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