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Pathophysiology of gallstone formation
- Cholesterol Supersaturation
- Bile stasis - secondary to fasting, TPN or truncal vagotomy.
- Increased bilirubin secretion in bile - ++ red cell lysis e.g. spherocytosis or sickle cell disease.
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Risk Factors for Gallstone disease
- Age
- Female sex
- Obesity
- Multiparity
- Haemolytic disease
- Long term TPN
- Previous surgery / disease of distal small bowel
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Presentations of Gallstone disease
- Biliary Colic:
- - Intermittent severe epigastric / RUQ pain ; associated with N+V. Resolves within hours.
- Acute Cholecystitis:
- - Severe, continuous RUQ pain ; often radiates to right flank and back. Associated with anorexia and pyrexia. Classically Murphy's sign +ve.
- Chronic Cholecystitis:
- - Repeated episodes of inflammation causes thickening and fibrosis of gallbladder wall.
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Investigation in gallbladder disease
- Bloods: - FBC - infection
- - U+Es - dehydration
- - LFTs - obstruction
- - Blood Cultures - infective agent
- - Amylase - rule out pancreatitis
- AXR: - 10% of stones are radio-opaque
- Abdominal USS: - Gold Standard. Identifies stones, determine wall thickness and assess ductal dilatation.
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Complications of Gallstone disease
- Gallbladder: - Empyema
- - Mucocoele
- - Carcinoma
- - Perforation + Peritonitis
- - Carcinoma
- - Fistula
- - Mirizzi Syndrome
- Common Bile Duct: - Obstructive Jaundice
- - Cholangitis
- - Pancreatitis
- Small Bowel: - Gallstone ileus
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Treatment of Gallstone Disease (Surgical)
- Surgical = Cholecystectomy. Indications:
- - Symptomatic gallbladder stones
- - Asymptomatic patients at high risk e.g. diabetes, porcelain gallbladder, Hx of pancreatitis.
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Risks of Cholecystectomy
- Conversion to open - 5-10%
- Bile Duct injury - <1%
- Bleeding - 2%
- Bile leak - 1%
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Treatment of Gallstone Disease (non-surgical)
- US/CT guided percutaneous drainage of gallbladder
- Dissolution therapy*
- Lithotripsy*
- *rarely done due to side effects
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Anatomy of the Biliary Tree
Picture
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Causes of Obstructive Jaundice
- Intra-luminal - Gallstones
- Luminal - cholangiocarcinoma, stricture
- Extra-luminal - Pancreatitis, head of pancreas tumour, lymph nodes
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Investigation of obstructive jaundice
- Bloods:
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LFTs: - - Bilirubin - raised in obstruction
- - ALP - Present in ductal cells, raised in obstruction
- - Transaminases - Hepatocellular, raised more typically in hepatitis.
