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Toronto Notes 2019
Pancreas
Gastroenterology G43
Ascending Cholangitis
• seeGeneralSurgery,GS49 Definition
• infectionofthebiliarytree
Etiology
• stasisinthebiliarytractduetoobstructionorstricture(usuallyfrompreviouscholecystectomy) • infectionoriginatesintheduodenumorspreadshematogenouslyfromtheportalvein
• bacteria
■ E. coli, Klebsiella, Enterobacter, Enterococcus
■ co-infection with Bacteroides and Clostridia can occur
Signs and Symptoms
• Charcot’striad:fever,RUQpain,jaundice(50-70%)
• Reynolds’pentadinpatientswithsuppurativecholangitis:fever,RUQpain,jaundice,hypotension,
altered mental status
Investigations
• increasedWBC
• usuallyincreasedALPandbilirubin,ALTvariablyelevated • bloodculture
• abdominalU/S:CBDdilation,stones
Treatment
• mostimportantisdrainage,ideallyviaERCP;performbypercutaneousbiliaryorbysurgicalroutes (least often) if ERCP not possible
• antibiotictherapy:broadspectrumtocoverGram-negatives,Enterococcus,andanaerobes(especiallyif CBD manipulation); no clear consensus on antibiotic choice but consider:
■ ampicillin+sulbactamorpiperacillin/tazobactam
■ metronidazole + 3rd generation cephalosporin (e.g. ceftriaxone) or fluoroquinolone (e.g.
ciprofloxacin or levofloxacin)
■ carbapenem monotherapy (e.g. imipenem or meropenem)
Prognosis
• goodwitheffectivedrainageandantibioticsinmildtomoderatecases • highmortality(~50%)inpatientswithReynoldspentad
Pancreas
Pancreatic Enzyme Abnormalities
Causes of Increased Serum Amylase
• pancreaticdisease
■ pancreatitis, pancreatic duct obstruction (e.g. ampullary cancer), pseudocyst, abscess, ascites,
trauma, cancer
• non-pancreaticabdominaldisease
■ biliary tract disease, bowel obstruction/ischemia, perforated or penetrating ulcer, ruptured ectopic pregnancy, aneurysm, chronic liver disease, peritonitis
• non-abdominaldisease
■ cancer (lung, ovary, esophagus, etc.), salivary gland lesions, bulimia, renal transplant/insufficiency,
burns, ketoacidosis ■ macroamylasemia
Causes of Increased Serum Lipase
• pancreaticdisease:sameasabove
• non-pancreaticabdominaldisease(mildelevationsonly):sameasabove • non-abdominaldisease
■ macrolipasemia ■ renal failure
Charcot’s Triad
• RUQ pain • Fever
• Jaundice
Reynolds Pentad
• Charcot’s triad
• Hypotension
• Altered mental status
Pancreatic Enzymes
TALC
Trypsin Amylase Lipase Chymotrypsin
When serum amylase >5x normal, the cause is almost always pancreatitis or renal disease