4.3 Pancreatitis, Biliary Tract & GI Bleeding
Key Takeaways
- Acute pancreatitis severity is stratified within 48 hours using the Modified Glasgow criteria (score ≥3 indicates severe disease); routine prophylactic antibiotics are not recommended.
- Glasgow-Blatchford Score (GBS) of 0-1 identifies low-risk upper GI bleeding suitable for safe outpatient management, avoiding unnecessary hospital admission.
- Acute variceal hemorrhage requires immediate pre-endoscopy IV terlipressin (2 mg bolus) and prophylactic IV ceftriaxone (1 g daily), followed by endoscopy within 12 hours for band ligation.
- Early pre-emptive TIPS within 24-72 hours improves survival in high-risk variceal bleeds (Child-Pugh C score 10-13 or Child-Pugh B with active bleeding).
Pancreatitis, Biliary Tract & GI Bleeding
Acute & Chronic Pancreatitis
Pancreatitis ranges from mild self-limiting interstitial edematous inflammation to severe necrotizing pancreatitis with systemic inflammatory response syndrome (SIRS) and multi-organ failure.
Etiology of Acute Pancreatitis
The most common causes are Gallstones (40%) and Alcohol (35%). The mnemonic GET SMASHED outlines the comprehensive etiology:
- G: Gallstones
- E: Ethanol
- T: Trauma
- S: Steroids
- M: Mumps / Coxsackie B virus
- A: Autoimmune (IgG4-related disease)
- S: Scorpion venom
- H: Hypertriglyceridemia (serum triglycerides >11.3 mmol/L or >1000 mg/dL) / Hypercalcemia
- E: ERCP (post-procedure risk 5–10%)
- D: Drugs (Azathioprine, 6-Mercaptopurine, Thiazides, Sodium Valproate, Didanosine)
Diagnostic Criteria
Requires at least two of the following three features:
- Severe, persistent epigastric pain classically radiating to the back.
- Serum amylase or lipase >3 times the upper limit of normal (Lipase is more specific and remains elevated longer up to 8–14 days).
- Characteristic imaging findings on contrast-enhanced CT (CECT), MRI, or transabdominal ultrasound.
Severity Stratification: Modified Glasgow (Imrie) Criteria
Evaluated within 48 hours of admission. A score of ≥3 indicates severe acute pancreatitis (predicting increased risk of pancreatic necrosis and mortality):
| Parameter | Cut-off Value for 1 Point | Memory Aid (PANCREAS) |
|---|---|---|
| PaO<sub>2</sub> | <7.9 kPa (<60 mmHg) | PaO2 |
| Age | >55 years | Age |
| Neutrophils (WBC) | >15 × 10<sup>9</sup>/L | Neutrophils |
| Calcium | <2.0 mmol/L | Calcium |
| Renal (Urea) | >16 mmol/L | Renal urea |
| Enzymes (LDH) | >600 U/L | Enzymes |
| Albumin | <32 g/L | Albumin |
| Sugar (Glucose) | >10 mmol/L | Sugar |
Management Principles of Acute Pancreatitis
- Fluid Resuscitation: Goal-directed intravenous fluid replacement with Ringer's lactate or Hartmann's solution (200–500 mL/hr initially, adjusted to maintain urine output >0.5 mL/kg/hr and hematocrit 35–44%). Avoid excessive over-hydration.
- Nutritional Support: Early oral feeding with low-fat solid or liquid diet as tolerated within 24 hours is recommended for mild pancreatitis. In severe cases, early enteral nutrition (via nasogastric or nasojejunal tube) within 24–48 hours is vastly superior to Total Parenteral Nutrition (TPN), preserving gut mucosal barrier and preventing bacterial translocation.
- Prophylactic Antibiotics: NOT recommended routinely in acute pancreatitis, even in the presence of sterile necrosis. Antibiotics (e.g., IV Meropenem 1 g TDS) are indicated only when infected necrosis is documented (fine-needle aspiration culture or gas on CT).
Chronic Pancreatitis
Chronic pancreatitis results in progressive, irreversible exocrine and endocrine tissue destruction and fibrosis.
- Clinical Triad: Epigastric pain, Steatorrhea, and Diabetes Mellitus.
- Diagnosis: Fecal elastase-1 <100 µg/g stool indicates severe exocrine pancreatic insufficiency (normal >200 µg/g). Abdominal CT or MRCP reveals parenchymal calcification and ductal dilatation ("chain of lakes").
- Management: Pancreatic Enzyme Replacement Therapy (PERT: Creon) taken during meals alongside PPI therapy; pain management (stepwise analgesia); lifestyle intervention (strict alcohol and smoking cessation).
Biliary Tract Disorders
Spectrum of Gallstone Pathology
- Biliary Colic: Transient common bile duct or cystic duct obstruction by a gallstone. Epigastric/RUQ pain lasting <6 hours, precipitated by fatty meals. Normal inflammatory markers and LFTs.
- Acute Cholecystitis: Cystic duct obstruction leading to gallbladder inflammation. Continuous RUQ pain >6 hours, fever, leukocytosis, and Murphy's sign. Ultrasound shows gallbladder wall thickening (>4 mm), pericholecystic fluid, and sonographic Murphy's sign. Management: IV fluids, IV antibiotics (e.g., Amoxicillin/clavulanic acid), and early laparoscopic cholecystectomy within 72 hours of admission.
- Choledocholithiasis: Gallstone in the common bile duct (CBD). Cholestatic LFT profile (elevated ALP, GGT, conjugated bilirubin) and dilated CBD (>6 mm) on ultrasound. Managed by ERCP with endoscopic sphincterotomy and stone extraction.
