D/O of the Gallbladder & Exocrine Pancreas- Prof Wall & Porth, Chpt 30 Flashcards
1
Q
What does the so-called Hepatobiliary System consist of?
A
- Gallbladder
- Left & Right Hepatic Ducts
- come together & form: Common Hepatic Duct
- Cystic Duct
- Bile Duct =’s CBD + CD
2
Q
What forms the Hepatopancreatic Ampulla?
A
- Bile Duct
- Main Pancreatic Duct
- Empty into the Duodenum
3
Q
Can you palpate the Pancreas?
A
- No!
- Pretty much hiding (posterior region)
- (big issue re: pancreatic CA)
- Pretty much hiding (posterior region)
4
Q
What type of Organ is the Pancreas?
A
- Endocrine & Exocrine Organ
5
Q
What type of Organ is the Pancreas?
Exocrine Function
& Acinar Cells
A
- Exocrine =
- Acinar cells
- Secrete Digestive Enzymes* into Microscopic Ducts
- Empty into main pancreatic duct
- Secrete Digestive Enzymes* into Microscopic Ducts
-
*Digestive Enzymes:
- Proteolytic (protein)
- Amylase (carbs)
- Lipase (fat)
- Acinar cells
6
Q
What type of Organ is the Pancreas?
Exocrine Function
& Ductal Epithelial Cells
A
- Secrete
- Alkaline Solution
- Water, Electrolytes, Sodium Bicarb
- Increase pH in duodenum
- Alkaline solution = majority of what pancreas secretes
- Alkaline Solution
7
Q
What type of Organ is the Pancreas?
Endocrine Function
A
- Secretion into bloodstream
- Islets of Langerhans
- B-Cells
- Insulin syn/sec
- A-Cells
- Glucagon
- D-Cells
- Somatostatin
- Inhinits GH & TSH secretion
- Somatostatin
- B-Cells
8
Q
Pancreas…
So… what does this organ do?
A
-
Secretes
- aids in digestion, regulation of pH in intestines & blood sugar regulation
DO NOT MAKE THIS ORGAN ANGRY!!!! That would be bad.
9
Q
Gallbladder
A
Bile Storage Site
- Bile gets concentrated here
- Filled when Sphinter of Oddi closed
- Contracts to CKK
- Induces drug tolerance to opiods!
10
Q
Bile
A
- Breaks up Fats for small intestine digestion
- Secreted from Liver
- Made from:
- Bile salts
- cholesterol
- Bilirubin
- Worn out WBCs
- Alkaline Fluids
- Bile salts
11
Q
Cholecystic
A
- Referring to the Gallbladder
12
Q
Cholecystitis
A
- Inflammation of Gallbladder
- Chronic or Acute
13
Q
Cholelithiasis
A
- Stones in Gallbladder
- aka: cholecystolithiasis
14
Q
Choledocholithiasis
A
- Stone in Bile Ducts
15
Q
Cholecystectomy
A
- Removal of Gallbladder
16
Q
Cholecystalgia
A
- Pain
- aka: biliary colic
17
Q
Cholelithiasis
Gallstones!
A
- 10-15% adults get this
- 500,000 cholecystectomies/year
18
Q
Cholelithiasis
Composition
A
- Cholesterol
- Most common
- 75% of stones
- Calcium Bilirubinate/Ca Salts
- 25% of stones
- ‘pigmented’ black/brown
19
Q
Cholelithiasis
Etiology & Pathophyz
A
- Super Saturation of Cholesterol
- Diet is so important to prevention!
- Nucleation
- Microscopic cholesterol comes together & crystallizes
- Over time… more layers of cholesterol added
- GB hypo-motility
- Slower emptying = more time for stone formation
- pregnancy…
- Slower emptying = more time for stone formation
20
Q
Cholelithiasis
- The 5 F’s*
- *Risk Factors**
A
- Female
- Forty
- >40yo
- Fat
- Obesity, or rapid weight loss
- Fair
- White/pasty!
- Fertile
21
Q
Cholelithiasis
Other Risk Factors
A
- OCPs
- Preggers
- DM/Insulin Use
- Hemolysis
- Biliary Parasites
- Cirrhosis
- Crohn’s
- Hyperparathyroid Dz
22
Q
Cholelithiasis
Symptoms/Presentations
A
- Asymptomatic (50-60%)
-
Symptomatic (~40%)
- Biliary Colic
- Aching pain in RUH/Epigastric
- Referred Pain
- Back, Scapula, R. Shoulder
- Biliary Colic
23
Q
Cholelithiasis
Symptoms/Presentations
Non-Specific Symptoms
A
- Nausea
- Vomiting
- Fatty Food Intolerance
- Dyspepsia
- Heartburn
- Bloating
- Flatulance
- Belching
24
Q
Cholelithiasis
Diagnostics
A
-
ULTRASOUND!!!!!!!
