WORK–UP OF BILIARY

TRACT AND PANCREAS

Albert E. Ismael, MD
Department of Medicine
University of Santo Tomas
 Diagnostic Work-up for
Biliary Tract and Pancreas
 LFTs – test for cholestasis
 Bilirubin
 Alk phosphatase
 GGTP
 5’ nucleotidase

 Prothrombin time
 Serum markers
 Amylase/Lipase
 CA 19-9/CEA
Diagnostic Work-up for Biliary
Tract and Pancreas

 Plain Abdominal X-ray

 Ultrasound/Endoscopic
Ultrasound
 CT scan/CT cholangiography

 MRI/MRCP

 PTC/PTBD

 ERCP
A 48-yr old teacher consulted because of severe
epigastric pain radiating to the RUQ and back,
accompanied by cold sweats and vomiting. One
month ago, she had a similar incident necessitating
ER visit where she received an “injection” and was
prescribed Buscopan.

PE shows an afebrile woman without jaundice.

There’s slight epigastric tenderness. There is no
Murphy’s sign.
 Gallstone
 Plain Abdominal X-ray
 Ultrasound
 Diagnostic
accuracy > 95%
A 55-yr old female consulted because of severe
epigastric pain radiating to the RUQ and back,
accompanied by vomiting 3 days ago. One day
later, she noticed dark urine and yellow eyes. One
day before consultation she developed high fever
and chills.

She had several incidents of similar epigastric pain

for the past 6 months but did not experienced
jaundice or fever.

PE shows an acutely ill, jaundiced woman. BP

120/80 mm Hg, PR 100/min, RR 22/min, temp
39C.She has epigastric and RUQ tenderness.
A 28 year-old bank teller was admitted because
of epigastric pain and jaundice. One year ago, she
was diagnosed to have gallstones.

She is newly married and 10-11 weeks pregnant.

PE shows an apprehensive woman but not in distress.

VS are stable. Her sclerae have a tinge of jaundice.

US at the ER showed multiple gallstones without

biliary ductal dilatation. CBD was 5 mm.
 CBD Stone
 Ultrasound
 Endoscopic Ultrasound

 MRCP

 CT Cholangiography

 PTC

 ERCP
GALLSTONES

Hyperechoic structures inside

the gallbladder with posterior
acoustic shadow

BILIARY OBSTRUCTION

Dilated Common Bile Duct

and intrahepatic ducts
 EUS in Choledocholithiasis
 Sensitivity 98%
 Specificity 99%
 (+) Predictive Value 99%
 (-) Predictive Value 98%
 Accuracy 97%

Buscarini E. Gastrointest Endosc 2003. 57:510

 MRCP in Choledocholithiasis
 Sensitivity 84 - 88%
 Specificity 77 - 96%
 (+) Predictive Value 91- 95%
 (-) Predictive Value 73 - 96%
 Accuracy 85 - 97%

Griffin N et al. Eur J Gastroenterol Hepatol 2003.

15:809-13
Jedresen et al. E J Surg. 2002. 168:690-4
Familiari Gastrointest Endosc 2004. 58:AB198
 Elevated AP

History & PE
Comfirm Hepatic Origin
(GGTP / 5’ Nucleotidase)

Elevated Normal

Ultrasound Evaluate for

extrahepatic sources
No Biliary Obstruction Biliary Obstruction
or Hepatic mass

MRCP / ERCP MRCP / ERCP / PTC

AMA / AFP CT / MRI
Liver Biopsy AFP / CEA
Biopsy
ERCP
• Good visualization of biliary system
• Differentiate extra- and intrahepatic
cholestasis
• Therapeutic potential
• Invasive
 Surgery vs ERCP in
Acute Cholangitis
Surgery ERCP
n=41 n=41

Mortality 13 (32%) 4 (10%)

Complications 27 (66%) 14 (34%)

Lai et al. N Engl J Med 1992

Nasobiliary drain or Stent
in Acute Cholangitis

 Success rate 95 – 100 %

 Mortality 2.5 – 12%

Sharma et al Endoscopy 2005

Lee DW et al Gastrointest Endosc 2002
Acute Pancreatitis

 Plain Abdominal X-ray

 Ultrasound
 CT scan
 MRI
 Role of CT Scan in Acute Pancreatitis

A. Without contrast B. With contrast (enhancement)

CT grade C, no necrosis
 Role of CT Scan in Acute Pancreatitis

A. Severe pancreatitis: CT grade E B. Percutaneous needle aspiration for

necrosis 33 – 50% of pancreas gram stain and culture
CT severity index = 8
 CT Severity Index
 CT Grade Score
 A – normal pancreas 0
 B – focal or diffuse pancreatic enlargement 1
 C – B + peripancreatic inflammation 2
 D – C + one peripancreatic fluid collection 3
 E – C + 2 or more peripancreatic fluid collection 4
 Necrosis
 No necrosis 0
 < 1/3 of pancreas 2
 1/3 – 1/2 of pancreas 4
 > 1/2 of pancreas 6

Balthazar, Ranson, Naidich et al. Radiology 1985

Balthazar, Robinson, Megibow et al. Radiology 1990
Pseudocyst
Ultrasound
CT scan
EUS
 Chronic Pancreatitis

 Plain Abdominal X-ray

 Ultrasound

 CTscan/MRI

 ERCP
A 21-year-old student developed RUQ discomfort
and jaundice 6 weeks ago, preceded by a flu-like
syndrome.
On consultation: AST 800 IU/L ALT 1000 IU/L
IgM anti-HAV (+), HBs Ag (-)
IgM anti-HBc (-)

The jaundice did not recede and she developed

pruritus.
On admission: Bilirubin 8 mg/dL
Alk Phos 325 IU/L
AST 100 IU/L ALT 115 IU/L
US – diffuse parenchymal
liver disease
normal GBPS
A 76-year-old woman from Davao City
was admitted with a 2-month history of
jaundice, accompanied by pruritus and a
10-kg weight loss.

PE showed a frail elderly woman, who is

jaundiced with a palpable gall bladder.

Laboratory data: Bilirubin 12 gm/dL

Alk Phos 385 IU/L
AST 90 IU/L ALT 125 IU/L
Protime 17 sec
 Pancreatic CA
 Ultrasound
 Endoscopic Ultrasound

 CT scan

 MRI/MRCP

 ERCP

 PTC/PTBD
 Pancreatic CA: “Duoble Duct” sign

Role of ERCP
•Diagnosis
•Palliation
 Cholestatic Jaundice

Ultrasound

Dilated bile ducts No bile duct dilatation

CBD stone Mass Intrahepatic cholestasis

ERCP MRI / MRCP Pre-op staging

EUS / CT scan

Resectable Not resectable

Whipple’s Surgery ERCP

PTC / PTBD
Surgery