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Gall bladder and Pancreas Flashcards

1
Q

What is cholelithiasis

A

Gallstones, which are hard stone-like or gravel-like material found within the biliary system, most often in the gall bladder.

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2
Q

What is cholecystectomy

A

Surgical removal of the gallbladder

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3
Q

Constituents of normal bile

A

Cholesterol, phospholipids, bile salts and bilirubin

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4
Q

Structure of bile

A

Hydrophobic cholesterol aggregate in the middle with hydrophilic bile salts on the periphery and bilirubin scattered throughout.

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5
Q

Pathogenesis of cholesterol gallstones

A

Gallstones form where there is an imbalance between the ratio of cholesterol to bile salts. Micelle formation is disrupted causing free crystallization of cholesterol on micelle surface

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6
Q

Pathogenesis of bilirubin gallstones

A

Excess bilirubin can’t be solubilised in bile salts causing it to aggregate. This excess bilirubin is due to excess haemolysis

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7
Q

Treatment for pigment gallstones

A

Surgery

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8
Q

Are gallstones purely cholesterol or bilirubin based

A

No, they often occur in mixtures

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9
Q

Aetiology of gallstones

A

Gallbladder pH, mucosal glycoproteins

Infection and inflammation biliary lining

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10
Q

What is cholecystitis

A

Inflammation of the gallbladder

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11
Q

Acute cholecystitis common cause

A

Gallstone obstruct flow of bile - Initial sterile - Becomes infected - May cause empyema, rupture or peritonitis - Intense adhesions within 2-3 days

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12
Q

Development of chronic cholecystitis

A

Associated with gallstones, usually develops after bouts of acute cholecystitis. The gallbladder is thickened due to fibrosis but not distended

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13
Q

Chronic cholecystitis can cause inflammation leading to pockets in the wall of gallbladder known as

A

Rokitansky-Aschoff sinuses. They are outpouchings of gallbladder mucosa into the gallbladder muscle layer and subserosal tissue as a result of hyperplasia and herniation of epithelial cells through the fibromuscular layer.

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14
Q

What causes Rokitansky-Aschoff sinuses

A

Increase pressure and recurrent damage to the wall of gallbladder

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15
Q

Carcinoma of gallbladder is what type

A

Adenocarcinoma

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16
Q

What is cholangiocarcinoma

A

Cancer of the bile ducts, presents with obstructive jaundice

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17
Q

What type of cancer is cholangiocarcinoma

A

Adenocarcinoma

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18
Q

Cholangiocarcinoma is associated with what other diseases

A

Ulcerative colitis and Primary sclerosing cholangitis

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19
Q

Why does pancreas present with back pain

A

Pancreas is very posterior and has a dermatome at the upper half of the back

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20
Q

What is pancreatitis

A

Inflammation of the pancreas

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21
Q

What is elevated in acute pancreatitis

A

Serum amylase, patient’s in severe abdominal pain

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22
Q

Pathogenesis of acute pancreatitis

A

Blockage of bile duct via gallstones damages the Sphincter of Oddi causing pancreatic duct epithelial injury.
Autodigestion of pancreatic acinar cells due to loss of protective barrier
The release of lytic enzymes from pancreas causes -
Lipase: Intra and peripancreatic fat necrosis
Protease: Tissue destruction and haemorrhage

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23
Q

What is a pancreatic pseudocyst

A

A circumscribed collection of fluid rich in pancreatic enzymes, blood and necrotic tissue. It is a complication of pancreatitis and is prone to infection, haemorrhage, rupture and obstruction

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24
Q

What is chronic pancreatitis

A

Repeat bouts of acute pancreatitis may lead to chronic pancreatitis which is very fatal. Pancreatic tissue is replaced by chronic inflammation and scar tissue. This destroys exocrine acinar cells and endocrine Islets of Langerhaan

