Lecture 28 January 19th-gi

1DDX: LECTURE 28 – JANUARY 19TH 2007 GASTROINTESTINAL DISORDERS: GALLBLADDER Page 1 Pictures of flushed gallstones: largest is 3.5cm across! Someone passed this under supervision. Gallbladder flush: 1 cup olive oil, ½ cup lemon juice, pinch of cayenne. Drink this once a day on empty stomach. Must be done under supervision! Will be medical emergency if they impact in ducts. Other option: drink Epsom salt solution first (1/2 – 1 tbsp). Have to have an ultrasound before doing the flush. Have to know what we are dealing with. Can’t do this with everyone, only with stones under 3.5cm. Can take up to several months to pass stones. CHOLELITHIASIS “Female Forty, Fertile, Fair”: highest risk for gallstones: the F-words. Over 50% are in women afflicted with obesity (but they occur in thin women too!) Page 2 Diabetes: more stasis in the gallbladder: increases chance of forming gallstones. LT parenteral nutrition: eg. Burn units: higher incidence. Several types of gallstones: • 70% cholesterol monohydrate. Also pure ones where they are >90% cholesterol. Tend to be larger than other types of stones. • Pigmented stones: tend to be smaller stones Obstruction can be caused by parasitic infection (I think?). Pancreatic tumours can cause obstruction of the biliary tree. Increased synthesis of cholesterol by the liver. See this in chronic inflammation. This will produce small cracks in arteries, esp. with deficiency of Vitamin C and bioflavinoids. More cholesterol is produced, get adhesions, atherosclerosis. 3 factors for synthesis: Production of lithogenic bile Gallbladder motility: if slow, more chance of forming stones. Nucleation factors: like forming a pearl around a grain of sand. The stone forms around the nucleation factor. Random thoughts: Can be different shapes and sizes. Can have a couple or thousands in a gall bladder. Stones that are ½ cm in size or larger are most likely to impact. As mentioned, with treatment, stones of 3.5 cm can be passed (muscle relaxant, make stones slippery, easier to pass) Lots of naturopathic treatments to dissolve stones: chlesterol stones dissolved by lecithin Asymptomatic: Patients may not seek treatment for non-specific symptoms: diarrhea etc. Symptoms: of infection, inflammation or impaction. Treatment: (even allopathic) is with oral bile acids: they can dissolve gallstones. This isn’t done too often in allopathic medicine, more common to get surgery. Bile acids can alleviate need for removal of gallbladder. Patient has impacted stone: you can try to treat, but after 8-12 hours of pain, have to refer elsewhere for treatment. In impaction, you don’t have time to dissolve the stone anymore. Can relax muscles, make the stone more slippery so that they can pass the stone. Page 3 BILIARY COLIC • Can be caused by stone, or by spasm without a stone. 99% of time there is a stone, but remember this possibility. • Sudden, severe, steady pain after meal, (could be normal meal). If pain doesn’t subside after 3 hours, there may be a complication (will talk about), or could be cholecystitis (infection, inflammation). If it resolves in 2-3 hours, there are no complications, biliary colic can resolve on its own, but can recur regularly after meals. • If complications, pain may not resolve: could be infection. Instead of resolving, pain can go up and down, up and down, building to crescendo. May have ache for 1-2 days after. • Restless patient: from pain. Allopathic setting: pain relieved by narcotics. No sign of peritoneal irritation. Might have dehydration (patient may be vomiting) During obstruction, bacteria can start to accumulate and infection can set in at this point. People can have repeated episodes of biliary colic, but with repeated episodes, there is an increased risk of infection. If the stone is in the COMMON BILE DUCT, jaundice may occur: will cause pruritis (itching of the skin). With pruritis, we know that this is a complete obstruction. There is no passage of bile at all. If giving cholestyramine: check for vitamin deficiency. Diagnosis: ULTRASOUND: this is the best test, and CAT scan. If liver is affected, increase in liver enzymes (see notes)

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Sometimes, surgery is necessary: cases of increased risk, repeated episodes of acute infection Colic with no complications may resolve spontaneously. We can make attempt to dissolve gallstones, but we have to be prepared to deal with a medical emergency that may present. Mistake in notes: Remove line that says “asymptomatic patients under the age of 50 who have no contraindication to surgery” (slide 5, page 3) DDX list in notes: these are other pathologies that may not be as obvious as appendicitis, pancreatitis… These resemble biliary colic. Not as common as other pathologies, but we have to be aware of them.

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Abdominal angina; after a large meal there is not enough blood to feed the mesenteric artery. Angina sets in. Mainly with elderly, or with patiensts with other existing conditions. DDX: Will not find typical signs of biliary colic. AA: Peritoneum is soft. May have weight loss, will auscultate bruits, other signs of peripheral vascular disease, often occurs in elderly smokers. Abdominal aortic aneurism: Not so good resolution to pain. With pain, something is about to rupture: Medical emergency. If there is a patient with known abdominal aneurism and they experience sudden abdominal pain, have to rush them to the hospital. Abdominal abscesses: All organs can develop an abscess: this develops over time, not 10-15 minutes. Abscess: not clear-cut symptomatology. Treatment of choice is allopathic: drainage of abscess (attempt), get out as much fluid as possible, follow with other surgical measures.

