BILIARY AND PANCREATIC PATHOLOGY Flashcards
what is in bile?
bile salts, bilirubin phospholipid, cholesterol, amino acids, steroids, enzymes, porphyrins, vitamins, and heavy metals, as well as exogenous drugs, xenobiotics and environmental toxins
what are the functions of bile?
helps break down fats by emulsification
helps elimate waste products e.g. bilirubin and excess cholesterol
contains some signalling molecules
what breaks down cholesterol and what does it break down into?
7 alpha hydroxylase breaks it down into 2 primary bile acids - cholic acid and chenodeoxycholic acid
(hepatocytes)
where do the primary bile acids get broken down and into what?
in the intestines they get de-hydroxylated into 2 secondary bile acids deoxycholic acid and lithocholic acid
what gives rise to bile salts?
primary and secondary bile acids are conjugated by the liver with glycine and taurine
what are some pre-hepatic causes of jaundice?
Gilbert disease haemolytic anaemias drugs resorption from a bleed ineffective erythropoeisis
what is gilberts disease?
It is an inherited metabolic disorder that causes excess unconjugated bilirubin due to defective conjugating enzymes in the hepatocytes. 3% of the population have it
what are some hepatic causes of jaundice?
hepatitis drugs toxins cancer primary sclerosing cholangitis alcohol non-alcoholic fatty liver disease
what are some post-hepatic causes of jaundice?
gallstones pancreatic cancer CCA strictures biliary atresia primary sclerosing cholangitis
what is primary sclerosing cholangitis?
inflammation causes scars within the bile ducts
what are some gallbladder pathologies?
cholecystoses stones cholecystitis carcinoma congenital anomalies
what are cholecystoses?
conditions characterised by the accumulation of cholesterol and other fats in the gallbladder
what are the 2 main types of cholecystoses?
cholesterolosis
adenomyomatosis
what are some risk factors of gallstones?
rapid weight loss obesity being female being >40 being pregnant not moving/stasis
why are women more at risk than men of gallstones?
oestrigen increases cholesterol stone formation
why is obesity associated with increased gallstone risk?
obesity is linked to increased levels of cholesterol
why is rapid weight loss a risk factor for gallstones?
asthebody starts to metabolize fats so more cholesterol is released
what are most gallstones composed of?
80% cholesterol
rest are bilirubin
what are the 3 general reasons for gallstones?
bile contains too much cholesterol, too much bilirubin or not enough bile salts
outline the pathology of cholesterol stones?
bile becomes supersaturated with cholesterol/not enough bile salts/gallbladder stasis
= cholesterol precipitates out of bile and forms solid stones
outline the pathology of bilirubin stones?
too much bilirubin in bile = combines with Ca2+ to form calcium bilirubinate which is a solid precipitate
what are brown pigmented gallstones usually caused by?
gallbladder/biliary tract infection
outline the pathology of brown pigmented gallstones?
bacteria causing the infection brings hydrolytic enzymes which hydrokyze conjugated bilirubin and phospholipids. These then combine with Ca2+ and precipitate out to form stones
which population is brown gallstones common?
why
China, Korea, Vietnam
clonochis sinensis is an endemic infection there that causes this
what does ERCP stand for?
Endoscopic retrograde cholangiopancreatography
what is ERCP used for?
a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. It combines X-ray and the use of an endoscope
what does MRCP stand for?
Magnetic resonance cholangiopancreatography
what is MRCP used for?
examine diseases of the liver, gallbladder, bile ducts, pancreas and pancreatic duct
which type of gallstones cant be seen on X-ray?
cholesterol (but you usuaully can see all as they tend to be partially mixed with some radio opaque material)
what are some complications of gallstones?
cholecystitis mucocoele empyema perforation gallstone ileus cholangitis
whats the exocrine fucntion of the pancreas?
powerful digestive enzymes released into the small intestine e.g. trypsin/lipases/amylase
whats the endocrine function of the pancreas?
insulin and glucagon
outline the pathology of alcohol induced pancreatitis?
alcohol increases zymogen secretion from acinar cells as well as decreasing fluid and bicarbonate from ducts
pancreatic juice becomes really thick and viscous and can block ducts
pancreatic juices back up, increasing presure and distending the ducts
membrane traffiking becomes chaotic which can lead to random enzyme activation which causes autodigestion of the pancreas
whats a zymogen?
an inactive precursor of an enzyme
outline the pathophysiology of gallstone induced pancreatitis?
gallstones can get lodged and block the release of pancreatic juices
pancreatic juices back up, increasing presure and distending the ducts
membrane traffiking becomes chaotic which can lead to random enzyme activation which causes autodigestion of the pancreas
what are some causes of acute pancreatitits?
trauma, steroids use, infections like mumps, autoimmune, scorpion stings, hypertriglyceridaemia, hypercalcaemia, drugs, gallstones, alcohol
what are the symptoms of acute pancreatitis?
acute abdo paiin in epigastric area that radiates to the back
vomiting
what are some signs of acute pancreatitis?
gaurding
tenderness in epigastric area
cullens sign
grey turners sign
what is cullens sign?
bruising around the periumbilical region
what is grey turners sign?
bruising along the flank of the body
what will be raised in pancreatitis?
amylase and lipase srum levels
CRP and white cell count
what are some complications of acute pancreatitis?
abscesses, pseudocyst, chronic pancreatitis, diabetes, haemorrhage, acute respiratory distress syndrome and death
outline the pathology behind chronic pancreatitis?
persistent inflamamtion of the pancreas causes ductal dilation and damaged tissue. In response, stellate cells in the pancreas lay down fibrotic tissue causing duct stenosis and acinar atrophy. As acinar cells become impaired, they produce fewer digestive enzymes which leads to pancreatic insufficiency
how does pancreatic insufficiency caused by pancreatitis present?
trouble absorbing food and fat so we see weigt loss, vit ADEK deficiencies and steatorrhoea
why can chronic pancreatitis cause the development of diabetes mellitus?
the inflammation of the pancreas destroys alpha and beta pancreatic cells
why may amylase and lipase serum levels be raised in acute pancreatitis but not chronic?
it could be but there may not be enough tissue to make lipase and amylase in the first place
what are some causes of pancreatitits?
alcohol cystic fibrosis hyperriglyceridaemia tumour pancreatic resection familial congenital abnormalities autoimmune
whst are some risk factors of pancreatitis?
excessive alcohol\
obesity
diabetes
Fhx
what are some complications of chronic pancreatitis?
calcification of the pancreas chronic pain diabetes gallstones kidney failure pseudocysts pancreatic cancer acute flare ups
where do most pancreatic carcinomas form?
the head of the pancreas
do pancreatic tumours usually develop in the exocrine or endocrine glands?
exocrine
what type of carcinoma are most pancreatic tumours?
adenocarcinomas
what are risk factors for pancreatic cancer?
smoking obesity diet high in red meat male african american >65 having diabetes chronic pancreatitits or liver cirrhosis Fhx (particularly BRCA2 and PALB2)
what are symptoms of pancreatic cancer?
nausea vomiting fatigue weight loss epigastric pain back pain painless jaundice troisseas sign couvoisiers sign
what is troisseaus sign?
blood clots appearing in the superficial veins causing lumps
what is Courvoisier sign?
an enlarged, palpable but non tender gallbladder
what is the medium survival of pancreatic tumours?
2-3 months
