP is acute pancreatitis

Acute Pancreatitis – Causes: I GET SMASHED

• Idiopathic
• Gallstones
• Ethanol (alcohol)
• Trauma
• Steroids
• Mumps and other infections (Coxsackie B virus, Epstein Barr virus)
• Autoimmune (IgG4)
• Scorpion sting
• Hypertriglyceridaemia, hypercalcaemia
• ERCP
• Drugs: Azathioprine, Thiazides, Furosemide, Valproate, Metronidazole, Sulphonamides
• Most common causes: Gallstones and Ethanol

Acute Pancreatitis - Diagnosis

• Atlanta Guidelines 2013 (2/3 criteria):
  • Abdominal pain consistent with the disease.
  • Serum amylase +/- lipase x3 upper limit of normal.
  • Characteristic findings on abdominal imaging.

Acute Pancreatitis - Investigation

• First line investigation for suspected pancreatitis is serum amylase – 3 times the upper limits

Acute Pancreatitis – Severity Grading

• Management depends on severity, determined using:
  • Ranson score
  • Glasgow-Imrie scale
  • CT severity index

Management of Pancreatitis

• Mild Pancreatitis:
  • Fluids
  • Analgesia +/- anti-emetics
  • Abdominal US (<24 hrs of admission)
  • Oral diet
• Mod-Sev Pancreatitis:
  • Aggressive fluid resuscitation
  • Nutrition: NPO, NJ tube
  • IV analgesia
  • Strict fluid I/O monitoring (urinary catheter)
  • Antibiotics (may be used)

Complications of Pancreatitis

• Pseudocyst formation
• Necrotising pancreatitis
• ARDS (Acute Respiratory Distress Syndrome)
• Pleural effusions (due to third spacing of fluid)
• Acute kidney injury (due to third spacing of fluid)
• Disseminated intravascular coagulation