Pancreas and Hepatobiliary Diseases

Question 1

What is the duodenal mucosal response to food and acid?

Answer 1

S cells release secretin - stimulates biliary and pancreatic duct epithelium to secret bicarb and water
I cells cause release of CCK - enzyme secretion from pancreatic acinar cells and stimulates gallbladder contraction, relaxes sphincter of oddi

Question 2

What are risk factors for pigment gallstones?

Answer 2

excess bilirubin –> black stones

bacterial contamination of bile - bacteria chemically alter bile –> soft brown stones

Question 3

What is the pathophysiology of the development of acute pancreatitis?

Answer 3

inciting factor induces premature enzyme activation, immune system activation, oxidative stress, and ischemia-reperfusion injury that drive local manifestations (edema, necrosis, sequestration of fluid)

Question 4

What is the pathophysiology of chronic pancreatitis?

Answer 4

irreparable damage to liver from number of sources
mutations that create super trypsin resistant to cleavage and inactivation
CFTR mutations impair ductal bicarb secretion

Question 5

What drives the progression to pancreatic adenocarcinoma?

Answer 5

Over expression of growth factors (EGF, TGF-alpha)
activation of oncogenes (K ras)
inactivation of tumor suppressors (p53, p16)
paracrine effects of islet cell hormones (IGF)
overexpression of TGF beta drives fibrosis

Question 6

What is the progression of lesions in pancreatic cancer?

Answer 6

precursor lesions within duct called PanINs

then angiogenesis, neural invasion, metasatic spread

Question 7

What are exceptions to the no surgery for asymptomatic cholelithiasis rule?

Answer 7

sickle cell
extreme remote assignments (space, pilots)
liver transplant recipients (gallbladder removed)
diabetics

Question 8

What is the pathophysiology of biliary colic?

Answer 8

episodic abdominal pain caused by gallbladder attempting to contract in presence of obstructed cystic duct

Question 9

What investigations should be used with biliary colic?

Answer 9

sonogram demonstrating cholelithiasis

absence of cholelithiasis –> CCK HIDA

Question 10

What results from a CCK HIDA indicate a biliary source of symptoms of biliary colic?

Answer 10

diminished gallbladder EF and pain with CCK infusion

Question 11

What is the pathophysiology of acute cholecystitis?

Answer 11

gallbladder wall is inflamed
usually caused by stasis of bile due to gallstone obstructing cystic dugt
sometimes ischemia (PAN) or inf cause

Question 12

What are the clinical features of acute cholecystitis?

Answer 12

RUQ sharply localized pain, tenderness over gallbladder, fever, Murphy’s sign

Question 13

What investigations are used to evaluate acute cholecystitis?

Answer 13

leukocytosis, sonogram shows cholelithiasis if that’s the cause, thickened gallbladder wall or pericholecystic fluid collection on sonogram
HIDA scan if still doubt - if dye concentrates in gallbladder, NOT acute cholecystitis

Question 14

What is the pathophysiology of ascending cholangitis?

Answer 14

stagnant bile proximal to obstructed common bile duct becomes infected with bacteria (usually GNR)

Question 15

What are the clinical features of ascending cholangitis?

Answer 15

fever, jaundice, RUQ pain = Charcot's triad
septic appearance (hypotensive)

Question 16

What is Reynold’s Pentad?

Answer 16

constellation of symptoms seen in ascending cholangitis = delirious, febrile, septic appearing (hypotensive), elderly, jaundice and tenderness in RUQ

Question 17

What investigations are done in ascending cholangitis?

Answer 17

leukocytosis, elevations in all liver enzymes, elevated bilirubin, schistocytes and left shift, positive blood cultures
sonogram MAY show dilated common duct

Question 18

What is the treatment of ascending cholangitis?

Answer 18

antibiotics (quinolones), repletion of fluids, urgent dcompression of duct by ECRP to remove stone or PTC

Question 19

What is the treatment for acute cholecystitis?

Answer 19

cholecystectomy, antibiotics in toxic patients or in those with complication

Question 20

What are the most common risk factors for acute pancreatitis?

