Gallbladder/Pancreatic Lecture Flashcards
Bile storage site
Concentrates bile
Contracts in response to cholecystokinin (CCK)
Filled when spincter or Oddi is closed
Gallbladder
Helps break up fats (for digestion in sm intestine, terminal ileum
and recycled to liver for re-excretion)
500-1500 mL secreted from liver each day!
Bile
Made up of:
- Bile salts (from cholesterol)
- Bilirubin (waste product from old worn out RBCs)
- Alkaline fluid
Bile
Cholecystic
Referring to gallbladder
Cholecystectomy
Removal of gallbladder
Cholecystalgia
Pain from gall bladder (aka biliary colic)
Acute cholecystitis
Inflammation (can be chronic)
What percentage of gallstones are cholesterol?
What percentage are calcium bilirubinate/ Ca salts?
Cholesterol 75%
Calcium 25%
“Pigmented” black/brown stones
Calcium bilirubiante stones
- Cholesterol supersaturation (bile gets supersaturated with cholesterol)
- Nucleation (Microscopic cholesterol comes together and crystallizes. Over time, additional layers of cholesterol added on)
- Gallbladder hypomotility (Slower emptying=more time for stone formation, ie pregnancy)
Causes of gallstones
Age (traditionally, over 40y/o)
Obesity (or rapid weight loss)
Sex: Female
Race (example: Native Americans)
(Female, Fat, Forty, Fair, and Fertile)
Risk factors for stones
Cholelithiasis
Stones in GB
Choledocholithiasis
Stone in bile duct
Oral contraceptives, Pregnancy, Diabetes/Insulin use, Hemolysis, Biliary parasites, Cirrhosis, Crohn’s, Hyperparathyroid Dz.
Contributing factors for gallstones
What % of ppl have gallstones and are asymptomatic
50-60% (most are never symptomatic)
Biliary colic (aching pain in the RUQ/epigastric)
Referred pain: to back, scapula, or R shoulder area
Symptoms of cholelithiasis
Best diagnostic (especially initial) for cholelithiasis
Ultrasound (95%)
Cystic ducts become blocked due to:
- gallstones
- sludge, infection cancer (less common)
Acute cholecystitis
Gallbladder blockage –> distention/edema –> ischemia
..this causes?
RUQ pain
RUQ and epigastric pain
R scapula/shoulder pain
N/V
Fever/Chills
Acute cholecystitis symptoms
Tenderness RUQ/epigastric area
+ Murphy’s sign
Possibe jaundice (late sign)
Acute cholestitits
Are plain radiographs good diagnostic images of gallstones?
NO..can only see about 25% (Ca containing stones are only about 25%)
Hepatobiliary IminoDiacetic Acid Scan
Radioactive tracer injected, followed thru liverGB
Best test, but usually not necessary
HIDA scan
..expensive! only use if odd presentation
CBC w/ diff:
Elevated WBC count (leukocytosis) 12-15k
Hepatic function tests:
LFT’s: elevated, sometimes
Alkaline phosphatase: usually elevated (at least a little)
Gamma-glutamyl transpeptidase (GGT): elevated
Bilirubin: elevated, especially in common duct stone
Amylase: elevated, sometimes
Labs in acute cholecystitis
Stone in common bile duct
- usually migrates from gallbladder
- less common: form in GBD
Choledocholithiasis
Can be asymptomatic (30-40%)
Biliary colic
Jaundice, pancreatitis, maybe cholangitis
ERCP (endoscopic retrograde cholangiopancreatography) can be used to DIAGNOSE and TREAT
Choledocholithiasis
Contraindication of ERCP?
Pancreatitis
ERCP is diagnosis and treatment ONLY if the stone is..
in common bile duct
(Choledocholithiasis)
Infection and inflammation of biliary tract
Due to obstruction, then infection
(retrograde infection: E.coli, Enterococcus, Klebsiella and Enterobactor)
Acute cholangitis
Potentially life threatning- can lead to sepsis/shock
Most often caused by choledocholithiasis
Signs/symptoms: RUQ pain, jaundice, fever (**Charcot’s triad)
Acute cholangitis
- Abdominal pain (RUQ)
- Jaundice
- Fever
Charcot’s triad
(pathognomonic for Acute Cholangitis)
How many blood cultures do you need for Acute Cholangitis?
TWO! different locations
Labs:
CBC: leukocytosis
Hyperbilirubinemia
Alkaline Phosphatase: elevated / increasing
Blood cultures X 2
Tx:
Abx (to cover for gm negs, anaerobes, enterococci)
Removal of obstruction via ERCP
Acute cholangitis
sits in retroperitoneum
Head near duodenum
Tail posterior to stomach, near spleen
During development two ‘buds’ get together and fuse
Pancreas
2 portions of Pancreas
Exocrine and Endocrine portions
Ducts –> duodenum
Acinar cells (95% of pancreas)
Lipase
Ductal epithelial cells
Part of exocrine portion or pancreas
Secretes:
- Proteolytic enzymes (trypsinogen, chymotrypsinogen, procarboxypeptidase)..protein digestion
- Amylase…carbohydrate digestion
- Lipase…fat digestion (more sensitive on test)
Acinar cells (make up 95% of pancreas)
Fat digestion is done by…
Lipase
Amylase digests…
Carbohydrates
Secretes:
Alkaline solution- water, electrolyes, sodium bicarb (NaHCO3)
- majority of what pancreas secretes
- 1-2 L a day
Ductal epithelial cells
Where does the exocrine portion of the pancreas empty into?
