Disorders of the Pancreaticobiliary System Flashcards by Katie Keller

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

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Gallstones is also called what?

Cholelithiasis

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What is a major cause of acute cholecystitis?

Cholelithiasis

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

Cholesterol stones

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What are the major risk factors for cholelithiasis?

The Four F’s:

Female
Fat
Forty
Fertile

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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

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

Cystic fibrosis
Sickle cell disease

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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

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Acute gallbladder wall inflammation (sustained obstruction of cystic duct)

Acute Cholecystitis

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What are some causes of acute cholecystitis?

Gallstones (90%)
Bile stasis
Bacterial infection

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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

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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

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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

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What is the treatment for acute cholecystitis?

Broad spectrum antibiotics

May need stent for drainage

Cholecystectomy

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

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What are some complications of acute cholecystitis?

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

Localized abscess

Cholecystoenteric fistula

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Persistent gallbladder wall inflammation

Low grade irritation from gallstones or recurrent attacks of cholecystitis

Chronic Cholelithiasis/Cystitis

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What are some risk factors for chronic cholelithiasis/cystitis?

Obesity
diabetes

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What are some complications of chronic cholelithiasis/cystitis?

Biliary sepsis

Porcelain gallbladder - Associated with a higher risk of cancer

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

Diagnosed: Xray plain films

Treatment: Cholecystectomy

Porcelain Gallbladder

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Why is it so important to remove a porcelain gallbladder?

There is a high association with carcinoma of the gallbladder

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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

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Why are we so concerned about choledocholithiasis?

May progress to pancreatitis

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

ERCP (Endoscopic retrograde cholangiopancreatography with stone removal)

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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

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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

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

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