3. Biliary and Pancreatic Pathology

Question 1

define the following:

1. CHOLESTASIS
2. CHOLELITHIASIS
3. CHOLEDOCHOLITHIASIS
4. CHOLECYSTITIS
5. CHOLANGITIS

Answer 1

1. impairment of bile formation and/or bile flow
2. presence of gall stones in the gall bladder
3. presence of gall stones in the common bile duct
4. inflammation of the gall bladder
5. Inflammation of the billiary tree

Question 2

Describe the anatomy of the billiary tree

Answer 2

cystic duct drains gall bladder; common hepatic duct drains liver
cystic duct joins common hepatic duct - forms common bile duct
common bile duct joins with pancreatic duct at the ampulla

Question 3

1. What are gall stones a result of?
2. How can gall stones cause billiary colic
3. How can gall stones cause jaundice?

Answer 3

1. bile super saturation
2. stone migrates to the opening of the cystic duct and obstructs the neck of the gall bladder → increase in bladder wall tension
3. obstruction results in a backflow of bilirubin into the bloodstream. Usually results from obstruction of COMMON BILE DUCT

Question 4

describe the following types of gall stone and conditions in which they are associated:

1. cholesterol
2. pigment
3. mixed

Answer 4

1. composed purely of cholesterol; result of excess cholesterol production; associated with obesity
2. composed purely of bile pigments; result of excess bile pigment production; associated with haemolytic anaemia
3. composed of both cholesterol and bile pigments

Question 5

Name the 6 risk factors for gall stone disease

Answer 5

1. fat
2. female (oestrogen increases billiary cholesterol secretion); HRT and oestrogen containing contraceptives also increase risk
3. forty
4. fertile (progesterone decreases gall bladder contractility)
5. family history
6. haemolytic anaemia
7. malabsorption - Ileal resection; Crohn’s

Question 6

1. What is uncomplicated billiary colic

2. Describe the pain associated with uncomplicated billiary colic

Answer 6

1. impaction of gallbladder neck by stone. No inflammatory response but contraction against the stone causes colicky pain
2. sudden, dull, colicky pain. poorly localised and visceral. precipitated by fatty foods. associated nausea and vomiting. Examination unremarkable

Question 7

1. What is acute cholecystitis?
2. Describe the pain associated with acute cholecystitis
3. Examination findings

Answer 7

1. CYSTIC DUCT OBSTRUCTION → gall bladder inflammation
2. colicky pain. pain often well localised to RUQ. May be persistent and constant due ti inflammatory process
3. Positive murphy’s sign - press on costal margin and ask patient to take deep breath. Will elicit pain
   patient may be jaundiced.
   associated signs of inflammation

Question 8

1. What is ascending cholangitis?
2. What is this condition characterised by?
3. what is this condition regarded as?

Answer 8

1. infection of the billiary tree
   COMMON BILE DUCT OBSTRUCTION → bile stasis
   stagnant bile becomes infected with bacteria - bacteria spreads up ductal system causing inflammation. can cause bacteremia and sepsis
2. CHARCOT’S TRIAD - RUQ pain; jaundice, fever
3. medical emergency

Question 9

What investigations are useful in the diagnosis of gall stone pathology? (7)

Answer 9

1. urinalysis - exclude pregnancy, renal or tubo-ovarian pathology
2. Inflammatory markers - raised in cholecystitis and cholangitis
3. LFTs - biliary colic and acute cholecystitis are likely to show raised ALP
4. amylase - pancreatitis
5. trans-abdominal ultrasound - visualise the presence of gall stones, assess gall bladder thickness and any bile duct dilatation
6. MRCP
7. ERCP

Question 10

Why is pancreatitis a complication of gall bladder disease?

Answer 10

gall stones can become impacted in the ampulla, which impairs drainage of pancreatic duct

Question 11

Name the 4 types of cholangitis

Answer 11

1. Acute ascending cholangitis
2. primary sclerosing cholangitis
3. secondary scleroising cholangitis
4. recurrent pyogenic cholangitis

Question 12

Apart from stones, name 2 other causes of obstruction that can lead to ascending cholangitis

Answer 12

1. malignancy

2. strictures

Question 13

1. What is primary biliary cholangitis?
2. What is common in patient’s hx
3. What serological test are characteristic of this disease?

