Alcoholic liver disease

Complications of alcohol abuse

Alcohol abuse may lead to steatosis, steatohepatitis, cirrhosis, and hepatocellular carcinoma

Asymptomatic gallstones

• Role of Cholecystectomy? - Majority followup clinically with NO surgery • When to Consider surgery for Asymptomatic GS: - Patients at increased risk of gb cancer: • GB polyp/adenoma • Porcelain gallbladder • Large gallstone especially if > 3 cm - Hemolytic Disorder: • Sickle Cell and Hereditary Spherocytosis • If having abd surgery for another reason, add cholecystectomy - Gastric Bypass: • Post gastric bypass >30% incidence of gallstone development • Consider prophylactic cholecystectomy

Pancreatitis BISAP

• BISAP= bedside index of severity in acute pancreatitis • Components (Each counts 1 Point): - BUN > 25 - Abnormal Mental Status - Evidence of SIRS (T,HR, RR, WBC) - Age > 60 - Imaging with pleural effusion • Point total - 0 - 2 -lower mortality < 2% - 3 - 5—higher mortality > 15%

Acute cholecystitis treatment (surgical)

• Cholecystectomy - Symptomatic gallstones - Asymptomatic gallstones with high risk condition • Complications 4% • Conversion to open chole 5% • Death rate <0.1% • Bile Duct Injury 0.2 to 0.6%

Types of gallstones: Cholesterol

• Cholesterol 90% - Lithogenic bile - Increased biliary cholesterol secretion - Nucleation of cholesterol crystals - Gallbladder hypomotility—allow crystals to grow • Assoc with fasting • TPN • Pregnancy • Drugs that inhibit gallbladder motility

Porcelain gallbladder

• Chronic cholecystitis assoc with intramural calcification of gallbladder • Increased incidence of gb cancer = 2-3 % - May be increased risk of gb cancer with incomplete mural calcification • Recommend Cholecystectomy

Cholecystitis and infection

• Common isolates: - E Coli 41% - Enterococcus 12% - Klebsiella 11% - Enterobacter 9%

acute cholecystitis

• Cystic Duct Obstruction with Stone • Mechanical Inflammation • Chemical Inflammation • Bacterial Inflammation • ABD pain-RUQ/epigastric - Murphy's Sign - inspiratory arrest with palpation ruq • N/V • Fever • Leukocytosis

Approach to establishing cause of acute pancreatitis

• Gallstone?? ABD Ultrasound/MRCP/EUS • Alcohol?? Hx of alcohol xs, Abd Xray or CT to check for Pancreatic Calcifications • Drug-Induced??—Discuss with pharmacist • Genetic factors?? • Hypertriglyceridemia?? Milky serum • Post ERCP?? Temporal relationship • Vascular issue?? Hypotension, Vascular surg • HyperCalcemia

Abdominal pain evaluation

• Hx - acute v chronic, n/v, wt loss, gi bleeding, altered bm's • P.E.- Fever, Hypotension, Peritonitis, Pain Location, Abdominal Mass? • Lab- Elev WBC, Elev LFTS, Elev amylase, U/A • Imaging- - ABD Series - ABD/Pelvic US - ABD/Pelvic CT - MRCP • EGD • EUS • ERCP

Evaluation for etiology of pancreatitis

• Hx and PE • Lab (amylase, lipase, TG, Calcium, LFTs) • ABD Ultrasound • CT ABD Pelvis • MRCP • EUS • ERCP

acute cholecystitis tx

• Initial: - Antibiotics - 75% improve in 2 to 7 days - 25% complication —need more urgent surg • Mirizzi's Syndrome - Cystic Duct or GB neck stone impaction - Causes compression of CBD and jaundice - Dx with MRCP or ERCP

Biliary colic

• Intermittent RUQ or Epigastric abd pain • Dull, constant pain, may radiate to back • Possible nausea and vomiting • Duration: 30 min to 6 hours • Gallbladder stone causes transient cystic duct obstruction with increased GB pressure w/ pain • Pain resolves when stone stops obstructing