Answer 20

choledocholithiasis (middle aged women and elderly patients)

alcohol

Question 21

What are the clinical features of acute pancreatitis?

Answer 21

sharp epigastric pain radiating to interscapular, subsequent nausea and emesis, maybe fever, volume depletion (orthostasis), decreased bowel sounds

Question 22

Why are antibiotics usually not indicated in acute pancreatitis?

Answer 22

infection does not occur earlier than 5-7 days after symptom onset, no antibiotics before this time

Question 23

What is a possible complication of acute pancreatitis and what does it cause?

Answer 23

retroperitoneal hemorrhage
Cullen sign - ecchymoses around umbilicus
Grey-turner sign - eccyhmoses in flanks or loins

Question 24

What lab investigations are seen with acute pancreatitis?

Answer 24

elevated pancreatic enzymes (amylase, lipase)

leukocytosis, plain ab films may show focal or diffuse ileus, elevated hematocrit IF SEVERE

Question 25

What is the best imaging modality for the pancreas?

Answer 25

ab CT with IV and oral contrast

Question 26

What is the leading cause of mortality 2-3 weeks after symptom onset of acute pancreatitis?

Answer 26

infection of necrotic pancreas

Question 27

When should multi-phasic CT be used in patients with acute pancreatitis?

Answer 27

diagnosis in doubt
deteriorate or fail to improve
>50 YO and unclear etiology (r/o cancer)
evidence of ongoing biliary obstruction

Question 28

If the gallbladder is still present, what additional imaging test must be done to work up acute pancreatitis?

Answer 28

sonogram - need to look for gallstones

if choledocholithiasis –> ERCP

Question 29

What determines severity of an episode of acute pancreatitis?

Answer 29

scoring systems up to 48 hrs from symptom onset
dev of local complications, systemic complications, need for surgery, death
patients not meeting criteria w/i 24-48 hrs not likely to be severe course (majority)

Question 30

What is the usual treatment of acute pancreatitis?

Answer 30

fasting, IV volume repletion*, narcotic analgesics (demerol > morphine), antiemetics, nasogastric tube if symptomatic ileus, monitor urine output and oxygenation, daily CBC, metabolic panel, liver panel, Ca and Mg testing

Question 31

When should antibiotics be used in the treatment of acute pancreatitis?

Answer 31

only in necrotic pancreas, hematocrit >40

Question 32

When should nutritional support be provided in the treatment of acute pancreatitis?

Answer 32

predicted to follow severe course
failure to improve after 48-72 hours
manifestations of severity

Question 33

When and why should ERCP be used in the treatment of acute pancreatitis?

Answer 33

if gallstones and patient worsens or fails to improve - reduces risk of cholangitis without worsening pancreatitis
quinolone antibiotics and time to those improving to try and pass stones

Question 34

What are risk factors for pancreatic carcinoma?

Answer 34

smoking
chronic pancreatitis
hereditary pancreatitis
hereditary pancreatic cancer

Question 35

What is the relationship between diabetes and pancreatic carcinoma?

Answer 35

glucose intolerance can be a manifestation of cancer, but not a large percentage of diabetics get cancer

Question 36

What is the most common marker checked in patients suspected of having pancreatic cancer?

Answer 36

CA 19-9, marker for adenocarcinoma

levels >250 in presence of mass and absence of pancreatitis usually diagnostic

Question 37

What is the diagnostic modality of choice in otherwise normal pancreas to work up pancreatic cancer?

Answer 37

EUS - also when CT equivocal, or tissue diagnosis required prior to therapy
CT biopsies when EUS not available
MRI/MRCP depends, but superior to CT in detecting peritoneal metastases

Question 38

What is the surgical procedure performed for resectable pancreatic carcinoma?

Answer 38

Whipple (or variant that spares the stomach)

Question 39

What are palliative procedures performed in pancreatic carcinoma?

Answer 39

decompress bile obstruction (ERCP)
relief of duodenal obstruction (gastrojejunostomy)
can also give Gemcitabine to prolong survival