Lecture 23; Pancreatic and gallbladder pathology

Question 1

Describe the examination of pancreas;

Answer 1

“hidden” non palpable organ and symptoms are late onset (Late stage of detection often)

Question 2

What can the functions of the pancreas be categorised into?

Answer 2

• Exocrine (80-90%)

- Endocrine (10-20%)

Question 3

Describe the cellular structure of the pancreatic exocrine glands;

Answer 3

• Composed of acinar cells and ducts

- Acinar cells contain zymogen granules

Question 4

Whats in the zymogen granules?

Answer 4

Zymogens = inactive enzyme precursors for trypsin, chymotrypsin, amylase, lipase, nucelase and elastase.

Released as pro-enzymes then activated by trypsin

Question 5

Describe the cellular structure of the pancreatic endocrine glands;

Answer 5

Islets of langerhans

- Secrete insulin, glucagon and other hormones

Question 6

What are some potential pathologies of the pancreas;

Answer 6

• Congenital/Genetic: Cystic fibrosis
• Inflammatory/Ineffective: Actue and chronic pancreatitis
• Malignant: Carcinoma of the pancreas

Question 7

Describe what acute pancreatitis is and its spectrum;

Answer 7

Inflammation of the pancreas - associated with acinar cell injury

• Spectrum of severity and duration
• Mild 60-70% cases, low mortality
• Severe 30-40% cases, 20-30% mortality

Question 8

What are the four major categories of acute pancreatitis eitiology? and an example for each;

Answer 8

• Metabolic -> ALCOHOL
• Mechanical -> GALLSTONES, trauma
• Vascular -> Shock, vasculitis
• Infection -> Mumps

and drugs.

Question 9

What is the most common causes of acute pancreatitis?

Answer 9

Alcohol and gallstones

Question 10

What does damage to pancreatic acinar cause?

Answer 10

Damage to pancreatic acinar and release of enzymes into immediate environment/ducts. This results in damage to the pancreas (Think POM and how this might cause damage)

Question 11

What is the pathology of pancreatitis?

Answer 11

• Autodigestion by pancreatic enzymes

- Cell injury response mediated by inflammatory enzymes

Question 12

What are the consequences of pancreatic enzyme release in the ducts;

Answer 12

• Proteases: Proteolytic destruction acini, ducts, islets
• Lipases: Fat necrosis- Pancreas and other sites
• Elastases: Blood vessel destruction leading to interstitial haemorrhage

Cell injury response: Inflammation, oedema, impaired blood flow, ischemia

Question 13

What are the key events to trigger an acute pancreatic event?

Answer 13

• Obstruction

- Direct injury to acinar cells

Question 14

Write some notes on obstruction and duct pressures;

Answer 14

Pancreatic duct obstruction by gallstones and ductal concretions present in alcoholics

• Increased intrapancreatic ductal pressure
• Accumulation of enzyme rich interstitial fluid
• Fat necrosis as lipases already active
• promotes oedema and local inflammation
• Pressure and oedema compromises local blood flow

Question 15

What are the clinical features of acute pancreatitis?

Answer 15

• Acute pain, epigastric
• Nausea and vomiting
• Fever, tachycardia
• Marked abdominal tenderness
• may have ileus
• rarely shock

Question 16

How is acute pancreatitis diagnosed?

Answer 16

• High white cell count
• Elevated serum amylase (lipase)
• CT scan; Oedema, necrosis and psuedocysts
• Rarely may need laprotomy (but imaging now so good, rare)

Question 17

How is acute pancreatitis managed?

Answer 17

Rest the pancreas

• IV fluids
• NG suction (decrease pressure)
• Analgesia
• Close monitoring

Question 18

What are complications of acute pancreatitis at a systemic, metabolic and visceral level?

Answer 18

• Hypotension, shock, renal and respiratory failure due to massive release of pro-inflammatory cytokines
• Metabolic; Low Ca, hyperglyceamia, jaundice
• Pancreatic psuedocysts

Question 19

What is chronic pancreatitis defined as?

Answer 19

Defined as repeated bouts of pancreatic inflammation with loss of pancreatic parenchyma and replacement of fibrous tissue

Question 20

What is the eitiology of chronic pancreatitis?

Answer 20

60-70% have heavy alcohol intake.
- Intraductal plugs; Proteins, cell debris

Other causes;

• Previous acute pancreatitis
• Severe malnutrition
• Hereditary/CFTR mutations (CF)

Question 21

What is the pathology of chronic pancreatitis?

Answer 21

• Fibrotic organ
• Atrophy of the exocrine component (relative sparing of islets)
• Mild chronic inflam infiltrate i.e macrophages
• Intraductal protein plugs and calcified concretions (seen on imaging)

Question 22

What are the clinical features of chronic pancreatitis?

