Pancreas and gallbladder Flashcards
Annular pancreas
Developmental malformation in which the pancreas forms a ring around the duodenum
- risk of duodenal obstruction
Acute pancreatitis
Inflammation and hemorrhage of the pancreas –> due to autodigestion of pancreatic parenchyma by pancreatic enzymes
- premature activation of trypsin leads to activation of other pancreatic enzymes
- results in liquefactive hemorrhagic necrosis of the pancreas and fat necrosis of the peripancreatic fat
- most commonly due to alcohol and gallstones –> other causes = trauma, hypercalcemia, hyperlipidemia, drugs, scorpion stings, mumps and rupture of a posterior duodenal ulcer
Clinical features
- epigastric abdominal pain that radiates to the back
- nausea and vomiting
- periumbilical and flank hemorrhage –> necrosis spreads into the periumbilical soft tissue and retroperitoneum
- elevated serum lipase and amylase; lipase is more specific for pancreatic damage
- hypocalcemia –> ca is consumed during saponification in fat necrosis
Complications of acute pancreatitis
- shock –> due to peripancreatic hemorrhage and fluid sequestration
- pancreatic pseudocyst –> formed by fibrous tissue surrounding liquefactive necrosis and pancreatic enzymes
- –> presents as an abdominal mass with persistently elevated serum amylase
- –> rupture is associated with release of enzymes into the abdominal cavity and hemorrhage
- pancreatic abscess –> often due to e coli, presents with abdominal pain, high fever and persistently elevated amylase
- DIC and ARDS –> when enzymes get into the blood, they can digest the coagulation factors and can also digest the alveolar endothelial barrier
Chronic pancreatitis
Fibrosis of pancreatic parenchyma, most often secondary to recurrent acute pancreatitis
- most commonly due to alcohol (adults) and CF (kids) –> many cases are idiopathic
Clinical features
- epigastric abdominal pain that radiates to the back
- pancreatic insufficiency –> results in malabsorption with steatorrhea and fat soluble vitamin deficiencies
- –> maylase and lipase are not useful serologic markers of chronic pancreatisis as a result
- dystrophic calcification of pancreatic parenchyma on imaging –> contrast studies reveal a “chain of lakes” pattern due to dilation of pancreatic ducts
- secondary diabetes mellitus –> late complication due to destruction of islets
- increased risk for pancreatic carcinoma
Pancreatic carcinoma
Adenocarcinoma arising from the pancreatic ducts –> most commonly seen in the elderly (avg age = 70)
- major risk factors = smoking and chronic pancreatitis
Clinical features
- usually occur late in disease
- epigastric abdominal pain and weight loss
- obstructive jaundice with pale stools and palpable gallbladder –> associated with tumors that arise in the head of the pancreas (most common location)
- secondary DM –> associated with tumors that arise in the body or tail
- pancreatitis
- migratory thrombophlebitis (Trousseau sign) –> presents as swelling, erythema, and tenderness in the extremitis (10% of patients)
- serum tumor markers = CA 19-9
Surgical resection involves en bloc removal of the head and neck of pancreas, proximal duodenum and gallbladder = whipple procedure
- very poor prognosis –> 1 yr survival < 10%
Biliary atresia
Failure to form or early destruction of extrahepatic biliary tree
- leads to biliary obstruction within the first 2 months of life
- presents with jaundice, and progresses to cirrhosis
Cholelithiasis (gallstones)
Solid, round stones in the gallbladder
- due to precipitation of cholesterol (cholesteroal stones) or bilirubing (bilirubin stones)
Arises with…
- supersaturation of cholesterol or bilirubin
- decreased phospholipids (e.g. lecithin) or bile acids (normally increase solubility)
- stasis –> increased risk of bacteria growth
Usually asymptomatic –> complications include biliary colic, acute and chronic cholecystitis, ascending cholangitis, gallstone ileus and gallbladder cancer
Cholesterol stones
Most common type (90%) –> yellow
- usually radiolucent (10% are radiopaque due to associated calcium)
Risk factors
- age (40s)
- estrogen –> female gender, obesity, multiple pregnancies, ocps)
- clofibrate (lipid lowering agent)
- native american ethnicity
- crohn disease
- cirrhosis
Bilirubin stones
Pigmented, composed of bilirubin
- usually radiopaque
Risk factors –> include extracascular hemolysis (increased bilirubin in the bile) and biliary tract infections (ascaris lumbricoides, e coli and clonorchis sinensis)
Biliary colic
Waxing and waning right upper quadrant pain
- due to the gallbladder contracting against a stone lodged in the cystic duct
- symptoms are relived if the stone passes
- common bile duct obstruction may result in acute pancreatitis or obstructive jaundice
Acute cholecystitis
Acute inflammation of the gallbladder wall
- impacted stone in thecystic duct results in dilation with pressure ischemia, bacterial overgrowth (e. coli) and inflammation
- presents with right upper quadrant pain, often radiating to the right scpula, fever with increased WBC count, nausea, vomiting and increased serum alk phosphatase (from duct damage)
- risk of rupture if left untreated
Dx = HIDA scan
Chronic cholecystitis
Chronic inflammation of the gallbladder
- due to chemical irritation from longstanding cholelithiasis, with or without superimposed bouts of acute cholecystitis
- characterized by herniation of gallbladder mucosa into the muscular wall (rokitansky-aschoff sinus)
- presents with vague RUQ pain, especially after eating
- porcelain gall bladder is a late complication –> shrunken, hard gallbladder due to chronic inflammation, fibrosis and dystrophic calcification
- –> increased risk for carcinoma
Treatment –> cholecystectomy, especially if porcelain gallbladder is present
Ascending cholangitis
Bacterial infection of the bile ducts
- usually due to ascending infection with enteric gram negative bacteria
- presents as sepsis, jaundice, and abdominal pain
- increased incidence with choledocholithiasis (stone in biliary ducts)
gallstone ileus
gallstone enters and obstructs the small bowel
- due to cholecystitis with fistula formation between the gallbladder and small bowel
Gallbladder carcinoma
Adenocarcinoma arising from the glandular epithelium that lines the gallbladder wall
- gallstones are a major risk factor, especially when complicated by porcelain gallbladder
- classically presents as cholecystitis in an elderly woman
- poor prognosis
