Disorders of the Pancreaticobiliary System Flashcards
Transient cystic duct obstruction
Right upper quadrant pain or epigastric pain
Occurs 15min – 2 hours after fatty foods
Nocturnal pain is common
Abdominal exam and labs will often be normal if the patient isn’t having an attack
Biliary Colic
Gallstones is also called what?
Cholelithiasis
What is a major cause of acute cholecystitis?
Cholelithiasis
In cholelithiasis, what is the most common type of stone produced?
Cholesterol stones
What are the major risk factors for cholelithiasis?
The Four F’s:
Female
Fat
Forty
Fertile
What are some other risk factors for cholelithiasis (other than the 4 Ps) in adults?
Obesity
Diabetes
Pregnancy
Oral contraceptives
Fibric acid drugs
Prolonged fasting
Rapid weight loss
TPN
Spinal cord injuries
Hypertriglyceridemia
What are some other risk factors for for cholelithiasis (other than the 4 Ps) in children?
Cystic fibrosis
Sickle cell disease
What are some signs/symptoms of cholelithiasis?
Biliary colic: constant epigastric or RUQ abdominal pain
Can radiate to the back
Nausea/vomiting (post-prandial)
Some patients may be asymptomatic
Acute gallbladder wall inflammation (sustained obstruction of cystic duct)
Acute Cholecystitis
What are some causes of acute cholecystitis?
Gallstones (90%)
Bile stasis
Bacterial infection
Describe Acalculous cholecystitis
No gallstone present
Associated with - Major surgery
Critical illness, Burns, Trauma, TPN
Patients typically male >50 years old
Serious complications can occur
What are some signs/symptoms of acute cholecystitis?
Severe RUQ pain (intense and persistent pain) - May radiate to back
Nausea/vomiting
Abdominal tenderness
Fever
Positive murphy’s sign
Palpate and ask the patient to inhale; positive if the patient will experience pain and stop inhaling as the irritated gallbladder gets closer to the examiners fingers
Positive murphy’s sign
What is the treatment for acute cholecystitis?
Broad spectrum antibiotics
May need stent for drainage
Cholecystectomy
Supportive: IV fluids (NPO), NG tube, Analgesics
What are some complications of acute cholecystitis?
Inflammation 🡪 gangrene 🡪 rupture of gallbladder wall (leading to sepsis or peritonitis)
Localized abscess
Cholecystoenteric fistula
Persistent gallbladder wall inflammation
Low grade irritation from gallstones or recurrent attacks of cholecystitis
Chronic Cholelithiasis/Cystitis
What are some risk factors for chronic cholelithiasis/cystitis?
Obesity
diabetes
What are some complications of chronic cholelithiasis/cystitis?
Biliary sepsis
Porcelain gallbladder - Associated with a higher risk of cancer
Calcium salts are deposited within the gallbladder wall of a chronically inflamed gallbladder
Diagnosed: Xray plain films
Treatment: Cholecystectomy
Porcelain Gallbladder
Why is it so important to remove a porcelain gallbladder?
There is a high association with carcinoma of the gallbladder
Calculus in the common bile duct (may now see some pancreatic involvement)
Occurs in approximately 15% of patients with gallstones
Frequently occur in those with previous episodes of biliary colic
These stones usually originate in the gallbladder
May also form spontaneously in the common bile duct s/p cholecystectomy
Choledocholithiasis
Why are we so concerned about choledocholithiasis?
May progress to pancreatitis
What imaging for assessing for choledocholithiasis can be both diagnostic and therapeutic?
ERCP (Endoscopic retrograde cholangiopancreatography with stone removal)
Infection of the common bile duct
Bacterial infection superimposed over an obstructed biliary tree from gallstones, stricture, or neoplasm, or post ERCP
Essentially caused by anything that leads to stasis (gallstone, tumor, etc) - Stasis 🡪 bacterial growth
This can be fatal - HIGH mortality and morbidity
Acute Cholangitis
What is the pathophysiology of acute cholangitis?
