Biliary And Pancreatic Pathology

Question 1

1. Where does bile come from and stored?
2. What is the histology of gallbladder?
3. What stimulates CKK?
4. What is the role of bile

Answer 1

1. Bile from hepatocytes and is stored in the gallbladder
2. Simple columnar with Rugae
3. Eating which results in bile release into bowel through ampulla of vater
4. Helps small intestine digest fats and absorb fats, cholesterol and some vitamins >95% of bile is reabsorbed in terminal ileum and return to liver

Question 2

What is contained in bile?

Answer 2

Bile acid (cholic acid, chenodeoxycholic acid, glycine and taurine conjugates, secondary bile acids; deoxycholic acid lithocholic acid)
Phoshatidycholine
Bilirubin
Cholesterol

Question 3

What is the function of bile?

Answer 3

Absorb necessary fats-emulsification of dietary fat
Help eliminate waste products
Signalling molecules-MAPK pathway, ligand receptor for TGR5, active hormone receptors

Question 4

How are bile salts reabsorbed?

Answer 4

Active transport

Returned to live via anterohepatic circulation

Question 5

What is jaundice?

Answer 5

Hyperbilirbinaemia (high bilirubin in blood)

Question 6

What affect does obstructive jaundice have on bowels and urine?

Answer 6

Dark urine due to bilirubin and chalky white stools due to lack of stercobilinogen

Question 7

How can causes of jaundice be split up?

Answer 7

Pre-hepatic (unconjugated bilirubin)
Hepatic (mixed bilirubin)
Post hepatic (conjugated bilirubin)

Question 8

What are pre-hepatic causes of jaundice

Answer 8

Haemolytic (RBCs broken down too quickly)
Resorption from bleed eg dissected aortic aneurysms, breakdown of blood products is slowly reabsorbed
Gilbert congenital condition where unconjugated bilirubin struggles to get into liver made worse at times of stress
Ineffective erythropoiesis

Question 9

What are hepatic (mixed bilirubin) causes of jaundice?

Answer 9

Liver disease 
Drugs 
Toxins 
Cancer 
PSC (primary sclerosing cholangitis

Question 10

What are post hepatic causes of jaundice?

Answer 10

Obstruction of bile duct
Gallstones 
Ca pancreas 
CCA (cholangiocarcinoma) 
Strictures
Biliary atresia

Question 11

What is cholesterolosis?

Answer 11

Accumulation of cholesterol

Question 12

What causes stones?

Answer 12

Cholesterol
Pigment
Mixed

Question 13

What causes cholecystitis?

Answer 13

Infection (calculus, acalculous (5-10%), chronic stones (90%)-in elderly this carries a significant mortality

Question 14

What is mucocoele?

Answer 14

Distension of gallbladder by accumulation of mucous

Question 15

What are the risk factors for gallstones

Answer 15

Female 
Forty 
Fat 
Fertile 
Fair

Question 16

What are the signs and symptoms of gallstones

Answer 16

Right upper quadrant pain

Murphys sign

Question 17

What are the causes of gallstones

Answer 17

Chronic haemolytic 
Lithogenic bile
Infection/inflammation
Rapid weight reduction 
Stasis (pregnancy, TPN, spinal cord injuries

Question 18

What are the majority of gall stones?

Answer 18

80% are cholesterol stones

>50% crystalline cholesterol mono hydrate

Question 19

How to test for gallstones?

Answer 19

ERCP (endoscopic retrograde choangiopancretogaphy)

MRCP (magnetic resonance choangiopancreatograpy)

Question 20

What are the complications of gallstones in the cystic duct?

Answer 20

80% are silent 
Acute/chronic cholecystitis 
Mucocoele 
Emphyema-gallbladder fill with pus, can perforate, life threatening 
Performation 
Gallstone ileum

Question 21

What are the complications of gallstones in the common bile duct?

Answer 21

Partial, total or intermittent obstruction
Pain
Cholangitis
Gallstone ileus

Question 22

What are the investigations for carcinoma of the gallbladder and bile duct?

Answer 22

Blood tests
Imaging (ultrasound, CT, EUS, MRCP, RECP)
Laparoscopy

Question 23

What is the treatment for carcinoma of the gallbladder and bile duct?