Interstitial vs. necrotizing pancreatitis

• Interstitial - pancreas blood supply maintained • Necrotizing—pancreas blood supply interrupted • Auto-digestion—proteolytic enzymes are activated in the acinar cell

Etiology of acute pancreatitis

• Mechanical - Gallstones/Biliary Sludge - Pancreatic or periampullary cancer • Toxic--Ethanol • Metabolic--Hypertriglyceridemia • Drugs—multiple—Don't Forget to Consider!! • Trauma - ERCP - Abdominal Trauma

Severity of acute pancreatitis

• Mild --improves in 3 to 7 days • Moderately Severe -possible >7 day hosp - Transient organ failure <48 hours - Local or systemic complication • Severe - Persistent organ failure > 48 hours - Resp, cardiovasc, renal dysfunction - CT or MRI assess for necrosis/ complications

Nutritional therapy for pancreatitis

• Mild pancreatitis—resume po when pain gone • Severe pancreatitis—enteral nutrition in 2 to 3 days preferred over TPN - Enteral nutrition helps maintain intestinal barrier and decrease bacterial translocation from gut - Avoids complications of TPN including bacteremia from Central line infection • TPN primarily for those who do not tolerate enteral nutrition

Chronic pancreatitis etiology

• Most Common: - Alcohol abuse - Cigarette Smoking - Idiopathic pancreatitis • Other Causes: - Hereditary/Genetic causes e.g. mutations of Cystic Fibrosis Gene - Ductal obstruction e.g. trauma, stone, tumor - Tropical pancreatitis (children in Southern India of unknown etiol) - Systemic Disease • Cystic Fibrosis • CFTR (CF transmembrane conductance regulator) gene mutation • Lupus • Hypertriglyceridemia - Autoimmune Pancreatitis

Mortality in acute pancreatitis

• Overall mortality- 5% • Interstitial pancreatitis—3% • Necrotizing pancreatitis—17% (lower in specialized centers 6 to 9%) - Sterile Necrosis—12% - Infected Necrosis—30% - Multisystem Organ Failure—47%

Chronic pancreatitis ddx

• Pancreatic Cancer • Pancreatic endocrine tumors • Autoimmune pancreatitis • Acute pancreatitis

Conditions associated with hyperamalesmia

• Pancreatic Disease - Pancreatitis - Trauma - Cancer • Salivary Disease • GI Disease - Perforated ulcer/bowel - Mesenteric infarct - Bowel obstruction • Gyn Disease - Ruptured ectopic preg - Ovarian cysts • Neoplasm - Ovarian Tumors - Lung tumors • Other - Renal Failure - Macroamylasemia

Differential diagnosis of pancreatitis

• Peptic Ulcer Disease • Perforated viscus • Acute cholecystitis and biliary colic • Intestinal obstruction • Mesenteric ischemia/vascular occlusion • Hepatitis • Renal colic • Inferior wall MI • Dissecting Aortic Aneurysm • Connective Tissue Disease w/Vasculitis—SLE, PAN • Pneumonia

Treatment of autoimmune pancreatitis

• Prednisone 40mg/d - 40 mg/d for 2 to 4 weeks - Then taper daily dose by 5 mg/d every 2 to 4 wks - Maintenance dose 2.5 to 5 mg/d • Azathioprine - May be needed for failure to respond to prednisone or potential relapse after Prednisone treatment

Hepatic steatosis

Hepatic steatosis is seen in approximately 90% of heavy drinkers and is typically macrovesicular

Classic liver function test finding

-Moderately elevated transaminases, with an aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio >1 (and often >2). -Typically in other forms of liver disease, the serum ALT level often is higher than the serum AST level. -The most common pattern in alcoholic liver disease is a disproportionate elevation of the AST compared to the ALT, resulting in a ratio greater than one. -Gamma-glutamyl transpeptidase (GGT) is often elevated in patients with alcoholic liver disease