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Bowel obstruction: can be many kinds. If you know your patient has cholelithiasis and has successfully passed stone through biliary tree, it can impact in the small intestine. Case: impaction of bags filled with drugs that Dr. W. removed from patient. Can’t remove once impacted: had to cut out part of the small intestine.

See DDX chart in notes: Biliary colic from acute cholecystitis. Biliary colic is just a spasm, not an infection. Other DDX: Myocardial infarction: if it occurs on the inferior wall of the heart, pain may be felt in similar place. If pain is 5-6 hours, something else has developed (not just cholelithiasis) Inflammation, with or without pain, patient will lie motionless. Without inflammation, will be restless. With cholecystitis: there is more of a chance of N/V (almost always presents with this), but this is more rare with bilary colic. Murphy’s sign: patient doesn’t totally stop breathing, but they will catch their breath temporarily. This occurs d/t peritoneal irritation which you will see with infection, not with colic. Predisposition to cholecystitis: see notes. Jaundice will not present in the beginning of cholecystitis. Page 5 Cholecystitis CAN resolve spontaneously if the stone moves either in or out of gallbladder. Stone impacts

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Biliary cholic

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cholecystitis

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can resolve spontaneously can lead to further complications.

If patient is on anti-inflammatory medication, their symptoms will be less acute even if the infection is serious. Laparoscopic chlescystectomy: done with instrument inserted without cutting skin. Complications:

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Empyema: GB fills with purulent material. Sepsis will occur if not treated, can lead to gangrene. Medical emergency. Perforation: Can occur even if cholecystitis is treated. o Can go into adjacent organ-the wall of the GB thickens, contacts other organs, get inflammation, adhesions, easier for a perforation to occur between these organs because they are stuck together. o Perforation can also be free: contents of GB (bile) spill into abdominal cavity in this case, not into another organ that is part of the GI tract which would contain contents. o Therefore, it is better for perforations to occur into an adjacent organ to contain the contents of the GB) Hydropic Gallbladder: Cystic duct obstructed: the “white bile” that accumulates is not purulent. White bile has no digestive function. Can lead to other complications.

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Fistula: a kind of perforation: a small perforation (tract) that develops between the gall bladder and another organ. The GB pushes bile into the organ. Gallstones may be discovered in this second organ. Fistula develops over time and is smaller, whereas the perforation is larger and is more of an acute situation.

DDX: Amoebic Liver Abscess: usually from travel (eg. South America). See DDX signs. Hemorrhagic gangrenous cholecystitis: Mostly in patients who are using blood thinners who aren’t followed up. Bleeding into the gall bladder: accumulation of blood that gets infected. Gallbladder can become infected. Acalculous cholecystitis: No gallstones on unltrasound, can see fluid. CHF: can also thicken GB wall d/t portal hypertension  edema around gallbladder. Intestinal lymphoma: will experience pain with perforation Pneumonia: lots of DDX problems between this and cholecystitis, especially if low: both have fever, leukocytosis, cough, prostration, pain.

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ACUTE PANCREATITIS Because the pancreas is retroperitoneal, infection can set in quickly and spread quickly. Hemorrage, necrotising pancreatitis can occur quickly. Page 7 History: not always involving alcohol. Abdominal trauma: car accidents Pain: characteristic, across abdomen. N/V present, may palpate mass. Retroperitoneal bleeding will cause hematoma around umbilicus (Cullen’s) or at flank (Turner’s) Picture in notes is a guy who will get pancreatitis. Rooted to ground, smoking, drinking beer… Chronic pancreatitis is progressive and irreversible. Process of auto-digestion is more intense than in acute. Even with intervention, the process may not stop. Can have acutisations of chronic pancreatitis: foundation is chronic, but have acute attacks. Can develop diabetes d/t changes in the pancreas Transient adynamic ileus: transient obstruction of the intestine due to inflammation of the pancreas. Transient paralysis of small intestine is produced. It will pass in a matter of hours or days. But, if patient has large meal and food doesn’t move, this can lead to infection in the intestine. Paralysis is due to blockage. Diagnosis: Inflammation will attract calcium: there may be deposits on pancreas. Ultrasound and CAT scan are diagnostic techniques of choice. Azotemia: increased nitrogen in the blood. Page 8 ERCP=Endoscopic retrograde cholangiopancreatography: diagnostic procedure. (I found some info on this page: http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/index.htm ) Case of a patient who had pancreatic cancer. Tumour had metastasized to lung and liver. With naturopathic treatment (started with juice fast), tumour on pancreas shrunk to 2cm from 6cm. Doctors didn’t believe it, said it couldn’t be cancer, they had misdiagnosed. Cancer stabilized. Later, she went on chemo and started deteriorating from this point. Died of pneumonia recently. Page 9 To formulate a DDX: Have to develop a hypothesis, rank DDXs. In establishing DDX, have to look at the following elements: VINDICATE Can be a combination of these things.

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