CH11 - Exocrine Pancreas, Gallbladder, and Liver Pathology Flashcards
What is annular pancreas?
Developmental malformation in which the pancreas forms a ring around the duodenum
In annular pancreas what is there a risk of?
duodenal obstruction
What is acute pancreatitis?
Inflammation and hemorrhage of the pancreas
What is acute pancreatitis due to?
autodigestion of pancreatic parenchyma by pancreatic enzymes
What does premature activation of trypsin lead to?
activation of other pancreatic enzymes
What does acute pancreatitis result in?
liquefactive hemorrhagic necrosis of the pancreas and fat necrosis of the peripancreatic fat
What is acute pancreatitis most commonly due to?
alcohol and gallstones;
Beside alcohol and gallstones what are some other causes of acute pancreatitis?
include trauma, hypercalcemia, hyperlipidemia, drugs, scorpion stings, mumps, and rupture of a posterior duodenal ulcer
What are the clinical features for acute pancreatitis?
1) Epigastric abdominal pain that radiates to the back 2) Nausea and vomiting 3) Periumbilical and flank hemorrhage 4) Elevated serum lipase and amylase - lipase is more specific for pancreatic damage 5) Hypocalcemia - calcium is consumed during saponification in fat necrosis
In acute pancreatitis why is there periumbilical and flank hemorrhage?
necrosis spreads into the periumbilical soft tissue and retroperitoneum
In acute pancreatitis why is there elevated serum lipase and amylase?
lipase is more specific for pancreatic damage
What are the complications for acute pancreatitis?
- Shock 2. Pancreatic pseudocyst 3. Pancreatic abscess 4. DIC and ARDS
In acute pancreatitis why is shock one of the complications?
Its due to peripancreatic hemorrhage and fluid sequestration
In acute pancreatitis what happens in pancreatic pseudocyst?
Its formed by fibrous tissue surrounding liquefactive necrosis and pancreatic enzymes
How does a pancreatic pseudocyst present?
as an abdominal mass with persistently elevated serum amylase
What happens when a pancreatic pseudocyst ruptures?
it is associated with release of enzymes into the abdominal cavity and hemorrhage.
What is pancreatic abscess often due to?
Ecoli
How does pancreatic abscess present?
with abdominal pain, high fever, and persistently elevated amylase
What happens in chronic pancreatitis?
Fibrosis of pancreatic parenchyma, most often secondary to recurrent acute pancreatitis
What is chronic pancreatitis most commonly due to?
Alcohol in adults and cystic fibrosis in children, many cases are idiopathic.
What does acute pancreatitis leading to pancreatic insufficiency result in?
malabsorption with steatorrhea and fat soluble vitamin deficiencies. Amylase and lipase are not useful serologic markers of chronic pancreatitis.
What are the clinical features of acute pancreatitis?
- epigastric abdominal pain that radiates to the back 2. Pancreatic insufficiency 3. Dystrophic calcification of pancreatic parenchyma on imaging, contrast studies reveal a [chain of lakes] pattern due to dilatation of pancreatic ducts. 4. Secondary diabetes mellitus 5. Increased risk for pancreatic carcinoma
In acute pancreatitis why is there a chain of lakes pattern on contrast studies?
It is due to the dilation of pancreatic ducts and dystrophic calcification of pancreatic parenchyma
How is secondary diabetes mellitus related to acute pancreatitis?
It?s a late complication due to destruction of the islets
What is pancreatic carcinoma?
Adenocarcinoma arising from the pancreatic ducts
What is pancreatic carcinoma most commonly seen in?
the elderly (average age is 70 years)
What are the major risk factors for pancreatic carcinoma?
smoking and chronic pancreatitis.
What are the clinical features for pancreatic carcinoma?
They usually occur late in disease. 1. Epigastric abdominal pain and weight loss 2. Obstructive jaundice with pale stools and palpable gallbladder 3. Secondary diabetes mellitus 4. Pancreatitis 5. Migratory thrombophlebitis (Trousseau sign) 6. Serum tumor marker is CA 19-9
What tumor is secondary diabetes mellitus associated with?
It?s associated with tumors that arise in the body or tail
How does Trousseau sign present?
as swelling, erythema, and tenderness in the extremities (seen in 10% of patients)
For pancreatic carcinoma with obstructive jaundice with pale stools and palpable gallbladder what is it associated with?
tumors that arise in the head of the pancreas (most common location)
What does surgical resection of the pancreatic carcinoma involve?
en bloc removal of the head and neck of pancreas, proximal duodenum, and gallbladder (Whipple procedure).
What is the prognosis for pancreatic carcinoma?
Very poor prognosis; 1-year survival is < 10%
What is biliary atresia?
Failure to form or early destruction of extra hepatic biliary tree
What does biliary atresia lead to?
biliary obstruction within the first 3 months of life
What does biliary atresia present with?
jaundice and progresses to cirrhosis
What does cholelithiasis lead to?
(gallstones) Solid, round stones in the gallbladder
What is cholelithiasis due to?
precipitation of cholesterol (cholesterol stones) or bilirubin (bilirubin stones) in bile
What does cholelithiasis arise with?
