Biliary and Pancreatic Disorders
Biliary and pancreatic items test risk stratification: who needs ERCP, when to drain an infected biliary tree, and how to grade and feed acute pancreatitis.
Gallstone disease and choledocholithiasis
- Symptomatic cholecystitis: right upper quadrant pain, Murphy sign, leukocytosis, ultrasound showing stones and wall thickening; treat with antibiotics and early laparoscopic cholecystectomy, ideally within 72 hours.
- Predictors of choledocholithiasis: choledocholithiasis on imaging, bilirubin above 4 mg/dL with dilated duct (high risk), or abnormal liver enzymes with age above 55 (intermediate). High-risk patients go to ERCP; intermediate-risk get MRCP or EUS first.
- Acute cholangitis (Tokyo Guidelines 2018): Charcot triad, then Reynolds pentad with shock and confusion. Give antibiotics and IV fluids; biliary drainage by ERCP within 24 hours for moderate severity and within 12 hours for severe disease.
- Mirizzi syndrome: extrinsic compression of the common hepatic duct by a stone in the cystic duct or gallbladder neck.
Acute pancreatitis
- Diagnosis needs two of three: typical pain, amylase or lipase above three times the upper limit, and imaging findings. Use the revised Atlanta classification: interstitial edematous versus necrotizing, and mild, moderately severe or severe.
- Early care: aggressive lactated Ringer solution, analgesia, antiemetics, early enteral feeding when tolerated. Do not give prophylactic antibiotics.
- ERCP is indicated in pancreatitis with concurrent cholangitis; it is not routine for predicted severe disease without cholangitis.
- Score severity with BISAP or APACHE II; watch for pseudocyst (4 weeks or more) and walled-off necrosis.
Chronic pancreatitis and pancreatic cancer
- Chronic pancreatitis: calcification, ductal dilation, atrophy; fecal elastase under 200; treat with enzymes, analgesia, and address alcohol and smoking.
- Autoimmune pancreatitis type 1: IgG4 elevation, sausage pancreas, steroid-responsive; distinguish from cancer.
- Pancreatic head cancer: painless jaundice, weight loss, double duct sign; CA19-9 for prognosis not screening; EUS with FNA for tissue; resectable disease treated with pancreaticoduodenectomy.
Worked example
A 62-year-old with fever, jaundice and right upper quadrant pain has a dilated common bile duct with a stone on ultrasound. This is acute cholangitis: start antibiotics and fluids, and arrange ERCP with sphincterotomy and stone extraction urgently rather than elective surgery.
Traps
- Giving prophylactic antibiotics in sterile necrotizing pancreatitis.
- Doing ERCP for every severe pancreatitis.
- Using CA19-9 to screen asymptomatic patients.
- Delaying drainage in severe cholangitis.