Biliary and Pancreatic Disease

Question 1

Is the pancreas peritoneal or retroperitoneal?

Answer 1

It is retroperitoneal, except for the tip of the tail, which is peritoneal.

Question 2

What are the three phases of pancreatic secretion? What happens in each?

Answer 2

1. Cephalic phase - vagal stimulation for sight / smell of food releases some acinar juices
2. Gastric phase - antral distension stimulates secretin -> cAMP-mediated water and bicarbonate secretion from ductal cells
3. Intestinal phase - decrease in duodenal pH + increase in amino acids from gastric emptying leads to CCK secretion. CCK stimulates acinar cell secretion

Question 3

What are the three forms of acute pancreatitis? How are they defined?

Answer 3

Mild = interstitial damage, with absence of organ failure or necrosis

Moderately severe = local complications and may have transient organ failure for <48 hours

Severe = necrotizing - persistent organ failure + local complications, high mortality, especially if infected

Question 4

What mediates the local effects of acute pancreatitis? Describe the process of damage

Answer 4

Pancreatic exudate containing activated enzymes spreads through various fascial planes in retroperitoneum -> all around the organs. Leads to fat necrosis of surrounding tissues.

Fluid is protein-rich and when lost leads to hypovolemia / hypotension from third space losses

Question 5

What are the mediators of the system effects of pancreatitis.

Answer 5

Trypsin -> activates complement, elastase, thrombin, chymotrypsin, PLA2, and kallikrein
-> widespread complement activation, damage to cell membranes, and damage to capillaries / blood vessels

Thrombin activation leads to DIC

Lipase release causes widespread fat necrosis

Question 6

What are some common obstructive causes of acute pancreatitis?

Answer 6

Gallstones

Inspissated (thickened) secretions from alcohol

Pancreas divisum

Strictures / malignancies / other compressions

Question 7

What are some metabolic causes of acute pancreatitis?

Answer 7

Hypertriglyceridemia (>1000), hypercalcemia (enzyme activation), ischemia / hypoperfusion, systemic inflammatory vasculitides (SLE, polyarteritis nodosa)

Question 8

What causes hereditary pancreatitis and what is it associated with risk of?

Answer 8

Mutation in trypsin making it resistant to lysis

Autosomal dominant -> cumulative risk of pancreatic cancer is 40% (very high)

Question 9

What are some medications associated with acute pancreatitis?

Answer 9

Azathioprine / 6-MP (think of the sponge being held in sketchy)

All sulfa drugs - furosemide, thiazides, sulfonamides

Valproic acid (sponge being held again)

Didanosine - NRTI - think of Dan holding it at the round table

Question 10

What are the two distinct phases of pancreatitis which have been identified?

Answer 10

Early phase - within 1 week, systemic inflammatory response syndrome +/- organ failure

Late phase - after 1 week, characterized by local complications

Question 11

What are the common presenting symptoms of acute pancreatitis?

Answer 11

Abdominal pain with radiation to the back, worsened by food and relieved by bending forwards (takes pancreas off of back)

Low grade fever, volume depletion (orthostatic changes), and jaundice if obstruction

Question 12

What are some common signs of acute pancreatitis on abdominal exam?

Answer 12

Grey Turner’s sign - flank discoloration

Cullen’s sign - periumbilical discoloration

Paralytic ileus (absent ball sounds)

Pleural effusions, ascites, jaundice

Question 13

What are the diagnostic criteria for making the diagnosis of acute pancreatitis?

Answer 13

Present of at least 2/3 of the following:

1. Acute epigastric pain radiating to the bag
2. Amylase and lipase levels elevated >3x ULN
3. Characteristic imaging findings

Question 14

What are the characteristic imaging modalities for acute pancreatitis?

Answer 14

Ultrasound - check for stones. Initial study of choice.

CT scan with contrast or abdomen MRI is more specific and can show the degree of necrosis

Question 15

What are some prognostic indicators which would suggest a poor outlook for acute pancreatitis?

Answer 15

Severe orthostatic changes

Systemic inflammatory response syndrome

Declining kidney function

Pulmonary involvement

Old age, fat, with altered mental status

Question 16

What are some common local complications of acute pancreatitis?

Answer 16

Necrosis, abscess, pseudocyst

Ileus

GI hemorrhage, splenic vein thrombosis (vessel damage)

Question 17

What are some systemic complications of acute pancreaitis?

Answer 17

Organ failure - Shock, ARDS (membrane damage), renal failure

Hypocalcemia with distant fat necrosis

DIC

Question 18

What is the treatment of uncomplicated acute pancreatitis?

Answer 18

NPO - bowel rest, feed by tube

Restoration of volume state

Remove obstructing gallstone by ERCP if need be

Other supportive treatments for complications

Question 19

What are the causes of severe necrotizing pancreatitis and what is the treatment?

