Acute biliary pancreatitis Case 1. Question 8
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1 Past histry Suddent epigastric pain Ischemic cardipathy (stents; ( < 24 h) crnary artery by pass) Dyspnea Arterial hypertensin 19 Kg < 9 mnths Diabetes type 2 N alchl Esphagitis (reflux) Physical examinatin : aspirin ; glicazide, metfrmine ; Upper abdmen tenderness bisprll, eprsartan, Pulse : 90/M ; AP : 14/9 simvastatine ; pantprazle Bilgy : HB : 15.7 WBC : CRP : 31 mg/l Lipase : 3970 Bili : 9,2 GPT : 89 A.P. : 193 Creat : 1.7 US : Stnes in the gallbblader Q8 Whats the mre precise diagnsis? A. Mild acute biliary pancreatitis B. Mderately severe acute biliarypancreatitis C. Predicted severe acute biliary pancreatitis D. Severe acute biliary pancreatitis ii 1. Answer A 2. Answer B Questin 8 Revisin f Atlanta s Classificatins fr Acute Pancreatitis Mild acute N rgan failure N cmplicatin Mderately severe N (r transient) rgan failure (>48h) Lcal cmplicatins Severe Persistent rgan failure (>48h) Predicted severe P Banks et al Gut
2 Q9. What s the next examinatin d yu will perfrm? A. EUS B. MRCP C. ERCP D. 1 r 2 1. Answer A 2. Answer B Questin 9 EUS (> MRCP, [G 2C] ) prevent unusefull ERCP Persistant liver tests elevatin (withut chlangitis) Dilatin f CBD ERCP impssible r technically challenging, ex : Pregnancy Gastric surgery NO ERCP Mild pancreatitis withut chlangitis (G 1A) Imprvment f liver tests N stne n CBD (EUS r MRCP) EUS Bilgy (24 h) Papilla nt seen (diverticula) HB : 13.7 Wirsung nt dilated ; WBC : hetergenus pancreatic CRP : 89 mg/l parenchyma Lipase : 854 Stne in cmmn bile duct and Bili : 13.7 severe chlangitis GPT : 51 A.P. : 308 Creat : 1.9 Q. Why d yu d ERCP in this patient? A. Persistent bstructin f BCD B. Persistent pain C. Chlangitis D. Predicted severe pancreatitis 1. Answer A 2. Answer B Questin 2
3 Indicatin f ERCP with papilltmy : ERCP Papilltmy A. Persitent bstructin f CBD [G 1C] B. Persistent pain : n C. Chlangitis [G 1B] D. Predicted severe pancreatitis : E. A+D When d we perfrm papilltmy fr ABP? Acute chlangitis [G 1B, strng agreement] Early in the curse (24 h < admissin) Stne in CBD (CT EUS MRCP, [G 1C]) Persitant bstructin withut chnlangitis? IN ABP, URGENT ERCP IS CONTROVERSIAL Papilltmy, evaluating severity f ABP SEVERITY Papilltmy BALTHAZAR s SCORE h after nset Obstructin G 1C, strng agreeement CHOLANGITIS f CBD PAPILLOTOMY? NO ERCP Difficulties «ERCP did nt lead t a significant reductin in the risk f verall cmplicatins and mrtality» Petrv MS et al, Ann Surg.2008; 247 (2): 250 Tse F. et al, CchranDatabase Syst Rev. 2012; 5: CD «ERCP reduced pancreatitis-related cmplicatins but nt mrtality in patients predicted t have severe pancreatitis (n benefit fr mild pancreatitis)» Mretti A et al. Dig Liver Dis. 2008; 40 (5): 379 PAIN B i l g y ADMISSION B i l g y time 3
4 Papilltmy fr edema and/r spasm f the papilla? : questin 27/08 : Marrc Admissin fr acute biliary pancreatitis Renal functin altered 04/09 : ICU Renal insufficiency CRP > 300 mg/l Imipenem EUS : Severe pancreatitis. N stne seen but examinatin very difficult Rdil Radilgicali l drainage ARDS Respiratry assistance Gastric aspiratin Trachetmy Clnic exsufflatin Hemfiltratin US : Dilatin f IHBD & CBD WHAT d yu d? Q11 A: Red EUS (in 72h) B: MRCP (3 days) C : ERCP D: Surgery Difficulties fr specific CBG cannulatin Radilgical i l drainage Respiratry assistance Gastric aspiratin Trachetmy Clic exsufflatin Renal epuratin Chlestasis ERCP 4
5 Past histry Arterial hypertensin Diabetes Peptic ulcer disease with UGI bleeding 1990, endscpical hemstasis aspirin ; glicazyde, metfrmine ; valsartan, simvastatin. Sudden severe right upper abdmnal pain Fever 38,7 C Puls : 120/M Physical examinatin Epigastric pg tenderness Jaundice US : sludge, dilatin IHBD Bilgy : HB : 12.4 WBC : CRP : 269 mg/l Bili : 33 GPT : 246 A.P. : 154 Lipase : 2 (60) Bld C : E. Cli EUS : Dilatin f CBD Sludge : CBD and gallblader N stne seen Q11. Whats the mst likely diagnsis? A: Mild acute biliary pancreatitis B: Other C : Chlangitis < biliary sludge, withut pancreatitis D: Acute pancreatitis + chlangitis 1. Answer A 2. Answer B Questin 11 (wrng) Acute biliarypancreatitis 5
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