Duodenum
Where does the endocrine portion of the pancreas empty into?
Bloodstream
Secretion –> bloodstream
Consists of:
Islets of Langerhans (1-2%)
Beta-Cells
Alpha Cells
Delta Cells
Endocrine portion of the pancreas
These cells are responsible for insulin synthesis/secretion
Beta cells
These cells produce glucagon
Alpha cells
These cells produce somatostatin, serves to inhibit several processes including GH and TSH secretion
Delta cells
- Digestion
- regulation of pH in intestines
- blood sugar regulation
Role of pancreatic secretions
Pancreatitis usually results in _______ cell injury
Acinar
(can be acute or chronic)
Can be related to an obstruction of the pancreatic duct (due to several different things, including stones & failure of the 2 parts of the pancreas to fully join during development: “pancreas divisum”)- 5-10% pop.
Pancreatitis
The inactive proenzymes (like Trypsinogen) are activated early, while still in pancreas
Fat necrosis
Pancreatic enzymes digest itself
Possible causes of pancreatitis
Gallstones (45%)
Alcohol (35%)
Together they make up about 80%
Idiopathic
MC: cholelithiasis or alcohol abuse
Causes of acute pancreatitis
Trauma (ie MVA)
Drugs
Infections (mumps, EBV, CMV, HIV)
Peptic ulcer disease
Metabolic issues (hyperlipid, hyperCa)
Toxins (methyl alcohol)
Scorpion stings
Autoimmune
ERCP
Other causes of pancreatitis
Valproic acid
Tetracycline
Metronidazole
Furosemide
Nitrofurantoin
Estrogens
Thiazides
Drugs that can cause pancreatitis
If a gallstone is blocking the common bile duct and the pancreatic duct, what might happen?
Acute pancreatitis
Upper abdominal pain/epigastric pain..may radiate to back
Rapid onset
Worse supine
Better leaning forward
N/V
Fever, chills
Acute pancreatitis
PE: most tender epigastric
maybe distention, guarding
vitals: tachycardic, fever
Acute pancreatitis
If gallstone is obstructing common bile duct in acute pancreatitis, what might develop?
Jaundice
- Cullen’s sign= periumbilical ecchymosis
- Grey-Turner sign= flank ecchymosis
Signs of hemorrhagic pancreatitis
(these signs are rare, <1%)
What is more sensitive and specific for acute pancreatitis
..amylase or lipase?
Lipase
- *increased** WBCs
- *increased** amylase and lipase
- *increased** LFTs
in severe dz..elevated glucose, decreased calcium
Acute pancreatitis
Image of choice for acute pancreatitis?
CT!!!
Bilirubin
ALT and AST
Alk-Phos (ALP)
Albumin
Prothrombin time
LFTs
Helps assess severity of acute pancreatitis
Ranson’s criteria
Age >55
WBCs >16
Glucose >200
ALT > 250 (6x norm)
LDH >350 (2x norm)
Ranson’s criteria
higher scores= more severe dz and increased chance of death
Ranson’s score of 0-2
3-5
6+
0-2: low mortality. ~1%
3-5: 10-20% mortality
6+: 50% mortality
Acute pancreatitis tx
NPO (esp NO ALCOHOL!)
Supportive..fluid, pain, nutrition
Correct electrolyte imbalance
Inflammatory disease
Irreversible changes
Can lead to permanent loss of function
Chronic pancreatitis
Causes of chronic pancreatitis
- Non obstructive (#1 cause is alcohol!!)
- Obstructive
- benign..sphincter of oddi dysfunction
- neoplasm
Do gallstones cause chronic pancreatitis?
NO! only acute
Epigastric/LUQ pain (episodic or continuous)
Diarrhea
Steatorrhea (as damage decreases lipase production)
diabetes (very late sign, as islets are damaged)
Chronic pancreatitis
Gold standard of pancreatic function
(can dz early chronic pancreatitis)
Secretin stimulation test
4th leading cancer death
5 year survival rate= 4%
s/s: wt loss, painless jaundice, pale stool, dark urine, Virchow’s node, Trousseau’s sign (migratory thrombophlebitis)
Pancreatic cancer
Image of choice for pancreatic cancer
CT scan dual phase helical- head of pancreas
Pancreatic cancer tumor marker?
CA 19-9 (75-85%)
What happens to direct bili and alk phos levels in pancreatic cancer?
Increase!
Tx= chemo/radiation (poor response)
Whipple surg
Palliative care
Pancreatic cancer