Biliary tree obstruction leads to increased intraluminal pressure - Bile becomes infected - Can travel through the lymph and result in bacteremia
Charcot’s triad
RUQ quadrant pain
Jaundice
Fever (>40) with chills
(acute cholangitis)
Reynold’s Pentad
RUQ quadrant pain
Jaundice
Fever (>40) with chills
Altered mental status
hypotension
(acute cholangitis)
What are some signs/symptoms of acute cholangitis?
Charcot’s triad
Reynold’s Pentad
What is the treatment for acute cholangitis?
Hospitalization - ICU
ERCP
IV broad-spectrum antibiotics and blood cultures
Hydration/electrolyte correction
Autoimmune destruction of intrahepatic bile ducts and cholestasis
Inflammation and fibrosis leads to portal HTN then eventually cirrhosis (in 10-12 years)
Occurs primarily in middle aged women
Primary Biliary Cirrhosis
What is the gold standard for diagnosing primary biliary cirrhosis?
Liver biopsy
In primary biliary cirrhosis, what autoimmune lab is positive >95% of the time?
+ AMA
What is the treatment for primary biliary cirrhosis?
Ursodiol
Cholestyramine to decrease pruritis
Liver transplant
Diffuse and chronic inflammation and fibrosis of the biliary tree –
leads to a thick and narrowed bile duct system
Autoimmune, post infectious, vascular
Mostly young men 20-40 years old
Primary Sclerosing Cholangitis
In about 80% of the cases, the patient has ulcerative colitis as well as this condition?
Primary Sclerosing Cholangitis
What is the procedure of choice for diagnosing primary sclerosing cholangitis?
MRI – procedure of choice
Less than 2% of all malignant tumors
Increased incidence in women and elderly
Metastasize early to liver and regional lymph nodes
Poor prognosis
Biliary Tract Carcinoma
What is the most common type of biliary tract carcinoma?
Adenocarcinoma
What is the treatment for biliary tract carcinoma?
Cholecystectomy
Chemo/radiation if indicated
Rare biliary tumor
Male > female
50-70 year olds
Cholangiocarcinoma
Hilar cholangiocarcinoma that most commonly occurs at the
junction of the right and left main hepatic ducts
Klatskin tumor
What is the treatment for cholangiocarcinoma?
Improved prognosis with complete surgical resection of tumor
Typically found late 🡪 poor prognosis
Pancreatic inflammation with enzymatic release into parenchyma 🡪 enzyme activation 🡪 autodigestion of pancreas
Ranges from mild to life threatening: exocrine and endocrine functions may be impaired for lengths of time
Incidence: 1-5 individuals per 10,000 in US
Acute Pancreatitis
List some causes of acute pancreatitis
BAD SHIT:
B - Biliary tract disease (gallstones) 30-60%
A - Alcohol
D – Drugs – azathioprine, pentamide, valproate, ACE inhibitors, thiazides/diuretics, corticosteroids
S – Scorpion bites
H – hypercalcemia
I – idiopathic
T – triglycerides >500 (hypertriglyceridemia Type IV – exact cause unknown)
Trauma
Viral infection
Post ERCP
What are some signs/symptoms of acute pancreatitis?
Epigastric/LUQ pain - Radiates through to the back; steady, boring pain, increases in intensity, pain is improved/relieved by leaning forward
Nausea/vomiting
Abdominal distension
Exquisite tenderness to palpation
+/- fever
Tachycardia
Orthostasis/hypotension
Anxious, “shocky”
May have jaundice
Erythematous skin nodules from fat necrosis
Rales, atelectasis, effusions
Diminished/absent bowel sounds
Cullen’s sign
Turner’s sign
Blue discolorations to umbilicus
Cullen’s sign
Green/brown discoloration to flanks
Seen with severe, necrotizing pancreatitis
Turner’s sign
What is the gold standard imaging for acute pancreatitis?
CT abdomen (Pancreas looks boggy)
Which lab test is more specific, elevated longer, preferred test when evaluating for acute pancreatitis?
Lipase
What is the ICU admission criteria for acute pancreatitis?
Encephalopathy (altered mental status)
Hypoxemia
Tachycardia with hypotension
HCT >50 (dehydration)
Oliguria
azotemia
What guide is used in acute pancreatitis to help determine if a patient needs to be hospitalized?
