GI Conditions of the Biliary Tree + Pancreas Flashcards
How do gallstones form?
Due to abnormal bile composition (usually excess cholesterol) which causes hardening of bile
What are the risk factors for developing gall stones?
5 F's: Fair Fat Forty years + Female Foetus
What is biliary colic?
Pain associated with the temporary obstruction of the cystic or common bile duct by a stone
How does biliary colic present?
Recurrent episodes of RUQ pain which subsides after several hours. The pain is usually provoked by eating a fatty meal
How is the diagnosis of biliary colic made?
History + US showing gall stones
During an attack of pain there will be increased ALP and bilirubin
What features differentiates biliary colic from acute cholecystitis?
Absence of inflammatory features, e.g. fever and raised CRP
What is the treatment for biliary colic?
Cholecystectomy
If a patient with biliary colic had abnormal liver biochemistry and US showed dilated common bile duct, what would the treatment be?
Pre-Operative MRCP
What is acute cholecystitis?
Inflammation of the gall bladder following gall stone impaction
How does acute cholecystitis present?
RUQ pain and fever
What signs indicate acute cholecystitis on examination?
Murphy’s sign positive (tenderness worse on inspiration)
Muscle guarding
How is acute cholecystitis treated?
IV fluids
Nil by mouth
IV Cefotaxime
Cholecystectomy within 48 hours
What is acute cholangitis?
Bacterial infection of the biliary tree
What can cause acute cholangitis?
Obstruction of common bile duct by gall stones
HIV cholangiopathy
Biliary strictures following surgery
What is the classic presentation of acute cholangitis?
Charcot’s triad of RUQ pain, fever and jaundice
Jaundice associated with acute cholangitis is cholestatic in type. What are the clinical features of this?
Dark urine
Pale stools
Pruritus (itching)
Raised ALP + Bilirubin
Which organisms are the most common cause of acute cholangitis?
E.Coli and enterococcus
What if the definitive investigation for acute cholangitis?
ERCP. Shows site and cause of obstruction and allows bile to be sampled for culture and drained
Which antibiotics are given in acute cholangitis?
Cefotaxime + Metronidazole
or
Amoxicillin + Metronidazole + Gentamicin
What is the best imaging modality for stones in the common bile duct?
MRCP
What do the pancreatic acinar cells produce?
Pancreatic enzymes which are involved in the digestion of fat (lipase), carbohydrate (amylase) and protein (protease)
Does acute pancreatitis occur in a previously normal or damaged pancreas?
Normal. Usually returns to normal structure and function after the episode
How does acute pancreatitis commonly present?
Epigastric pain radiating to the back associated with nausea and vomiting. There is tenderness, guarding and rigidity on examination
What do Cullen’s sign and Grey turners sign mean? What do they indicate?
Redness around the umbilicus (Cullens) or flanks (grey turners)
Severe necrosiating pancreatitis
A high elevation of which substance is diagnostic of pancreatitis?
Serum amylase or serum lipase
Which investigations are performed to confirm diagnosis of pancreatitis?
CT scan or MRI
What are the causes of pancreatitis?
GET SMASHED
Gall stones Ethanol Trauma Steroids Mumps/malignancy Autoimmunity Scorpion stings Hyperlipidaemia/hypercalcaemia ERCP Drugs
What does a sentinel loop on an XR indicate?
Pancreatitis
What is chronic pancreatitis?
Continuing inflammation of the pancreas with irreversible structural changes
What is the most common cause of chronic pancreatitis in the UK?
Alcohol
How does chronic pancreatitis present?
Epigastric pain + weight loss
pancreatic carcinoma is the differential
What is the best investigation to diagnose chronic pancreatitis? What would it show?
CT scan showing:
Calcification of the pancreas
Dilated pancreatic duct
Fluid collection
How does chronic pancreatitis affect faecal elastase?
It reduces it
What conditions can cause hereditary chronic pancreatitis?
Cystic fibrosis
Alpha 1 antitrypsin deficiency
Hyperparathyroidism
What is the most common exocrine pancreatic cancer?
Adenocarcinoma
How do carcinomas affecting the head of the pancreas present? What is the diagnostic clinical sign?
Painless jaundice and weight loss
A palpable gall bladder will ALWAYS be caused by cancer (Courvoisier’s law)
How do carcinomas affecting the body or tail of the pancreas present?
Abdominal pain, anorexia and weight loss
Which investigation is used to diagnose pancreatic cancer?
Ultrasound
A patient presents with jaundice. An ultrasound and CT scan show a bile duct stricture and a hilar mass. What is the diagnosis?
Cholangiocarcinoma
What does a gastrinoma cause? What are the symptoms?
Acid hyper-secretion due to increased gastrin release
Recurrent duodenal ulcers and severe diarrhoea
What does an insulinoma cause?
Hypoglycaemia due to increased insulin secretion promoting storage of glucose
What does a glucagonoma cause?
Hyperglycaemia due to increased glucagon secretion promoting breakdown of glycogen to release glucose
