Benign Pancreatic and Biliary Disease

PRESENTATION AND MANAGEMENT

Introduction
Frequency of Diagnoses in Patients with Acute Abdominal Pain
Epidemiology
Gallstones

 One of the most common gastrointestinal disorders

 Post-mortem studies found gallstones in
 12% of men
 24% of women
Epidemiology
Gallstones

 10–30% of patients with gallstones develop

symptoms
 Every year in the UK
 50 000 cholecystectomies
 5 000 duct clearance procedures
Risk factors
Gallbladder - Anatomy
 Gallstone pathogenesis

Gallstones: composed mainly of cholesterol, bilirubin, and calcium salts

Western countries → cholesterol is the principal constituent in 80% of gallstones
Non-cholesterol stones → black / brown pigment stones (calcium salts of bilirubin)
Cholesterol gallstones form when the cholesterol concentration in bile exceeds the
ability of bile to hold it in solution
Gallstone pathogenesis
Gallstone Disease
Spectrum of diseases
 Asymptomatic cholelithiasis
 Symptomatic cholelithiasis
 Biliarycolic
 Cholecystitis → acute / chronic
 Choledocholithiasis → Obstructive jaundice
 Cholangitis
 Gallstone ileus
 Gallstone pancreatitis
Biliary colic

 2/3 of patients with GS disease are presenting with

biliary colic

 Maximum intensity within 60 minutes (66% of patients)

 Pain continues without fluctuation
 Resolves gradually over 2-6 hours
Biliary colic
 46yo F
 RUQ pain x 4hr
 Radiates to the right shoulder
 Following fatty meal
 Nausea
 Pt is pain-free now
 No prior episodes

 O/E: Minimal RUQ tenderness, Murphy’s (-ive)

 WBC / CRP / LFTs normal
Biliary colic
 Management
 ….

 ….

 Will all patients with biliary colic need a

cholecystectomy?
 Patients presenting with their 1st attack of biliary
colic
 38 - 50% chance of further attack / annum
Acute cholecystitis
 Prolonged obstruction of the CD
→ change in the composition of bile
→ acute chemical inflammation (cholecystitis)

 Superadded infection (30% of patients)

→ increases risk of complications
(empyema - gangrene - perforation)

 Abdo USS → 95% sensitivity for detecting gallstones

Acute cholecystitis
 Same pt as in case 1
 Returns to the A&E dept with
 > 24hrs of RUQ pain radiating to the R scapula
 Following fatty meal

 Nausea – vomiting – fever

 O/E: Palpable - tender GB, guarding, Murphy’s (+ive)

 WCC 13 – mild ↑LFT
Timing of cholecystectomy
Acute vs interval laparoscopic cholecystectomy

 Until recently acute cholecystitis was managed conservatively

→ analgesia – IVF – ABx
→ interval lap chole (within 6/52)
(acute surgery → an unacceptable risk of BD injury /
infection)
Timing of cholecystectomy
Laparoscopic Cholecystectomy
Laparoscopic Cholecystectomy
Laparoscopic Cholecystectomy
Choledocholithiasis
Choledocholithiasis

Mr H. Simpson
40 year old male
Fit and well
‘’Turned yellow’’
In pain
Types of jaundice
Types of jaundice
Obstructive jaundice
Management
 Admit under the

surgeons
 Diagnosis

 obstructive jaundice
? Cause
 Further Ix needed
Obstructive jaundice

Vs.
Ascending cholangitis
Pyogenic infection of the biliary tree
→ CBD obstruction 2o to stones – strictures

Presentation
 Deranged WBC and LFTs – usually raised bilirubin
 USS will often demonstrate biliary obstruction
 CT scan
 Biliary obstruction in 78% of patients

 Cause of obstruction in 61%

 Charcot’s triad (70% of patients)

 Reynold’s pentad → life threatening - bad prognosis
Ascending cholangitis

Management
 NBM
 IVI
 IV ABx
 Emergency decompression
 ERCP

 Percutaneous transhepatic cholangiogram (PTC)

 Emergency laparotomy
Ascending cholangitis

Patients with signs of cholangitis require

endoscopic sphincterotomy or duct drainage
by stenting to ensure relief of biliary obstruction
(recommendation grade A)

UK guidelines for the management of acute

Pancreatitis (Gut 2005;54(Suppl III):iii1–iii9)
Biliary tree decompression - ERCP
Biliary tree decompression - ERCP
Biliary tree decompression - PTC
Gallstone ileus
 Gallstone ileus
→ impaction of a gallstone within the lumen of the gut
→ mechanical GI obstruction

 Over 80% of gallstones entering the intestine are excreted

uneventfully
 Commonest site of impaction is the ileum → gallstone > 2–2.5
cm
Gallstone ileus
Gallstone ileus
Gallstone ileus

Tx: Enterolithotomy – inspection of bowel – cholecystectomy – repair of fistulas

Pancreatitis
Pancreas - Anatomy
Pancreatitis
Gallstone pancreatitis
Glascow Score
Complications
Natural history
Gallstone pancreatitis