Ranson’s Criteria
Ranson’s Criteria:
With three or more of the following present on admission, a severe
course complicated by pancreatic necrosis can be predicted
- age > 55 years old
- WBCs > 16,000
- blood glucose > 200mg/dL
- Serum LDH > 350 IU/L
- AST > 250 IU/L
In Ranson’s criteria, the more signs present, the greater the chance of what?
Fatal complications (mortality rates correlate with the number of criteria present)
What is the treatment for hospitalized acute pancreatitis?
ICU admission
NPO, IV fluids (“rest” the pancreas for 3-7 days)
NG tube to suction
Analgesics
Prophylactic antibiotics with necrotizing forms and aggressive support
TPN to prevent nutritional deficits
Pancreatic enzyme replacement – creon, pancrealipase
What are some complications of acute pancreatitis?
Pseudocyst – collection of fluid, tissue, and debris within or adjacent to the pancreas
Pancreatic ascites
Necrotizing pancreatitis
Hemorrhagic pancreatitis
Respiratory failure
Acute renal failure
Intra-abdominal abscess
hemorrhage
Episodes of acute inflammation in an already damaged pancreas
Pancreatic dysfunction occurs from weeks to months
Destruction of parenchyma 🡪 fibrosis and calcifications (Chronic inflammation leads to irreversible fibrosis)
Chronic Pancreatitis
List some conditions/factors chronic pancreatitis is associated with
Alcohol ingestion
Chronic pancreatic duct obstruction
Autoimmune (cystic fibrosis)
Idiopathic
Hereditary
Hyperparathyroidism
Trauma
History of acute pancreatitis
What is the most common factor associated with chronic pancreatitis?
Mainly associated with alcohol 🡪 when you see chronic, always think of alcohol
What are some signs/symptoms of chronic pancreatitis?
Steatorrhea 🡪 not breaking down fats
Recurrent episodes of epigastric and LUQ pain
Fat soluble vitamin deficiency
diabetes
How is chronic pancreatitis managed?
Abstinence from alcohol
Pain management
IV fluids/NPO
Low fat diet
Pancreatic enzyme replacement + PPI + low fat diet
Insulin
Surgical options for refractory cases: Decompression, resection, denervation procedures
In chronic pancreatitis, what could you see on ERCP to suggest the diagnosis?
“chain of lakes” – or areas of dilation and stenosis along the pancreatic duct
In chronic pancreatitis, what could you see on CT to suggest the diagnosis?
CT shows calcifications and atrophy
What are some complications of chronic pancreatitis?
Increased risk of pancreatic cancer
Chronic malabsorption syndromes
No serological evidence of viral hepatitis or history of alcohol, parenteral exposure
Elevated transaminases
+ANA
+ASMA
Autoimmune Hepatitis
How is autoimmune hepatitis confirmed?
Liver biopsy - Stage inflammation/fibrosis
What is the treatment for autoimmune hepatitis?
Combination Prednisone and immunomodulators (Azothioprine)
4th most common cause of cancer-related deaths
Pancreatic Cancer
Where are the majority of pancreatic cancer cases located on the pancreas?
75% head of pancreas
What is the major/most common type of pancreatic cancer?
> 90% are ductal adenocarcinomas
What are some risk factors for pancreatic cancer?
EtOH
Cigarette smokers (2-3x more common in heavy smokers)
Long history of DM
Chronic pancreatitis
Obesity (risk is directly related to calorie intake)
What are some signs/symptoms of pancreatic cancer?
Insidious onset (present for several months prior to diagnosis)
Weight loss/anorexia
Pain – gnawing, visceral 70% (radiates from epigastrium to back, improves with bending forward)
Painless jaundice (with tumors in the head of pancreas)
What are some methods used to diagnose pancreatic cancer?
Abdominal CT
Abdominal US
CA 19-9 – helpful tumor marker
CEA
What is the treatment for pancreatic cancer?
Surgical resection
Chemotherapy
What is the prognosis for pancreatic cancer?
Prognosis is poor - 2-5% 5 year survival