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25
Why is resection of pancreatic tumours hard
The pancreas is closely associated with the duodenum and hence this has to be resected together. It is an endocrine organ that affects the body functions along with endocrine roles in digestion
26
Pancreatic carcinoma is of what type
Adenocarcinoma
27
Pancreatic adenocarcinoma normally spreads to
Duodenum, stomach and spleen. Haematogenous spread to the liver and lymph nodes
28
Risk factors for gallstones
``` Female Fair Fertile - Had previous children Fat - High BMI > 30, hyperlipidaemia Forty - Age > 40 or Familial ```
29
What is biliary colic
Gallstone/bladder attack, when a gallstone temporarily blocks the bile duct.
30
Symptoms of biliary colic
Gradual build-up of pain in RUQ. Radiates to back/shoulder. May last 2-6 hours and associated with indigestion and/or nausea
31
What is the hartmann's pouch
A spheroid or conical pouch at the junction of neck of gallbladder and cystic uct. Gallstones can often be found here.
32
FIrst line investigation for gallstones
Ultrasound, it's cost effective, no radiation and diagnostic
33
CT scans and cholelithiasis
CT scan's aren't very useful if looking for gall stones, but can be used to deal with it's complications such as finding a tumour or a perforation
34
Treatment for acute cholecystitis
IV antibiotics and fluids, analgesics Abdominal US, FBC, CRP, Serum Amylase Monitor - BP, urine, pulse Surgical assessment for cholecystectomy
35
Complications of gallstones
``` Gallstone may travel to common bile duct causing - Jaundice Cholangitis Acute pancreatitis Gallstone ileus ```
36
What is gallstone ileus
Presence of a large gallstone (> 2.5cm in diameter) predisposes to cholecysto-enteric fistula formation by gradual erosion through the gallbladder fundus. This gallstone can travel into the bowel and get lodged along the GI tract
37
Follow up on ultrasound showing bile duct dilation with gallstones present
ERCP - Endoscopic retrograde cholangiopancreatography to clear duct or establish drainage
38
Follow up on US showing no bile duct dilation but gallstones suspected
MRCP - Magnetic resonance cholangiopanreatography to provide further diagnostic information on position or absence of gallstone.
39
Cause of acute pancreatitis
Alcohol, gallstones
40
Treatment for acute pancreatitis
Laparoscopic cholecystectomy or ERCP if frail
41
Treatment for gallstone ileus
Urgent laparotomy to remove stones | Interval cholecystectomy within 3 months
42
Cholangiocarcinoma treatment
Resection of liver and gallbladder due to high nodal metastases
43
Palliation of cholangiocarcinoma
Biliary stent, survivial 1 - 6 months
44
What arteries supply the pancreas
Ant. and post. sup. pancreaticoduodenal artery from coeliac trunk Ant. and post. inf. pancreaticoduodenal artery from SMA Dorsal pancreatic artery Transverse pancreatic artery
45
Venous drain of pancreas
Via splenic vein to the portal vein
46
Endocrine and exocrine cells of pancreas
Exocrine - Acinar cells | Endocrine - Islents of Langerhans
47
Pancreatic fluid secretion is regulated by
Vagus nerve and gastrin levels
48
What do acinar cells secrete
Protease, pancreatic lipase/amylase and other enzymes such as ribonuclease, deoxyribonuclease, gelatinase and elastase
49
Management of most cases of acute pancreatitis
80% by analgesics and IV fluids
50
Aetiology of acute pancreatitis
``` I GET SMASHED Idiopathic - 20% of cases Gallstones - 65% of cases Ethanol - >80mg ETOH/day Trauma Steroids Mumps and other infections coxsackie B and viral hep Autoimmune - IgG4 related disease Scorpion bite Hypercalcaemia, hyperparathyroidism, hyperlipidaemia ERCP - 30% of cases Drugs - Azathioprine ```
