Moffitt AM GI Report 11/23/16: Gallstone Pancreatitis!

Happy Thanksgiving, everyone!

We had a wonderful GI report today – thank you Matt and Josh for presenting twin cases of abnormal LFTs. Patient 1 was a 30 year old man presenting with gallstone pancreatitis, and patient 2 was a 40 year old man presenting with a history consistent with biliary colic, who was found to also have indirect hyperbilirubinemia.

 TOP PEARLS

  • An elevated ALT is one of the earliest, most sensitive laboratory tests for gallstone pancreatitis.
  • In Wilson Disease, the alkaline phosphatase to total bilirubin ratio is typically < 4. This ratio is highly specific and sensitive!
  • 1/3 of patients admitted with first-time gallstone pancreatitis will have a recurrent episode within 1 year of their incident event. Hence, we generally recommend cholecystectomy within the same hospitalization or shortly following discharge.

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When should you consider an ERCP on your patient with Gallstone Disease?

  • Dr. Ostroff taught us to ask ourselves, what is the probability of a retained stone?
    • Low probability (resolving transaminitis, resolving symptoms): no need for ERCP
    • Intermediate probability (persistently elevated liver enzymes or CBD dilatation): shared decision making with patient & inpatient GI consult team
    • High probability (rising LFTs, visualized stone on imaging, persistent jaundice): urgent ERCP is indicated
  • 1/3 of patients admitted with first-time gallstone pancreatitis will have a recurrent episode within 1 year of their incident event. Hence, we generally recommend cholecystectomy within the same hospitalization or shortly following discharge.

How should we think about indirect or unconjugated hyperbilirubinemia?

  • Think about indirect hyperbilirubinemia in 3 broad mechanistic categories:
  1. Overproduction of bilirubin
  2. Reduced bilirubin uptake
  3. Impaired bilirubin conjugation
  • Overproduction of bilirubin
    • Excessive breakdown of heme derived from hemoglobin: extravascular intravascular hemolysis, extravasation of blood
  • Impaired hepatic bilirubin uptake
    • Congestive heart failure or portosystemic shunts (due to spontaneous collaterals in cirrhosis or secondary to surgical shunts), Gilbert Syndrome (uptake of bilirubin at sinusoidal surface of hepatocytes is impaired)

 

  • Impaired bilirubin conjugation (due to absent or reduced UDP-glucuronosyltransferase activity)
    • Crigler-Najjar syndrome, Gilbert Syndrome, Hyperthyroidism, ethinyl estradiol, certain antibiotics, advanced cirrhosis, Wilson’s Disease

Evernote: https://www.evernote.com/shard/s338/sh/fbeddba7-d623-4115-9d8a-3dcf1013c046/6c8451f8769aeb3e7b009ef00087f53b

 

 

 

 

 

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