Gallstone Pancreatitis by liaoqinmei


									                            GALLSTONE PANCREATITIS

• Responsible for 40-50%% of all cases of acute pancreatitis
• 3/4th of all cases involve women
• The common channel concept- Caused by stone impaction at the ampulla of vater-supported
  by Acosta and Ledesma 1974 who found stones in feces of 94% of patients with acute
  gallstone pancreatitis
• Uncertain if obstruction causes bile reflux into the pancreatic duct or if increased duct
  pressures in conjunction with continued enzyme secretion in the face of obstruction

• Patients usually complain of epigastric pain radiating towards the back with associated
   nausea and vomiting.
• Labs- CBC, LFT’s (elevated Bilirubin/Alkaline Phosphatase, AST/ALT, Amylase/Lipase)
• KUB/CXR- rule out perforated viscus
• CT Scan with contrast- for delineation of pancreatic necrosis/edema
• U/S- Evidence of cholelithiasis, CBD dilation, choledocholethiasis- very difficult to detect
   stones in CBD

Predictors of Outcome
• In the majority of cases, symptoms are mild and the pancreatitis resolves
• 10% of cases are severe, progressing to pancreatic necrosis/sepsis/death
• Ranson’s Criteria- 11 variables in first 48hrs
          Admission          Within 48hrs
          Age>70             HCT drop>10                  2 or less-      mortality<1%
          WBC>18,000         BUN increase>2                 3 - 5-        mortality 10%
          Glucose>220        Calcium<8                    7 or more-      mortality 50%
          LDH>400            Base deficit>5
          AST>250            PaO2<60
                             Fluid requirement>4L

•  Glasgow Scale
   Age, Leukocyte count, glucose, BUN, PaO2, Calcium, albumin, LDH- all at 48hrs of

•     APACHE II (Acute Physiology Score And Chronic Heath Evaluation)
      Age points, Chronic health points, and lab values upon admission
      Score>9 denotes severe acute pancreatitis

• Supportive care- NPO/Fluid resuscitation/Correction of electrolyte
  imbalances/Analgesia/NGT for persistent vomiting
• Antibiotics are not indicated in mild forms of pancreatitis. If there is evidence of pancreatic
  necrosis on CT scan- antibiotics have been shown to reduce morbidity/mortality. Imipenem
  is drug of choice.
• In mild forms of pancreatitis, symptoms improve within 24-48 hrs with improvement in
• Amylase and Lipase levels do not predict severity or outcome

•  ERCP- Controversial if ERCP is necessary in all cases of gallstone pancreatitis. In mild
   forms of pancreatitis, the stone usually passes from the CBD to the duodenum within 24-48
   hrs. Manipulation of the ampulla as well as introduction of air into the ductal system
   elevates pressures and may worsen pancreatitis.
   However, if the attack is severe or if symptoms do not improve, ERCP may be indicated.
The stone is removed and a sphincterotomy performed with stent placement.

4 randomized controlled trials
                                                                     Complications of   Complication of     Length of
    Study      Predictor of         ERCP          Conservative        ERCP group         Conservative     Hospitalization
                 Severity                           Therapy                                Therapy
UK 1988       Glasgow scale   At 72hrs N=59          N=62
                0-2 Mild        Mild N=34          Mild N=34            Mild=12%          Mild=12%         ERCP-9.5
               3-8 Severe      Severe N=25        Severe N=28          Severe=24%        Severe=61%           days
Overall mortality did not differ between ERCP vs Conservative therapy (2% vs 8%) p=.23
      Study          Predictor of            ERCP             Conservative       Mortality            Complications
                       Severity                                 Therapy
    HK 1993        Ranson’s Criteria          N=64               N=63          2%vs8%(NS)          16%vs33% p=.03
                       <4 mild              Mild N=34          Mild N=35         0%vs0%              18%vs17%
                     4 or >severe          Severe N=30        Severe N=28       12%vs22%             13%vs54%
Patients underwent ERCP within 24hrs of admission
      Study          Predictor of            ERCP             Conservative       Mortality            Complications
                       Severity                                 Therapy
German 1997         Glasgow Scale          N=126                N=112         16%vs9%(NS)           46%vs51%(NS)
                       0-2 Mild        Mild N=100              Mild N=92
                     3-8 Severe        Severe N=26            Severe N=20
Higher rate of complications, especially respiratory failure in the early ERCP group
Highly criticized study- 22 participating sites, operator variability, exclusion of relevant patients

   Study       Predictor of Severity   ERCP         Conservative     Mortality         Complications
 Polish 1995          None             N=178          N=102         2%vs13%                 17%vs36
Published only in abstract form. No stratification of groups into mild vs severe forms of

*early ERCP (within 24 - 72hours) should only be performed in cases of severe acute gallstone

Patients should be started on oral feeds as soon as there is improvement in symptoms and
evidence of resolution of ileus.
For mild pancreatitis patients should undergo cholecystectomy with intra-op cholangiogram prior
to discharge as the risk of recurrence is high (30%).

                                                                                 Henry Lin, M.D.


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