Biliary Tract and Pancreatic Diseases

Question 1

Definition of cholelithiasis

Answer 1

presence of gallstones in the GB

Question 2

Definition of cholecystitis

Answer 2

gallstone obstruction of cystic duct, causing inflammation and infection

Question 3

Definition of choledocholithiasis

Answer 3

the presence of gallstones in the CBD

Question 4

Definition of cholangitis

Answer 4

gallstone obstruction of the biliary or hepatic ducts, causing inflammation and infection

Question 5

Cholelithiasis

Answer 5

Pathophysiology

• bile becomes supersaturated with cholesterol or bilirubinate, causing precipitation of microscopic crystals
• when these crystals get trapped in GB mucus–> sludge
• as crystals grow–> macroscopic gallstones
• either sludge or gallstones can cause obstruction

RF’s

• female, forty, fat, fertile

Sxs:

• most asymptomatic
• biliary colic: epigastric or RUQ pain that is intense and dull
• onset ~1hr after meal
• +/- diaphoresis, N/V

Labs:

• not indicated unless suspect cholecystitis
• *Imaging**: US

Tx:

• if asymptomatic–none
• elective cholecystectomy

Question 6

Cholecystitis

pathophys, RFs, sxs, PE, labs, imaging, tx, prognosis

Answer 6

Pathophysiology:

• Acute calculous cholecystitis (MC): obstruction of cystic duct–> distention of GB; blood flow/lymphatic drainage compromised–>mucosal ischemia and necrosis
• Acute acalculous cholecystitis: injury from retained, concentrated, and stagnant bile

RFs:

• Calculous: fat, fertile, female, forty
• Acalculous: critical illness, severe trauma, long term parenteral nutrition, prolonged fasting

Sxs:

• constant epigastric pain that later localizes to RUQ
• +/- N/V and fever
• most have hx of biliary pain
• differentiated from biliary colic b/c pain is constant and severe for more than 6hrs

PE:

• fever, tachycardia
• RUQ tenderness w/ guarding or rebound
• jaundice (15%)

Labs:

• leukocytosis
• ALT, AST, bili and alk phos may be elevated
• lipase
• urinalysis to r/o pyelophritis and renal calculi
• pregnancy test

Imaging:

• US is preferred
• can do CT to assess for complications

Tx:

• NPO, IV fluids, analgesia, IV abx
• cholecystectomy (can tx as outpt and perform electively later if uncomplicated)

Prognosis:

• pts with acalculous have higher mortality–calculous has very good prognosis

Question 7

Choledocolithiasis

sxs, labs, imaging, tx, prognosis

Answer 7

passage of gallstones into the common bile duct

Sxs:

• commonly asymptomatic
• RUQ or epigastric pain
• N/V

Labs:

• elevated AST, ALT, bili, alk phos

Imaging:

• US, EUS, or MRCP are diagnostic

Tx:

• ERCP

Prognosis:

• variable depending on complications present

Question 8

Cholangitis

common etiologies, sxs, labs, imaging, tx

Answer 8

Common causes

• MC choledocholithiasis
• ERCP/stents

Sxs:

• nonsuppurative–Charcot’s triad (RUQ pain, fever, jaundice)
• suppurative–Reynold’s pentad (Charcot’s + mental confusion and hypotension)

Labs:

• leukocytosis
• elevated bili and alk phos
• blood cultures

Imaging:

• US

Tx:

• nonsuppurative-MC and responds to abx
• suppurative: ERCP to relieve obstruction and drain infected bile (worse prognosis, needs early intervention)

Question 9

Gallbladder CA

Answer 9

Etiology

• arises in setting of chornic inflammation (MC cholesterol gallstones)

RFs

• MC in females, native americans/hispanics, ~65y.o.

Sxs:

• similar to gallstones/biliary colic but…
• more diffuse and persistent
• jaundice, anorexia, weight loss = more advanced disease

PE:

• palpable GB (can occur in any GB dz)–Coursoisier’s sign
• palpable nodules buling into the umbilicus (Sister Mary Joseph nodes)
• Left supraclavicular (Virchow node)
• jaundice

Labs:

• advanced disease–anemia and elevated alk phos and bili

Imaging:

• US or CT

Tx:

• surgical resection, radiation, chemo

Not a good prognosis

Question 10

Acute Pancreatitis

pathophys, etiology, sxs, PE, labs, imaging, tx, complications

Answer 10

pathophys

• injury to pancreas–> inflammation–> pancreatic vascular permeability–>hemorrhage, edema, necrosis
• inflammation commonly causes systemic complications: bacteremia from gut flora translocation, ARDS, shock, etc.

etiology:

• MC–gallstones (females, older) and ETOH (males, younger)
• post ERCP
• hypertrglyceridemia

Sxs:

• steady and boring epigastric/periumbilical pain
• radiates to back, chest, flanks, and lower abdomen
• worse when supine
• N/V, anorexia

PE:

• fever, tachycardia, hypotension
• abdominal tenderness, guarding, distension
• decreased BS’s
• Severe necrotizing pancreatitis:
  
  • Cullens sign: bluish discoloration around umbilicus
  • Turner’s sign: bruising of flanks

Labs:

• elevated lipase
• leukocytosis
• elevated hematocrit and BUN indicate more severe disease
• other labs to determine what caused pancreatitis

Imaging:

• CT

Tx:

• mild disease: NPO, IV fluids, analgesiscs
• severe disease: aggressive–fluids, abx
• ERCP if caused by gallstones

**Complications: **

• acute fluid collections
• pseudocysts
• pancreatic necrosis
• intra-abdominal infx

Question 11

Chronic pancreatitis

pathophys, sxs, PE, labs, imaging, tx, complications

Answer 11

Pathophys:

• chronic inflammatory process of the pancreas that leads to irreversible fibrosis with calcification
• impairs both endocrine and exocrine function of the pancreas
• MC cause is ETOH (adults) and CF (kids)

Sxs:

• abdominal pain (variable location, severity, frequency)
• malabsorption–chronic diarrhea, steatorrhea, weight loss, fatigue

PE:

• mild tenderness inconsistent with severity of pain pt reports

Labs:

• elevated lipase, fasting BG, bili and alk phos

Imaging:

• MRCP diagnostic procedure of choice
• can also do a CT or EUS

Tx:

• cessation of ETOH, smoking, dietary changes
• give pancreatic enzymes
• surgery when anatomical complication exists

Complications:

• pseudocysts
• obstruction of bile duct or duodenum
• impaired glucose tolerance
• GI bleeding
• cholangitis or biliary cirrhosis
• pancreatic cancer

Question 12

Pancreatic CA

sites of metastasis, RFs, Sxs, PE, imaging, tx, prognosis

Answer 12

Metastasizes to regional lymph nodes, then the liver

RFs

• smoking
• obesity and diet
• DM
• chronic pancreatitis
• genetic factors

Sxs

• gradual onset of nonspecific sxs of anorexia, malaise, nausea, fatigue, weight loss
• jaundice with pruritis
• mid epigastric pain
• recent diagnosis of DM

PE:

• jaundice adn cachexia
• Courvoisier’s sign
• hepatomegaly, ascites, Virchow’s node, Sister Mary Joseph’s nodes (related to metastasis)
• hypercoagulability

Imaging:

• CT

Tx:

• surgery (Whipple)
• chemo/radiation

**poor prognosis **