(1) supersaturation of cholesterol or bilirubin, (2) decreased phospholipids (e.g., lecithin) or bile acids (normally increase solubility), or (3)stasis
What is the most common type of cholelithiasis?
cholesterol stones (yellow) are the most common type (90%), especially in the West
How is cholelithiasis usually described?
radiolucent - 10% are radiopaque due to associated calcium
What are the risk factors for cholelithiasis?
They are age (40s), estrogen (female gender, obesity, multiple pregnancies and oral contraceptives), dofibrate, Native American ethnicity, Crohn disease, and cirrhosis.
What are bilirubin stones (pigmented) composed of?
bilirubin
How do bilirubin stones appear?
They are usually radiopaque
What are the risk factors for bilirubin stones?
They are extravascular hemolysis (increased bilirubin in bile) and biliary tract infection (eg. E coli, Ascaris lumbricoides, and Clonorchis sinensis).
How is Ascitris lumbricoides related to bilirubin stones?
it is a common roundworm that infects 25% of the world’s population, especially in areas with poor sanitation (fecal-oral transmission); infects the biliary tract, increasing the risk for gallstones
How is Clonorchis sinensis related to bilirubin stones?
It is endemic in China, Korea, and Vietnam (Chinese liver fluke); infects the biliary tract, increasing the risk for gallstones, cholangitis, and cholangiocarcinoma
What are the symptoms for gallstones?
they are usually asymptomatic;
What are the complications for gallstones?
They include biliary colic, acute and chronic cholecystitis, ascending cholangitis, gallstone ileus, and gallbladder cancer.
What is biliary colic?
Waxing and waning right upper quadrant pain
What is biliary colic due to?
the gallbladder contracting against a stone lodged in the cystic duct
How are the symptoms for biliary colic relieved?
if the stone passes.
What may common bile duct obstruction result in?
acute pancreatitis or obstructive jaundice.
What is acute cholecystitis?
Acute inflammation of the gallbladder wall
What does an impacted stone in the cystic duct result in?
dilatation with pressure ischemia, bacterial overgrowth (E coli), and inflammation
How does acute cholecystitis present?
with right upper quadrant pain, often radiating to right scapula, fever with increased WBC count, nausea, vomiting, and increased serum alkaline phosphatase (from duct damage), risk of rupture if left untreated
What is chronic cholecystitis?
Chronic inflammation of the gallbladder
What is chronic cholecystitis due to?
chemical irritation from longstanding cholelithiasis, with or without superimposed bouts of acute cholecystitis
What is chronic cholecystitis characterized by?
herniation of gallbladder mucosa into the muscular wall (Rokitansky-Aschoff sinus formation)
How does chronic cholecystitis present?
with vague right upper quadrant pain, especially after eating
What is a late complication of chronic cholecystitis?
Porcelain gallbladder is a late complication
What is porcelain gallbladder?
- Shrunken, hard gallbladder due to chronic inflammation, fibrosis, and dystrophic calcification 2. Increased risk for carcinoma
What is the treatment for porcelain gallbladder?
it is cholecystectomy, especially if porcelain gallbladder is present
What is ascending cholangitis?
Bacterial infection of the bile ducts
What is ascending cholangitis usually due to?
ascending infection with enteric gram-negative bacteria
What does ascending cholangitis present as?
sepsis (high fever and chills), jaundice, and abdominal pain
With what is there increased incidence of ascending cholangitis?
Increased incidence with choledocholithiasis (stone in biliary ducts)
What is gallstone ileus?
Gallstone enters and obstructs the small bowel
What is the gallstone ileus due to?
cholecystitis with fistula formation between the gallbladder and small bowel
What is gallbladder carcinoma?
Adenocarcinoma arising from the glandular epithelium that lines the gallbladder wall
What is a major risk factor for development of gallbladder carcinoma?
gallstones are a major risk factor, especially when complicated by porcelain gallbladder.
How does gallbladder carcinoma classically present?
as cholecystitis in an elderly woman
What is the prognosis for gallbladder carcinoma?
poor
What is jaundice?
Yellow discoloration of the skin; earliest sign is scleral icterus (yellow discoloration of the sclera)
What is jaundice due to?
Increased serum bilirubin, usually > 2.5 mg/dL
What does jaundice arise with?
disturbances in bilirubin metabolism
What happens to RBC?s in bilirubin metabolism?
RBCs are consumed by macrophages of the reticuloendothelial system.
What happens to the protoporphyrin after the reticuloendothelial system?
The protoporphyrin (from heme) is converted to unconjugated bilirubin (UCB)
What happens to the unconjugated bilirubin?
The albumin carries UCB to the liver
What happens to the UCB (unconjugated bilirubin) in the liver?
Uridine glucuronyl transferase (UGT) in hepatocytes conjugates bilirubin
What happens to conjugated bilirubin?
it is transferred to bile canaliculi to form bile, which is stored in the gallbladder
Where is bile released?
It is released into the small bowel to aid in digestion.
What happens to the conjugated bilirubin when it is in the intestines?
Intestinal flora convert CB to urobilinogen, which makes the stool brown.
How is conjugated bilirubin related to why urine is yellow?
Urobilinogen (which is what CB is converted into in the intestines) is also partially reabsorbed into the blood and filtered by the kidney, making the urine yellow
What is the etiology for Extravascular hemolysis or Ineffective erythropoiesis?
High levels of UCB overwhelm the conjugating ability of the liver.
What are the lab findings for extravascular hemolysis or Ineffective erythropoiesis?
Increased UCB