- Acute Ascending Cholangitis: Bacterial infection superimposed on biliary obstruction.
- Charcot's Triad: RUQ pain, Fever/chills, and Jaundice.
- Reynolds' Pentad: Charcot's Triad + Hypotension (septic shock) + Altered Mental Status.
- Emergency Management: Resuscitation, broad-spectrum IV antibiotics (e.g., Piperacillin-tazobactam), and urgent biliary decompression via ERCP within 24 hours.
Upper & Lower Gastrointestinal Bleeding
Acute GI bleeding is categorized into Upper GI (proximal to ligament of Treitz) and Lower GI bleeding.
Risk Stratification in Upper GI Bleeding (UGIB)
Glasgow-Blatchford Score (GBS)
Utilized pre-endoscopy to identify patients suitable for outpatient management:
| Clinical Parameter | Score Value |
|---|---|
| Blood Urea (mmol/L) | 6.5–7.9: 2 pts, 8.0–9.9: 3 pts, 10.0–24.9: 4 pts, ≥25.0: 6 pts |
| Hemoglobin (g/L) for Men | 120–129: 1 pt, 100–119: 3 pts, <100: 6 pts |
| Hemoglobin (g/L) for Women | 100–119: 1 pt, <100: 6 pts |
| Systolic BP (mmHg) | 100–109: 1 pt, 90–99: 2 pts, <90: 3 pts |
| Pulse ≥100 bpm | 1 pt |
| Presentation with Melena | 1 pt |
| Presentation with Syncope | 2 pts |
| Hepatic Disease History | 2 pts |
| Cardiac Failure History | 2 pts |
- GBS = 0–1: Low Risk. Can be safely discharged for outpatient gastroscopy.
- GBS ≥2: High Risk. Requires inpatient admission and upper GI endoscopy.
Rockall Score
Utilized post-endoscopy to calculate 30-day mortality risk based on age, shock, comorbidities, endoscopic diagnosis, and stigmata of recent hemorrhage.
Acute Variceal Hemorrhage Bundle
Variceal bleeding from portal hypertension carries a 15–20% 6-week mortality.
Management Protocol
- Resuscitation: Restrictive transfusion protocol targeting Hemoglobin 70–80 g/L (unless ischemic heart disease is present).
- Immediate Vasoactive Drug: Start Terlipressin 2 mg IV bolus immediately upon suspicion (followed by 1–2 mg QDS) to reduce splanchnic blood flow and portal pressure.
- Prophylactic Antibiotics: IV Ceftriaxone 1 g OD for 5–7 days reduces rebleeding and mortality.
- Urgent Upper GI Endoscopy: Perform within 12 hours. Execute Endoscopic Variceal Band Ligation (EBL) for esophageal varices or Cyanoacrylate tissue glue injection for gastric varices.
- Early / Pre-emptive TIPS: Transjugular Intrahepatic Portosystemic Shunt within 24–72 hours for high-risk patients (Child-Pugh C score 10–13 or Child-Pugh B with active bleeding at endoscopy).
Non-Variceal Upper GI Bleeding (Peptic Ulcer Bleeding)
Endoscopic therapy is dictated by the Forrest Classification of peptic ulcer stigmata:
| Forrest Class | Endoscopic Stigmata | Rebleeding Risk | Endoscopic Intervention Required? |
|---|---|---|---|
| Ia | Active arterial spurting bleed | 90% | Yes (Dual therapy) |
| Ib | Active oozing bleed | 50% | Yes (Dual therapy) |
| IIa | Non-bleeding visible vessel | 40–50% | Yes (Dual therapy) |
| IIb | Adherent clot | 20–30% | Consider clot removal + treatment |
| IIc | Flat pigmented spot | 7–10% | No (Pharmacotherapy alone) |
| III | Clean ulcer base | <3% | No (Pharmacotherapy alone) |
- Dual Endoscopic Modality: Epinephrine injection combined with thermal coagulation (bipolar electrocautery) or mechanical hemoclips.
- Post-Endoscopic PPI Protocol: Intravenous omeprazole 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours (or oral PPI 40 mg BD) to maintain intragastric pH >6.0, stabilizing clot formation.
A 65-year-old man presents to the emergency department with hematemesis and melena. On arrival, BP is 88/54 mmHg, HR is 118 bpm, and he appears pale and diaphoretic. He has a history of alcohol-related cirrhosis and portal hypertension. While peripheral IV lines are being established and restrictive blood transfusion is initiated, what is the most appropriate immediate pharmacological management prior to urgent endoscopy?
A 52-year-old woman is admitted with severe epigastric pain radiating to her back, accompanied by nausea and repeated vomiting. Serum lipase is 1,450 U/L (normal 10–60 U/L). Abdominal ultrasound confirms gallstones in the gallbladder with a normal common bile duct diameter (5 mm). Bloods at 24 hours show: PaO2 7.2 kPa, Age 52, WBC 18.5 × 10⁹/L, Calcium 1.85 mmol/L, Urea 18.2 mmol/L, Albumin 28 g/L. Glasgow score is 5 (indicating severe acute pancreatitis). CT scan reveals 40% pancreatic parenchymal necrosis. She is currently cardiovascularly stable. What is the evidence-based management strategy regarding antibiotics and enteral nutrition?
A 70-year-old man presents with black tarry stools for 2 days. He takes low-dose aspirin and naproxen for osteoarthritis. Vital signs: BP 128/76 mmHg, HR 72 bpm. Hemoglobin is 112 g/L, blood urea is 6.5 mmol/L, and all other lab parameters are normal. He has no syncopal symptoms, no cardiac history, and no hepatic disease. His Glasgow-Blatchford Score (GBS) is calculated as 1. What is the most appropriate management pathway?