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Gastroenterology > Disorders of the Pancreaticobiliary System > Flashcards

Disorders of the Pancreaticobiliary System Flashcards

1
Q

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

A

Biliary Colic

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2
Q

Gallstones is also called what?

A

Cholelithiasis

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3
Q

What is a major cause of acute cholecystitis?

A

Cholelithiasis

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4
Q

In cholelithiasis, what is the most common type of stone produced?

A

Cholesterol stones

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5
Q

What are the major risk factors for cholelithiasis?

A

The Four F’s:

Female
Fat
Forty
Fertile

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6
Q

What are some other risk factors for cholelithiasis (other than the 4 Ps) in adults?

A

Obesity
Diabetes
Pregnancy
Oral contraceptives
Fibric acid drugs
Prolonged fasting
Rapid weight loss
TPN
Spinal cord injuries
Hypertriglyceridemia

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7
Q

What are some other risk factors for for cholelithiasis (other than the 4 Ps) in children?

A

Cystic fibrosis
Sickle cell disease

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8
Q

What are some signs/symptoms of cholelithiasis?

A

Biliary colic: constant epigastric or RUQ abdominal pain

Can radiate to the back

Nausea/vomiting (post-prandial)

Some patients may be asymptomatic

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9
Q

Acute gallbladder wall inflammation (sustained obstruction of cystic duct)

A

Acute Cholecystitis

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10
Q

What are some causes of acute cholecystitis?

A

Gallstones (90%)
Bile stasis
Bacterial infection

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11
Q

Describe Acalculous cholecystitis

A

No gallstone present

Associated with - Major surgery

Critical illness, Burns, Trauma, TPN

Patients typically male >50 years old

Serious complications can occur

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12
Q

What are some signs/symptoms of acute cholecystitis?

A

Severe RUQ pain (intense and persistent pain) - May radiate to back

Nausea/vomiting

Abdominal tenderness

Fever

Positive murphy’s sign

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13
Q

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

A

Positive murphy’s sign

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14
Q

What is the treatment for acute cholecystitis?

A

Broad spectrum antibiotics

May need stent for drainage

Cholecystectomy

Supportive: IV fluids (NPO), NG tube, Analgesics

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15
Q

What are some complications of acute cholecystitis?

A

Inflammation 🡪 gangrene 🡪 rupture of gallbladder wall (leading to sepsis or peritonitis)

Localized abscess

Cholecystoenteric fistula

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16
Q

Persistent gallbladder wall inflammation

Low grade irritation from gallstones or recurrent attacks of cholecystitis

A

Chronic Cholelithiasis/Cystitis

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17
Q

What are some risk factors for chronic cholelithiasis/cystitis?

A

Obesity
diabetes

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18
Q

What are some complications of chronic cholelithiasis/cystitis?

A

Biliary sepsis

Porcelain gallbladder - Associated with a higher risk of cancer

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19
Q

Calcium salts are deposited within the gallbladder wall of a chronically inflamed gallbladder

Diagnosed: Xray plain films

Treatment: Cholecystectomy

A

Porcelain Gallbladder

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20
Q

Why is it so important to remove a porcelain gallbladder?

A

There is a high association with carcinoma of the gallbladder

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21
Q

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

A

Choledocholithiasis

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22
Q

Why are we so concerned about choledocholithiasis?

A

May progress to pancreatitis

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23
Q

What imaging for assessing for choledocholithiasis can be both diagnostic and therapeutic?

A

ERCP (Endoscopic retrograde cholangiopancreatography with stone removal)

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24
Q

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

A

Acute Cholangitis

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25
Q

What is the pathophysiology of acute cholangitis?

A

Biliary tree obstruction leads to increased intraluminal pressure - Bile becomes infected - Can travel through the lymph and result in bacteremia

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26
Q

Charcot’s triad

A

RUQ quadrant pain
Jaundice
Fever (>40) with chills

(acute cholangitis)

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27
Q

Reynold’s Pentad

A

RUQ quadrant pain
Jaundice
Fever (>40) with chills
Altered mental status
hypotension

(acute cholangitis)

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28
Q

What are some signs/symptoms of acute cholangitis?

A

Charcot’s triad
Reynold’s Pentad

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29
Q

What is the treatment for acute cholangitis?

A

Hospitalization - ICU

ERCP

IV broad-spectrum antibiotics and blood cultures

Hydration/electrolyte correction

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30
Q

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

A

Primary Biliary Cirrhosis

31
Q

What is the gold standard for diagnosing primary biliary cirrhosis?

A

Liver biopsy

32
Q

In primary biliary cirrhosis, what autoimmune lab is positive >95% of the time?

A

+ AMA

33
Q

What is the treatment for primary biliary cirrhosis?

A

Ursodiol

Cholestyramine to decrease pruritis

Liver transplant

34
Q

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

A

Primary Sclerosing Cholangitis

35
Q

In about 80% of the cases, the patient has ulcerative colitis as well as this condition?

A

Primary Sclerosing Cholangitis

36
Q

What is the procedure of choice for diagnosing primary sclerosing cholangitis?