- RUQ Transabdominal
- >95% sen/spec
25
**Cholelithiasis**
*Diagnostics*
**When is the Transabdominal Ultrasound NOT a good test?**
* When the stones are in the **COMMON BILE DUCT!**
* ****you just can't spot them there!
26
**Cholelithiasis**
*Treatment Options*
* Cholecystectomy - Take it out!
* Leave it in?
* Sure - Unless @ risk for complications
* Diabetes, Sickle Cell, & those @ risk for GB cancer
* Other Options:
* Dissolve Cholesterol Stones
* PO Ursodeoycholic Acid, or Chenodeoxycholic Acid
27
**Cholecystitis**
* Acute:*
* Etiology & Pathology*
* Cystic duct BLOCKED!
* Gallstones
* Less common:
* Sludge, infxn, cancer
* Gallbladder blocked -\> Distention/edema -\> Ischemia-\> RUQ Pain (esp. post-meal)
28
**Cholecystitis**
*Symptoms*
* RUQ & Epigastric pain
* Radiation: Right Shoulder/Scapula
* Nausea
* Vomiting
* Fever/Chills
29
**Cholecystitis**
*Signs*
* Tenderness
* RUQ/Epigastrium
* Murphy's sign:
* Tenderness & inspiration pause on RUQ palpation
* Jaundice
* (maybe)
30
**Cholecystitis**
* Diagnostic Options:*
* 1.* Ultrasound
* **Ultrasound\*\*\***
* ****May show:
* Gallstones
* Thickened GB walls (\>3mm)
* Pericholecystic Fluid
* Sonography Murphy's Sign
31
**Cholecystitis**
* Diagnostic Options:*
* 2. HIDA Scan*
**"The best test...BUT usually not necessary!"**
* Nuclear Med Study
* Hepatobiliary IminoDiacetic Acid Scan
* Radioactive tracer injected
* followed through liver to GB
32
**Cholecystitis**
* Diagnostic Options:*
* 3.* Plain Radiographs
* Not usually helpful
* ~25% of stones = radioopaque
* Calcium stones = radioopaque
33
**Cholecystitis**
*Lab Studies*
* CBC w/ diff
* elevated WBC (12-15K)
* Hepatic Function Tests
* LFTs:
* *sometimes* Elevated
* If REALLY elevated.. think, Liver!
* Alkaline Phosphatase
* Elevated
* GGT
* Elevated
* Bilirubin
* Elevated, esp in common duct stone
* Amylase
* Elevated (sometimes)
34
**Cholecystitis**
*Treatment*
* **Main Treatment =**
* **Take it out!!!**
* **_Cholecystectomy_**
* Leave it in?
* Maybe - if mild or unclear dx
* Drain it
* Cholecystostomy & Percutaneous Drainage
* Abx
* If fever +/- Leukocytosis
35
**Choledocholithiasis**
Stone in the Common Bile Duct
36
**Choledocholithiasis**
*Clinical Course*
* Asymptomatic (30-40%)
* Biliary Colic (painful)
* Jaundice, Pancreatitis, Colangitis
37
**Choledocholithiasis**
*Diagnosis & Treatment*
* _MRCP_
* Diagnosis only
* _ERCP_
* Diagnosis & Treatment
* _HIDA Scan_
38
**Acute Cholangitis**
Infection & Inflammation of the Biliary Tract
*Due to Obstruction, then Infection!*
LIFE THREATENING!!! (Sepsis, Shock)
39
**Acute Cholangitis**
*Differential*
Hard to differentiate from:
_Cholecystitis_
40
**Acute Cholangitis**
*Signs & Symptoms*
Charcot's Triad
* Abdominal Pain
* Jaundice
* Fever
41
**Acute Cholangitis**
*Diagnosis*
* Labs:
* CBC
* see Leukocytosis
* Hyperbilirubinemia
* Elevated/increasing
* Blood cultures x 2
42
**Acute Cholangitis**
*Treatment*
* Antibiotics
* Gram negative anaerobes, eneterococci
* Remove obstructions viaERCP
43
**Cholecystic Disorders**
Just remember...
* If it hurts... Take it out
* GB: Cholecystectomy
* CBD: ERCP
* If its infected... Antibiotic it
* Cholecystitis or Cholangitis
* If its blocked... Unblock it
* GB: - ectomy
* Choledocholithiasis: ERCP
44
**Pancreatitis**
Inflammation of the Pancreas
*Causes acinar cell injury*
45
**Pancreatitis**
*Why Does this Occur?*
* Theories:
* Obstruction of Pancreatic duct
* Stones cause this
* Pancrea divisum (developmental d/o)
* Inactive proenzymes activated too early (while in pancreas)
* Fat necrosis
* Pancreas starts to "Digest" itself