Spontaneous bacterial peritonitis

-Spontaneous bacterial peritonitis(SBP) is an ascitic fluid infection without an evident intra-abdominal surgically treatable source. -SBP occurs in patients with cirrhosis and ascites and should be suspected when there are clinical signs and symptoms of fever, abdominal pain, or altered mental status in patients with ascites. -A SBP diagnosis is established by a ascitic fluid absolute polymorphonuclear leukocyte count ≥250 cells/mm3positive and subsequent ascitic fluid bacterial culture. -SBP patients after culturing the ascites should be started on empiric, broad-spectrum antibiotics immediately after peritoneal fluid is obtained.

CBC for a patient with alcoholic liver disease

-The CBC in patients with alcoholic liver disease may show thrombocytopenia, anemia, an elevated mean corpuscular volume (MCV), a decreased lymphocyte count. -Macrocytosis suggests longstanding disease and may be a result from vitamin B12 or folate deficiency from, alcohol toxicity.

Complications of cirrhosis

-Variceal hemorrhage -Ascites -Spontaneous bacterial peritonitis -Hepatorenal syndrome -Hepatic encephalopathy -Hepatopulmonary syndrome -Hepatocellular carcinoma

Types of gallstones: Pigmented

Pigmented 10% • Black Pigment - Hemolysis - Calcium bilirubinate • Brown Pigment - Assoc with bacterial and helminthic infection - Post biliary system manipulation - Post cholecystectomy

Diagnosis of pancreatitis

• 2 of 3 of following: - Typical epigastric abd pain - 3 fold or greater elev of lipase and/or amylase - Cross sectional imaging showing pancreatic inflammation

Pancreatitis Clinical Presentation

• Abd pain epigastric/ rad to back • Nausea and vomiting • Distressed • May have Low grade Fever, tachycardia, hypotension • Exam tender upper abd, firm, decreased BS • Cullens sign—periumbilical blue discoloration from hemoperitoneum • Grey-Turner's Sign—Flank blue-red-purple discoloration from severe necrotizing pancreatitis with hemorrhage

Chronic pancreatitis presentation

• Abdominal Pain—epigastric, radiates to back, may increase pc, may be intermit or continuous • Pancreatic Insufficiency—with >90% pancreatic fxn lost, see protein and fat malabsorption • Pancreatic Diabetes—Glucose intolerance • Complications: - pseudocyst - biliary obstruction - duodenal obstruction - Ascites - splenic vein thrombosis - pancreatic cancer

Cholecysectomy timing

• Acute chole - Initial antibiotic rx - NPO - In 48 to 72 hours cholecystectomy - When to Delay surg to >6 wks post dx • Severe co-morbid with excess surg risk • Dx of acute chole not certain

Acute pancreatitis management

• Aggressive IV hydration - Bolus RL or NS 15 to 20 cc/kg -1-1.5 liters - Maint 3 cc/kg/hour - 200 to 250 cc/hour - RL may decrease incidence of SIRS more than NS • Serial Hemogram and BUN every 8 to 12 hours - Should drop - If increasing, then increase iv fluids if tolerates

Pancreatitis lab findings

• Amylase >3 x above normal • Lipase >3x elevation—more specific for pancreatitis • Elev WBC • Hemoconcentration (Elevated Hct) • Prerenal azotemia • Elev LFTs (e.g. with Gallstone pancreatitis)

Clinical presentation of gallstones

• Asymptomatic • Biliary Colic • Acute Cholecystitis • Cholangitis • Pancreatitis

Incidental gallstones

• Asymptomatic Gallstones found on imaging done for an unrelated problem • Majority of incidental GS remain Asymptomatic • In United States: - Gallstones found- 6% Men, 9% Women - 15 to 25% become symptomatic over 10 to 15 yrs followup. • Initial symptoms: - Usually biliary colic- ruq/epig pain, steady, 30 min to 6 hours - After first attack, 70% recur in next 2 years