A

MRI – procedure of choice

37
Q

Less than 2% of all malignant tumors

Increased incidence in women and elderly

Metastasize early to liver and regional lymph nodes

Poor prognosis

A

Biliary Tract Carcinoma

38
Q

What is the most common type of biliary tract carcinoma?

A

Adenocarcinoma

39
Q

What is the treatment for biliary tract carcinoma?

A

Cholecystectomy

Chemo/radiation if indicated

40
Q

Rare biliary tumor

Male > female

50-70 year olds

A

Cholangiocarcinoma

41
Q

Hilar cholangiocarcinoma that most commonly occurs at the
junction of the right and left main hepatic ducts

A

Klatskin tumor

42
Q

What is the treatment for cholangiocarcinoma?

A

Improved prognosis with complete surgical resection of tumor

Typically found late 🡪 poor prognosis

43
Q

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

A

Acute Pancreatitis

44
Q

List some causes of acute pancreatitis

A

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

45
Q

What are some signs/symptoms of acute pancreatitis?

A

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

46
Q

Blue discolorations to umbilicus

A

Cullen’s sign

47
Q

Green/brown discoloration to flanks

Seen with severe, necrotizing pancreatitis

A

Turner’s sign

48
Q

What is the gold standard imaging for acute pancreatitis?

A

CT abdomen (Pancreas looks boggy)

49
Q

Which lab test is more specific, elevated longer, preferred test when evaluating for acute pancreatitis?

A

Lipase

50
Q

What is the ICU admission criteria for acute pancreatitis?

A

Encephalopathy (altered mental status)
Hypoxemia
Tachycardia with hypotension
HCT >50 (dehydration)
Oliguria
azotemia

51
Q

What guide is used in acute pancreatitis to help determine if a patient needs to be hospitalized?

A

Ranson’s Criteria

52
Q

Ranson’s Criteria:

With three or more of the following present on admission, a severe
course complicated by pancreatic necrosis can be predicted

A
  1. age > 55 years old
  2. WBCs > 16,000
  3. blood glucose > 200mg/dL
  4. Serum LDH > 350 IU/L
  5. AST > 250 IU/L
53
Q

In Ranson’s criteria, the more signs present, the greater the chance of what?

A

Fatal complications (mortality rates correlate with the number of criteria present)

54
Q

What is the treatment for hospitalized acute pancreatitis?

A

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

55
Q

What are some complications of acute pancreatitis?

A

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

56
Q

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)

A

Chronic Pancreatitis

57
Q

List some conditions/factors chronic pancreatitis is associated with

A

Alcohol ingestion
Chronic pancreatic duct obstruction
Autoimmune (cystic fibrosis)
Idiopathic
Hereditary
Hyperparathyroidism
Trauma
History of acute pancreatitis

58
Q

What is the most common factor associated with chronic pancreatitis?

A

Mainly associated with alcohol 🡪 when you see chronic, always think of alcohol

59
Q

What are some signs/symptoms of chronic pancreatitis?

A

Steatorrhea 🡪 not breaking down fats
Recurrent episodes of epigastric and LUQ pain
Fat soluble vitamin deficiency
diabetes

60
Q

How is chronic pancreatitis managed?

A

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

61
Q

In chronic pancreatitis, what could you see on ERCP to suggest the diagnosis?

A

“chain of lakes” – or areas of dilation and stenosis along the pancreatic duct

62
Q

In chronic pancreatitis, what could you see on CT to suggest the diagnosis?

A

CT shows calcifications and atrophy

63
Q

What are some complications of chronic pancreatitis?

A

Increased risk of pancreatic cancer

Chronic malabsorption syndromes

64
Q

No serological evidence of viral hepatitis or history of alcohol, parenteral exposure

Elevated transaminases

+ANA

+ASMA

A

Autoimmune Hepatitis

65
Q

How is autoimmune hepatitis confirmed?

A

Liver biopsy - Stage inflammation/fibrosis

66
Q

What is the treatment for autoimmune hepatitis?

A

Combination Prednisone and immunomodulators (Azothioprine)

67
Q

4th most common cause of cancer-related deaths

A

Pancreatic Cancer

68
Q

Where are the majority of pancreatic cancer cases located on the pancreas?

A

75% head of pancreas

69
Q

What is the major/most common type of pancreatic cancer?

A

> 90% are ductal adenocarcinomas

70
Q

What are some risk factors for pancreatic cancer?

A

EtOH
Cigarette smokers (2-3x more common in heavy smokers)
Long history of DM
Chronic pancreatitis
Obesity (risk is directly related to calorie intake)

71
Q

What are some signs/symptoms of pancreatic cancer?

A

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)

72
Q

What are some methods used to diagnose pancreatic cancer?

A

Abdominal CT
Abdominal US
CA 19-9 – helpful tumor marker
CEA

73
Q

What is the treatment for pancreatic cancer?

A

Surgical resection

Chemotherapy

74
Q

What is the prognosis for pancreatic cancer?

A

Prognosis is poor - 2-5% 5 year survival

Gastroenterology (9 decks)

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