Answer 19

Cause is an infection, usually by E.coli, Klebsiella, or Enterococcus

Treatment - broad spectrum antibiotics until aspiration biopsy tells you sensitivities. Surgical debridement after infection clears.

Question 20

How do pseudocysts form and how can they cause symptoms?

Answer 20

Form from acute local fluid collections

Can cause obstruction, severe pain, bleeding / rupture, and ascites

Question 21

When should pseudocysts be treated and how is this done?

Answer 21

Treat if they are symptomatic

-> can treat endoscopically (via ERCP or across stomach), percutaneously under CT guidance, or surgically

Question 22

What are the etiologies of chronic pancreatitis?

Answer 22

Think pancreatic cirrhosis:

Alcoholism
CF - in children
Hemochromatosis - bronze diabates
Hereditary pancreatitis
Hyperparathyroidism - high calcium
Autoimmune

Question 23

What will lab data show for autoimmune pancreatitis? Imaging?

Answer 23

Elevated serum gammaglobulin IgG4, with autoantibodies

Imaging shows diffuse sausage-like enlargement of pancreas with irregular narrowing of pancreatic duct, and biliary duct abnormalities

Question 24

What will abdominal X-ray and ERCP show for chronic pancreatitis?

Answer 24

Abdominal X-ray - pancreatic calcification

ERCP - abnormal pancreatic ducts, with strictures and stones, distal narrowing of common bile duct

Question 25

What causes pain in chronic pancreatitis?

Answer 25

Minimal enzymes are being released due to ductal stenosis and fibrosis of tissues
-> constant stimulation to contract by CCK in the presence of inflammation / fibrosis causes severe pain

Question 26

What is the treatment for chronic pancreatitis?

Answer 26

Oral pancreatic enzyme replacement therapy -> improves maldigestion of fat, and gives negative feedback for CCK release

Analgesia, with denervation of the pancreas and Whipple procedure of needed.

Question 27

When is steatorrhea normally seen in chronic pancreatitis and what is the treatment?

Answer 27

When 90% of normal lipase activity is lost

• > treatment is lipase replacement with acid suppression so the enzymes aren’t destroyed in the stomach
• > also hold to a low / moderate fat diet

Question 28

Describe the diabetes which occurs in chronic pancreatitis and its management?

Answer 28

It’s a late complication since islets go last

Loss of both insulin / glucagon -> tend to be extremes of blood sugars

Minimal insulin in needed, and ketoacidosis is rare from lack of glucagon as well

Question 29

What is it called when you have obstructive jaundice with a palpable, nontender gallbladder, and what is it suggestive of?

Answer 29

Courvoisier sign - suggestive of pancreatic adenocarcinoma

-> especially when cancer is in the head of the pancreas and blocking the emptying of the common bile duct

Question 30

Other than obvious jaundice-related symptoms and Trousseau, what are a couple signs / symptoms which make you worry about pancreatic cancer?

Answer 30

1. New onset diabetes - in the absence of pancreatitis or past history, especially late in life
2. Depression - new onset depression with unclear reasoning, common in pancreatic cancer

Question 31

What is biliary colic and what is it associated with?

Answer 31

Nausea/vomiting and dull RUQ worsened by food (CCK forces stone into cystic duct)

Associated with cholelithiasis

Question 32

What are the indications for cholecystectomy?

Answer 32

1. Symptomatic gallstones
2. Persistent hemolytic anemias (sickle cell, hereditary spherocytosis)
3. Gastric bypass surgery (prophylactically, since rapid weight loss is a risk factor)
4. Porcelain gallbladder
5. Gallbladder adenomas / polyps

Question 33

What are the nonsurgical management options for gallstones?

Answer 33

Oral bile salt therapy (ursodeoxycholic acid)

Extracorproreal shockwave lithotripsy

Question 34

What is the characteristic pain felt in acute cholecystitis?

Answer 34

Severe, constant RUQ pain which may radiate to the shoulder

Positive Murphy’s sign (inspiratory arrest on RUQ palpation)

Question 35

What causes ascending cholangitis usually and how is it treated?

Answer 35

Usually an impact stone, but may also be due to biliary strictures, parasites, neoplasms, or congenital abnormalities

Treated via biliary decompression (make orifice larger) as well as antibiotics to treat the infection

Question 36

What is Charcot’s triad of cholangitis?

Answer 36

Jaundice, fever, RUQ pain

Question 37

What type of cancer is carcinoma of the extrahepatic biliary ducts and how does it present?

Answer 37

Adenocarcinomas - usually associated with cholelithiasis

Presentatino: Jaundice, pruritis, ascending cholangitis, and weight loss

Dismal prognosis, treatment is palliative

(think of Klatskin tumor from last Bosch lecture, that’s a type of this)