- - Amylase - Rule out pancreatitis
- - Albumin and clotting factors - check liver synthetic function
- - AFP - HCC
- - Viral markers
- Imaging:
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Ultrasound - duct dilation - - CT scan - unaffected by bowel gas or obesity
- - Cholangiography - MRCP provides good imaging of biliary tree
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Treatment of Obstructive Jaundice
- Remove cause of obstruction
- - ERCP / Intra-operative CBD clearence
- - Tumour Resection
- Stenting CBD
- Palliative / Curative chemotherapy
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Causes of Acute Pancreatitis
- G - Gallstones
- E - Ethanol
- T - Trauma
- S - Steroids
- M - Mumps
- A - Autoimmune (PAN)
- S - Scorpion Sting
- H - Hyperlipidaemia / Hypercalcaemia / Hypothermia
- E - ERCP
- D - Drugs (Aziathioprine, thiazide diuretics , mercaptopurines)
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Classification of Pancreatitis
- Oedematous (70%)
- Necrotising / Severe (25%)
- Haemorrhagic (5%)
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Assessing Severity of Pancreatitis
- Glasgow Imrie Score
- >2 positive criteria = severe attack
- Criteria:
- P - PaO2 <8kPa
- A - Age > 55
- N - Neutrophils / WCC > 15
- C - Corrected Calcium < 2mmol/l
- R - Raised Urea > 16mmol/l
- E - Elevated Enzymes - AST > 200, LDH >600
- A - Albumin <32g/L
- S - Sugar / Glucose > 10mmol/L
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Investigations in Pancreatitis
- Bloods:
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FBC - check Hb and WCC - - U+Es - check K and Na
- - LFTs - bilirubin, albumin and obstructive picture
- - Amylase - 3 x upper limit of normal (~300) is DIAGNOSTIC
- - Group and save - all surgical patients
- - Clotting - all surgical patients
- Imaging: - AXR - non-specific
- - CT - may be required - shows necrotic / haemorrhagic changes
- - Abdominal USS - must be done in first 48hrs to ID gallstone disease
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Treatment of Acute Pancreatitis
- Urgent ERCP in proven gallstone disease
- Prevent Complications:
- - IV antibiotics can be given in severe disease even in the absence of proven infection
- - Consider HDU / ITU
- Surgical debridement is necessary if necrosis is proven.
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Complications of Pancreatitis
- Local: - Pancreatic Pseudocyst (25% of cases)
- - infection +/- abscess formation
- - Haemorrhage
- - CBD obstruction
- - Progression to chronic pancreatitis
- - fistula
- Systemic: - ARDS
- - MODS
- - DIC
- - Hypocalcaemia
- - Hyperglycaemia
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What preventitive measures can be taken in chronic pancreatitis
- Stop Alcohol
- Remove gallstones
- Treat autoimmune disease
- Encourage anti-oxidant rich diet (ACE vitamins and selenium)
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How to control symptoms / complications in chronic pancreatitis
- Dietary modifications, reduce fat intake
- Exocrine enzyme supplementation - Creon
- Analgesia
- Insulin control of diabetes - may be challenging
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Surgical Resection of the Pancreas
- Whipples - Pancreaticoduodenectomy
- Frey's procedure - partial pancreatectomy of head
- Peustow / Duval - Pancreaticojejunostomy
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Risk Factors for Pancreatic Cancer
- Smoking
- Increasing age (6th + 7th decades most common)
- High fat diet
- Diabetes
- Alcoholism
- Chronic Pancreatitis
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Presentation of head of pancreas carcinoma
- Obstructive Jaundice (90%) - Due to compression / invasion of CBD
- Pain (70%) - Epigastric or LUQ, often vague and radiates to back
- Hepatomegaly - secondary to metastasis
- Acute Pancreatitis
- Thrombophlebitis migrans (10%) - cancer is a hypercoaguable state
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Carcinoma of body and tail of pancreas:
- Asymptomatic in early stages
- Weight loss
- Back pain
- Epigastric Mass
- Jaundice - secondary to spread to nodes or metastases
- Diabetes Mellitus
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Pathological Classification of Pancreatic Cancer:
- Ductal Adenocarcinoma (90%)
- Mucinous Cystic neoplasms (7%)
- Islet Cell Tumours (3%):
- - Insulinoma
- - Glucagonoma
- - Gastrinoma
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Investigating Pancreatic Cancer
- Bloods: - FBC
- - LFTs
- - Blood Sugar
- - CA19-9 (tumour marker)
- Imaging: - Transabdominal ultrasound
- - Helical CT scan of pancreas
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Treatment of Pancreatic Cancer
- 95% are not suitable for surgical resection
- Relief of jaundice:
- - Biliary stenting
- - Percutaneous biliary drainage
- - Surgical biliary drainage
- Relief of duodenal obstruction:
- - Gastric bypass
- Relief of pain:
- - Oral Morphine (oromorph / MST)
- - Chemical ablation of the coeliac ganglia
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