51
Pathophysiology of acute pancreatitis
Bile reflux theory - Obstruction of common bile duct leads to reflux of bile into pancreas Hyperstimulation of pancreatic acinar cells with CCK
52
Presentation of acute pancreatitis
``` Acute onset epigastric pain Radiating to the back Very severe Nausea + Vomiting Jaundice Might have trigger such as ERCP/gallstone ```
53
Examination of acute pancreatitis
``` Diffuse upper abdominal tenderness Soft Normal bowel sound Fullness in epigastrium - Pseudocyst Severe -Widespread gauarding and absent BS, presents like peritonitis ```
54
Classical signs visible in acute pancreatitis
Erythema abigne Cullen's sign Grey-Turner's sign
55
Investigations for acute pancreatitis
IV access Bloods - FCB, coagulation, U&E, LFT, CRP, lactate ABG Chest x-ray: Pleural effusion Abdominal x-ray: Sentinel loop, dilated terminal ileum close to the pancreas
56
CRP limit that points to acute pancreatitis
CRP > 150 requires urgent CT scan within 24 hours as it points to acute pancreatitis
57
First line diagnostic investigation for acute pancreatitis
Ultrasound scan -
58
US sign for gallstones
Absence of echoes posterior to calculi "shadowing"
59
CT scan in acute pancreatitis
Assess severity day 5 form onset of symptoms As follow up Potential intervention Look for complications
60
Complications of acute pancreatitis
``` Fluid collection Pancreatic/peripancreatic necrosis Ascites Bleeding Abscess ```
61
Is ERCp diagnostic in acute pancreatitis
No, used for treatment of CBD obstruction with gallstones
62
Prognostic tool for acute pancreatitis
``` Glasgow criteria PaO2 < 8kPa (60mmHg) Age > 55 Neutrophilic WBC > 15 * 10-9/l Calcium < 2 mmol//L Renal function (Urea > 16mmol/L) Enzymes (AST/ALT > 200or LDH > 600) Albumin < 32 g/L Sugar (Glucose > 10mmol/L) Score of 3 or more is severe pancreatitis ```
63
Management of acute pancreatitis
``` Conservative at first Electrolyte correction Fluid resusitation Oxygen Antibiotics and nutrition if needed Index admission laparoscopic cholecystectomy ```
64
Treatment of pancreatic pseudocyst
Nothing, endoscopic drainage if symptomatic | Can perform cystogastrotomy
65
Now can pancreatic necrosis be assessed
Via CT scan | Fine needle aspiration for microbiology sample
66
Presentation of chronic pancreatitis
Very similiar to acute pancreatitis Alcohol history, smoker, medication Masses/ascites/jaundice on examination
67
Investigating chronic pancreatitis
US, CT scan, CXR/AXR, MRI, ERCP
68
Aetiology of chronic pancreatitis
``` Alcohol Idiopathic PD obstruction Autoimmune Tropical countries due to deficiency in methionine, Zinc and Selenium Hereditary - CFand alpha-1-antitrypsin ```
69
Management of chronic pancreatitis
``` Manage acute episodes Creon as enzyme replacement Surgery - Pustow procedure Frey procedure ```
70
Complication of chronic pancreatitis
``` Splenic vein thrombosis Pseudoaneurysm of splenic vein Pleural effusion Ascites Pancreatic cancer Pseudocysts Biliary or duodenal obstruction ```
71
Types of pancreatic endocrine cancers
Gastrinoma, insulinoma and glucagonoma
72
Symptoms of pancreatic tumour
Weight loss Back pain Jaundice (painless loose pale stools, steatorrhoea) Dark urine
73
Investigating pancreatic tumours
US CT scan MRI and MRCP
74
Management of inoperable cases of pancreatic tumour
ERCP or PTC and stent insertion | Decompression of obstructed bile ducts
75
Management of operable cases of pancreatic tumour
Laparoscopy and staging ERCP stent Resection or palliative bypass

GI (32 decks)

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