Answer 13

1. autoimmune destruction of the liver
   - progressive destruction of the intrahepatic bile ducts
   - leads to the development of fibrosis, cholestasis and cirrhosis
2. fam hx of PBC
   hx of other autoimmune conditions
3. anti-mitochondrial autoantibodies

Question 14

1. What is primary sclerosing cholangitis?
2. What other conditions is this disease associated with?
3. describe LFT profile
4. What is seen on MRCP?
5. What is definitive management

Answer 14

1. idiopathic autoimmune mediated inflammation and scarring of intra- and extra-hepatic bile ducts. Results in progressive liver disease → cirrhosis
2. IBD (mostly UC); other autoimmune conditions
3. elevated ALP
4. irregular beaded appearance of the biliary tract
5. liver transplant

Question 15

1. What is secondary sclerosing cholangitis

2. Name 5 conditions which can cause secondary sclerosing cholangitis

Answer 15

1. condition which mimics primary sclerosing cholangitis but is secondary to other conditions
2. • chronic billiary obstruction by stones
   • following recurrent pyogenic cholangitis
   • toxic damage following intra-arterial chemo
   • following ischaemic damage
   • chronic pancreatitis

Question 16

1. Define acute pancreatitis

2. Define chronic pancreatitis

Answer 16

1. inflammation of a previously normal pancreas. initiated by acute injury; can return to normal following resolution of episode
2. continuing inflammation of the pancreatitis, with irreversible structural changes

Question 17

Describe the causes of Acute Pancreatitis

Answer 17

I GET SMASHED

• Idiopathic
• Gall Stones
• Ethanol (alcohol causes early activation of trypsinogen)
• trauma
• steroids
• mumps; malignancy
• autoimmune
• scorpion bite
• hypercalcaemia; hypertriglycerideamia
• ERCP
• drugs - tetracyclines, furosemide, azathioprine, thiazides)

Question 18

What is the underlying mechanism which causes pancreatitis (all aetiologies)

Answer 18

Pancreatic inflammation occurs secondary to premature and exaggerated activation of pancreatic enzymes, within the pancreas

Question 19

How does a patient with a patient with Acute pancreatitis present?

1. Pain
2. Associated symptoms
3. On examination

Answer 19

1. epigasyric pain, radiates to the back
2. nausea and vomiting
3. upper abdominal pain
   systemically unwell - tachycardia, hypotension, oliguria
   widespread tenderness with guarding
   periumbilical and flank bruising

Question 20

1. Which serum marker is sensitive (but not specific) for pancreatitis?
2. What other tests may be of diagnostic value

Answer 20

1. serum amylase

2. serum lipase
    transabdominal ultrasound (useful if ?biliary aetiology)

Question 21

Name 2 scoring systems which are useful in determining prognosis of acute pancreatitis

Answer 21

1. Atlanta Criteria of Disease Severity

2. Glasgow Prognostic Crtieria

Question 22

Name 3 metabolic complications of acute pancreatitis

Answer 22

1. hyperglycaemia
2. hypoglycaemia
3. hypocalcaemia

Question 23

1. What is a pancreatic pseudocyst?
2. What type of pancreatitis is it commonly associated with?
3. What is the risk of a pseudocyst?

Answer 23

1. fluid filled sac rich in pancreatic enzymes, blood and necrotic tissue
2. acute-on-chronic
3. can become infected, and can obstruct surrounding structures

Question 24

1. what is the most common cause of chronic pancreatitis?

2. name 3 other causes of chronic pancreatitis

Answer 24

1. alcohol

2. CF, recurrent acute pancreatitis; autoimmune

Question 25

Describe the pathogenesis of chronic pancreatitis, in relation to the formation of plugs

Answer 25

prolonged intrapancreatic enzyme activity leads to protein precipitation within the duct lumen - plugs these plugs can calcify, leading to further ductal obstruction, ductal hypertension and further pancreatic damage

Question 26

1. Describe the characteristic pain associated with chronic pancreatitis 2. Name 4 other clinical features of chronic pancreatitis

Answer 26

1. epigastric pain which radiates to the back. May be episodic or chronic 2. anorexia and weight loss steatorrhoea malabsorption diabetes

Question 27

1. Why are serum amylase and lipase not as useful in the investigation of chronic pancreatitis 2. Which enzyme marker is a useful diagnostic test for chronic pancreatitis? 3. Name 3 imaging techniques which are useful in the investigation of chronic pancreatitis

Answer 27

1. they may not be elevated in advanced disease 2. faecal elastase 3. transabdominal ultrasound contrasr CT - can show pancreatic calcification and dilated ducts MRCP/ERCP