D/O of the Gallbladder & Exocrine Pancreas- Prof Wall & Porth, Chpt 30 Flashcards
What does the so-called Hepatobiliary System consist of?
- Gallbladder
- Left & Right Hepatic Ducts
- come together & form: Common Hepatic Duct
- Cystic Duct
- Bile Duct =’s CBD + CD
What forms the Hepatopancreatic Ampulla?
- Bile Duct
- Main Pancreatic Duct
- Empty into the Duodenum
Can you palpate the Pancreas?
- No!
- Pretty much hiding (posterior region)
- (big issue re: pancreatic CA)
- Pretty much hiding (posterior region)
What type of Organ is the Pancreas?
- Endocrine & Exocrine Organ
What type of Organ is the Pancreas?
Exocrine Function
& Acinar Cells
- 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
What type of Organ is the Pancreas?
Exocrine Function
& Ductal Epithelial Cells
- Secrete
- Alkaline Solution
- Water, Electrolytes, Sodium Bicarb
- Increase pH in duodenum
- Alkaline solution = majority of what pancreas secretes
- Alkaline Solution
What type of Organ is the Pancreas?
Endocrine Function
- Secretion into bloodstream
- Islets of Langerhans
- B-Cells
- Insulin syn/sec
- A-Cells
- Glucagon
- D-Cells
- Somatostatin
- Inhinits GH & TSH secretion
- Somatostatin
- B-Cells
Pancreas…
So… what does this organ do?
-
Secretes
- aids in digestion, regulation of pH in intestines & blood sugar regulation
DO NOT MAKE THIS ORGAN ANGRY!!!! That would be bad.
Gallbladder
Bile Storage Site
- Bile gets concentrated here
- Filled when Sphinter of Oddi closed
- Contracts to CKK
- Induces drug tolerance to opiods!
Bile
- Breaks up Fats for small intestine digestion
- Secreted from Liver
- Made from:
- Bile salts
- cholesterol
- Bilirubin
- Worn out WBCs
- Alkaline Fluids
- Bile salts
Cholecystic
- Referring to the Gallbladder
Cholecystitis
- Inflammation of Gallbladder
- Chronic or Acute
Cholelithiasis
- Stones in Gallbladder
- aka: cholecystolithiasis
Choledocholithiasis
- Stone in Bile Ducts
Cholecystectomy
- Removal of Gallbladder
Cholecystalgia
- Pain
- aka: biliary colic
Cholelithiasis
Gallstones!
- 10-15% adults get this
- 500,000 cholecystectomies/year
Cholelithiasis
Composition
- Cholesterol
- Most common
- 75% of stones
- Calcium Bilirubinate/Ca Salts
- 25% of stones
- ‘pigmented’ black/brown
Cholelithiasis
Etiology & Pathophyz
- 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
Cholelithiasis
- The 5 F’s*
- *Risk Factors**
- Female
- Forty
- >40yo
- Fat
- Obesity, or rapid weight loss
- Fair
- White/pasty!
- Fertile
Cholelithiasis
Other Risk Factors
- OCPs
- Preggers
- DM/Insulin Use
- Hemolysis
- Biliary Parasites
- Cirrhosis
- Crohn’s
- Hyperparathyroid Dz
Cholelithiasis
Symptoms/Presentations
- Asymptomatic (50-60%)
-
Symptomatic (~40%)
- Biliary Colic
- Aching pain in RUH/Epigastric
- Referred Pain
- Back, Scapula, R. Shoulder
- Biliary Colic
Cholelithiasis
Symptoms/Presentations
Non-Specific Symptoms
- Nausea
- Vomiting
- Fatty Food Intolerance
- Dyspepsia
- Heartburn
- Bloating
- Flatulance
- Belching
Cholelithiasis
Diagnostics
-
ULTRASOUND!!!!!!!
- RUQ Transabdominal
- >95% sen/spec
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!
Cholelithiasis
Treatment Options
- Cholecystectomy - Take it out!
- Leave it in?
- Sure - Unless @ risk for complications
- Diabetes, Sickle Cell, & those @ risk for GB cancer
- Sure - Unless @ risk for complications
- Other Options:
- Dissolve Cholesterol Stones
- PO Ursodeoycholic Acid, or Chenodeoxycholic Acid
- Dissolve Cholesterol Stones
Cholecystitis
- Acute:*
- Etiology & Pathology*
- Cystic duct BLOCKED!
- Gallstones
- Less common:
- Sludge, infxn, cancer
- Gallbladder blocked -> Distention/edema -> Ischemia-> RUQ Pain (esp. post-meal)
Cholecystitis
Symptoms
- RUQ & Epigastric pain
- Radiation: Right Shoulder/Scapula
- Nausea
- Vomiting
- Fever/Chills
Cholecystitis
Signs
- Tenderness
- RUQ/Epigastrium
- Murphy’s sign:
- Tenderness & inspiration pause on RUQ palpation
- Jaundice
- (maybe)
Cholecystitis
- Diagnostic Options:*
- 1.* Ultrasound
-
Ultrasound***
-
May show:
- Gallstones
- Thickened GB walls (>3mm)
- Pericholecystic Fluid
- Sonography Murphy’s Sign
-
May show:
Cholecystitis
- Diagnostic Options:*
- HIDA Scan*
“The best test…BUT usually not necessary!”
- Nuclear Med Study
- Hepatobiliary IminoDiacetic Acid Scan
- Radioactive tracer injected
- followed through liver to GB
Cholecystitis
- Diagnostic Options:*
- 3.* Plain Radiographs
- Not usually helpful
- ~25% of stones = radioopaque
- Calcium stones = radioopaque
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
- LFTs:
- Amylase
- Elevated (sometimes)
Cholecystitis
Treatment
-
Main Treatment =
-
Take it out!!!
- Cholecystectomy
-
Take it out!!!
- Leave it in?
- Maybe - if mild or unclear dx
- Drain it
- Cholecystostomy & Percutaneous Drainage
- Abx
- If fever +/- Leukocytosis
Choledocholithiasis
Stone in the Common Bile Duct
Choledocholithiasis
Clinical Course
- Asymptomatic (30-40%)
- Biliary Colic (painful)
- Jaundice, Pancreatitis, Colangitis
Choledocholithiasis
Diagnosis & Treatment
-
MRCP
- Diagnosis only
-
ERCP
- Diagnosis & Treatment
- HIDA Scan
Acute Cholangitis
Infection & Inflammation of the Biliary Tract
Due to Obstruction, then Infection!
LIFE THREATENING!!! (Sepsis, Shock)
Acute Cholangitis
Differential
Hard to differentiate from:
Cholecystitis
Acute Cholangitis
Signs & Symptoms
Charcot’s Triad
- Abdominal Pain
- Jaundice
- Fever
Acute Cholangitis
Diagnosis
- Labs:
- CBC
- see Leukocytosis
- Hyperbilirubinemia
- Elevated/increasing
- Blood cultures x 2
- CBC
Acute Cholangitis
Treatment
- Antibiotics
- Gram negative anaerobes, eneterococci
- Remove obstructions viaERCP
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
Pancreatitis
Inflammation of the Pancreas
Causes acinar cell injury
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
- Fat necrosis
- Inactive proenzymes activated too early (while in pancreas)
- Obstruction of Pancreatic duct
