Biliary and pancreatic pathology Flashcards
gallstoes (cholelithiasis) formed from?
Formed from constituents of the bile:
–cholesterol
–calcium salts (phosphates, carbonates)
–bilirubin (calcium bilirubinate)
two types of gallstones?
Two main types
–Cholesterol stones
–Pigment stones
what increases bile cholesterol?
Obesity, females, increasing age
what decreaes bile acids?
Oestrogens
•Excessive gut loss (terminal ileal disease eg Crohn’s)
•Bile salts have been used to dissolve stones
3 types of pigmented galstones?
Calcium bilirubinate
•Chronic biliary infections
•Abnormal red cell breakdown (haemolytic anaemia)
what is chronic cholecystitis?
Longstanding irritation of gall bladder
•Thickening of gall bladder wall
–Muscle hypertrophy
–Low grade chronic inflammation
–Fibrosis
–Diverticula - misplacement of mucosa into wall
•“Rokitansky-Aschoff sinuses”
Motility disorders
–Dyspepsia
–Right upper quadrant pain, often related to fatty foods
what causes duct obstruction?
Secondary infection by bowel bacteria
–Purulent bile
–Empyema
–Septicaemia
–Perforation
acalculous cholcystitis?
Usually a complication of some other critical illness
–Sepsis, trauma, burns
–Total parenteral nutrition
•Due to increased bile viscosity and ischaemia
cystic duct obstuction?
Acute (on chronic) cholecystitis
•“Mucocoele” of gall bladder
Common duct stones?
Biliary colic
•Obstructive jaundice
–Dilated bile ducts (ultrasound)
–Enlarged green stained liver
extrahepatbic bile duct obstruction?
Extrahepatic bile duct obstruction
–Pale stools, dark urine
–Conjugated hyperbilirubinaemia
–Raised alkaline phosphatase
–Mildly raised transaminases
–Malabsorption of fat and vitamin K
–Itching
–Ascending cholangitis
–Septicaemia
–Liver abscess
causes of obstructive jaundice?
Benign bile duct strictures
–Instrumentation / surgery
–Sclerosing cholangitis
–HIV cholangiopathy (CMV, cryptosporidiosis)
–Parasites (Clonorchis, Ascaris, Fasciola)
•Carcinoma of
–the bile duct
–The duodenum (ampulla of Vater)
–The pancreas
•Compression of bile ducts by extrinsic masses
carcinoma of the biliary tract?
Associated with long-standing chronic irritation that leads to reparative epithelial hyperproliferation
•Carcinoma of the Gall Bladder
•Carcinoma of the Bile Ducts
carcinoma of the gall bladr?
Adenocarcinoma
•Preceded by dysplasia
•Rare
•Elderly women
•90% have gall stones
•Local structures (especially liver) usually invaded at presentation
•Poor prognosis
–Median survival 6 months
carcinoma of the bile duct?
Associated with
–Gall stones
–Clonorchis sinensis
–Inflammatory bowel disease (sclerosing cholangitis)
–Congenital abnormalities (eg choledochal cyst)
•Often multifocal
•Painless obstructive jaundice, cholangitis
•Poor prognosis
aatomy?
clonorchis sinensis?
Clonorchis sinensis, the Chinese liver fluke, is a human liver fluke in the class Trematoda, Phylum Platyhelminthes. This parasite lives in the liver of humans, and is found mainly in the common bile duct and gall bladder, feeding on bile. These animals, which are believed to be the third most prevalent worm parasite in the world, are endemic to Japan, China, Taiwan, and Southeast Asia, currently infecting an estimated 30,000,000 humans.
sclerosing cholangitis?
infection or inflammation of the common biel duct
signs of acute pancreatitis?
Common, incidence 0.1-1/1000 in West
•Acute inflammation, haemorrhage and necrosis of pancreas
•Liberation of digestive enzymes
•Raised serum amylase
Severe abdominal pain
•Jaundice if CBD obstructed
•Peritonitis - chemical, bacterial
•Shock
•Septicaemia
•Adult respiratory distress syndrome
•GI haemorrhage
•Acute renal failure
•10-15% mortality
acute pancreatitis?
Fat necrosis
•Secondary bacterial infection
•May lead to pancreatic pseudocyst
–Conversion of necrotic pancreas into a cyst filled with fluid and necrotic debris
causes of acute pancreatitis?
Alcohol
•Gall stones
•Iatrogenic
•Abdominal trauma
•Drugs
–azathioprine, antibiotics, diuretics, NSAIDs
•Infections
–Mumps, EBV
•Hereditary
–Autosomal dominant
•Hypercalcaemia
•Tumours (obstruction)
•Congenital anomalies
•Hypothermia
•Ischaemia
•Idiopathic
chronic pancreatitis?
Fibrosis and calcification
•Progressive destruction of acinar and endocrine tissue
•Duct dilatation and strictures
•Often indistinguishable from a tumour without histology
Recurrent abdominal pain
•Pancreatic exocrine insufficiency (malabsorption)
•Pancreatic endocrine insufficiency (diabetes mellitus)
•Serum amylase often normal
•May be bouts of superimposed acute pancreatitis
causes of chronic pancreattis?
Alcohol
•Autoimmunity (IgG4)
•Hereditary
–Cystic fibrosis (duct obstruction by viscid mucus)
–Autosomal dominant pancreatitis
–Haemochromatosis
•Tropical (India & Africa)
•Biliary disease
•Hypercalcaemia
•Idiopathic
tumouyrs ofthe pancrease?
Exocrine
–Benign - uncommon
•Cystadenomas
–Borderline - uncommon
•Intraductal papillary mucinous tumours
•Mucinous cystic tumours
–Malignant - common
•Ductal adenocarcinoma
•Rarities
•Endocrine (islet cell tumours)
causes of tumours in pancrease?
Aetiology largely unknown
–Smoking, diabetes, chronic pancreatitis
–5% have a family history (incl. BRCA2)
•Arises from ductal epithelium
–K-ras, CDKN2A and p53 mutation common
–Pre-invasive dysplasia recognised
common signs of pancreatic carcinoma?
60% head of pancreas
–Progressive painless jaundice
–Palpable dilatation of gall bladder (Courvoisier)
–Duodenal erosion / bleeding
•10% body, 10% tail
–Ill defined upper abdominal pain radiating to back
•Weight loss
•Metastases - lymph nodes, liver
•Migratory thrombophlebitis (Trousseau)
diagnostic marker for pancreatic cancer?
Diagnosis
–Tumour markers - CA19-9
–Imaging (CT, ERCP, endoscopic ultrasound)
–Pancreatic juice cytology (? molecular diagnosis)
–Biopsy
•Needle core, aspiration cytology, operative
pancreatic endocrine tumours?
Rare tumours of islets of Langerhans
•Usually solitary, except in inherited multiple endocrine neoplasia (MEN) syndrome
•May be functioning or non-functioning
•Mostly low grade, cured by surgery
•Functioning tumours may be controlled by somatostatin analogues (octreotide)
•Minority are high grade and aggressively malignant
functional tumours?
Often very small
•Insulinoma
–Hypoglycaemic attacks, confusion, behavioural disturbance
•Glucagonoma
–Anaemia, diabetes, skin disease (necrolytic migratory erythema)
•VIPoma
–Watery diarrhoea
•Gastrinoma
–Zollinger-Ellison syndrome (high gastric acid output)
•Somatostatinoma
–Diarrhoea, diabetes, gall stones