Answer 22

• Repeated attacks of abdominal pain-often bought on by alcohol
• Can be more persistent pain

If ongoing

• Loss of exocrine function (metabolic implications)
• Psuedocysts
• Rarely diabetes mellitus

Question 23

How is chronic pancreatitis diagnosed?

Answer 23

• Clinical suspicion
• Serum amylase - but may not be elevated
• CT imaging

Question 24

Whats often the outcome of pancreatic cancer?

Answer 24

• Survival is very poor as relies on pain or obstruction of pancreas. So if it occurs in tail then can be quite progressed.
• Whipples procedure if operation occurs.

Question 25

What are the risk factors of pancreatic carcinoma?

Answer 25

Theyre associations - Smokers - Rare hereditary cases - Alcohol and coffee are suggested

Question 26

Whats the pathology of adenocarcinoma;

Answer 26

Head; Biliary obstruction Tail; Often silent, spreads to nodes of adjacent organs Think location and what it will do

Question 27

Whats the clinical features of adenocarcinoma;

Answer 27

- Obstructive jaundice - Pain - Weight loss - Pancreatitis and obstruction - Thrombophlebitis (venous thrombosis) Confirmed on imaging and biopsy

Question 28

What may pancreatic endocrine tumours result in?

Answer 28

Islet cell tumor - Rare - May elaborate pancreatic hormones - Hypoglycemia - Most benign - Treat with resection

Question 29

What are pancreatic pathologies?

Answer 29

- Acute pancreatitis - Chronic pancreatitis - Carcinoma of the pancreas Other; CF or endocrine tumours

Question 30

What are gall bladder pathologies?

Answer 30

- Gallstones - Cholecystitis - Carcinoma of the gallbladder

Question 31

What is cholelithiasis?

Answer 31

Gallstones, 80% are 'Silent'

Question 32

What are the types of gallstones?

Answer 32

``` Cholesterol stones (80%); Cholesterol monohydrate Pigment stones; Bilirubin and calcium salts ```

Question 33

Whats the pathogenesis of cholesterol stones?

Answer 33

- Bile supersaturated with cholesterol - Conditions favouring crystal formation - Cholesterol crystals remain in gall bladder long enough for stones to form i.e stasis

Question 34

What are the risk factors for cholelithiasis?

Answer 34

- Age and gender (F) - Estrogenic influence (contraception, pregnancy), obesity and rapid weight loss - Gallbladder stasis - Family history Rare in underdeveloped or developing countries.

Question 35

What are the risk factors for a pigment stone?

Answer 35

Disorders that favour the formation of bilirubin stones are; - chronic heamolytic conditions - bacterial infection of the biliary tree predom in non-western pops

Question 36

What are the potential clinical consequences of gallstones?

Answer 36

May be asymptomatic - 70-80% Symptomatic; 1-3% per year - Cholecystisis (acute/chronic) - Biliary colic- due to choledocholithiasis Complications of above; - Cholangitis, obstructive cholestasis, pancreatitis

Question 37

What is acute cholecystisis?

Answer 37

- Mostly gallstones - Obstruction of the neck of gallbladder or cystic duct - Chemical irritation appears to be the major factor with bacterial infection later

Question 38

What are the clinical presentation and laboratory results of cholecystisis?

Answer 38

- RUQ pain and tenderness - Febrile Laboratory - Neutrophil leucocytosis - Raised bilirubin, ALP and GGT if stone common bile duct - Imaging = ultrasound of gall bladder

Question 39

How is acute or chronic cholecystisis managed?

Answer 39

Initial acute event; - Conservative therapy; IV fluid, pain releif - Up to 25% may require acute surgical intervention Chronic - Cholecystectomy

Question 40

What is choledocholithiasis? and complications?

Answer 40

Presence of stones within the biliary tree Complications - Biliary obstruction; colicky abdominal pain or obstructive jaundice - Pancreatitis - Cholangitis (inflam of bile duct system)

Question 41

What are the potential cancers of the biliary system?

Answer 41

- Carcinoma of the gall bladder | - Carcinoma of the extrahepatic ducts

Question 42

Describe the presentation of the gall bladder carcinoma;

Answer 42

Presents - Later in life - F>M - Poor prognosis - Increased with gallstones and chronic infections

Question 43

Describe the pathology of gall bladder carcinoma;

Answer 43

Pathology - Most are adenocarcinomas - Rarely squamous or mixed - Most have invaded the liver by the time of diagnosis.

Question 44

Write some notes on carcinoma of the extrahepatic bile ducts;

Answer 44

- Uncommon - May involve the ampullary region - Frequently present with slowly progressive obstruction of bile duct i.e jaundice, pale stools, weight loss, nausea

Question 45

Whats important to remember if theres any obstruction in the cysto-hepato-pancreatic network?

Answer 45

``` Think about its location (name) - Which organs itll obstruct i.e Pancreas -> pancreatitis Liver -> Jaundice (hyperbilirubinemia) Gall bladder -> Steatorhoea ``` Or all?