Answer 23

Rare cure
Surgery 
ERCP
Chemotherapy 
(<1% 5 yr survival)

Question 24

What is the exocrine function of the pancreas?

Answer 24

Powerful digestive enzymes (trypsin, lipases and amylase) released into small intestine to aid digestion of carbohydrates, proteins and fats

Question 25

What is the endocrine function of the pancreas?

Answer 25

Insulin and glucagon for glucose regulation

Question 26

Describe the embryology of the pancreas and why may it lead to abnormalities?

Answer 26

Develops in 2 parts Join at week 8 ‘Swinging round’ process to join the 2 parts doesn’t always occur and can lead to anomalies, it can also cause infective and inflammatory problems as a failure of the rotation

Question 27

Give examples of diseases of the pancreas?

Answer 27

Congenital anomalies-agnesis, divisum, annular pancreas, heterotrophic pancreas, pancreatic cysts Acute pancreatitis Chronic pancreatitis Tumour

Question 28

What is pancreatic pseudocyst?

Answer 28

Inflammatory cyst forming anterior to the pancreas, source of infection ad treatment is to drain endoscopically or percutaneously

Question 29

What are the types of exocrine pancreatic tumours?

Answer 29

Pseudocyst (contain fibrosis, organising blood clot, cholesterol crystals, debris) Pancreatic abscess Cystic tumour-benign (mucinous cystadenoma), malignant (mucinous cystadenocarcinoma) Carcinoma of the pancreas

Question 30

What is carcinoma of the pancreas?

Answer 30

Adenocarcinoma (60% head, 25% body, 15% tail)

Question 31

What are the symptoms and signs of carcinoma of the pancreas

Answer 31

``` Few symptoms and signs Weight loss Back pain Painless jaundice Trousseau’s sign (migratory thrombophlebitis) ```

Question 32

What investigations would be done for a patient with carcinoma of the pancreas?

Answer 32

``` CT USS EUS ERCP MRI Biopsy diagnosis difficult ```

Question 33

What is the treatment for carcinoma of the pancreas?

Answer 33

Surgery (<20%)-only 20% cured Chemotherapy Median survival 2-3 months

Question 34

Describe endocrine tumours of the pancreas?

Answer 34

``` Islet cell tumours Insulinoma Gastrinoma (zollinger-Ellison syndrome) Glucagonoma Somatostatinoma VIPoma-watery diarhea, hypokalaemia, achlorhydria Can be small, multiple or malignant Difficult to diagnose and rare ```

Question 35

What are the causes of acute pancreatitis

Answer 35

``` Idiopathic Gallstones Ethanol Trauma Steroids Mumps/malignancy Autoimmune Scorpion sting Hypercalcaemia ERCP Drugs ```

Question 36

What are the symptoms of acute pancreatitis?

Answer 36

Acute abdominal pain Central, severe radiates to back Vomiting Alcohol excess history

Question 37

What are the signs of acute pancreatitis?

Answer 37

Guarding and tenderness in upper abdomen | Complicated by shock, DIC, renal failure, haemolysis, ARDS

Question 38

What would be seen on investigation in acute pancreatitis?

Answer 38

``` Raised serum amylase Glucose intolerance Hypocalcaemia Raised CRP, white cell count Haemorrhaging peritoneal effusion ```

Question 39

What is the outcome for acute pancreatitis?

Answer 39

``` Abscess Pseudocyst Relapse Diabetes Death ```

Question 40

1. What is the commonest cause of chronic pancreatitis | 2. What are other causes

Answer 40

1. Alcohol 2. Biliary tract disease Hypercalcaemia Hyperlipidaemia Haemochromatosis Cystic fibrosis Idiopathic

Question 41

Describe the morphology of chronic pancreatitis?

Answer 41

Irregular gland with fibrosis, fatty infiltration, calcification Appearance mimics carcionma (difficult to biopsy diagnosis)

Question 42

What are the outcomes of chronic pancreatitis?

Answer 42

``` Endocrine pancrease relatively spared Pain Weight loss Steatorhoea Diabetes Jaundice Hypoalbuinaemia Pseudocyst Scenic vein thrombosis ```