Pancreas & Biliary Disease

Question 1

3 types of gallstones

Answer 1

*cholesterol stones
*pigment stones
*biliary sludge

Question 2

cholesterol gallstones

Answer 2

*form when CSI > 1 (cholesterol saturation index)
*risk factors: estrogen, diet, rapid weight loss, Crohn’s disease, meds (oral contraceptives, clofibrate, octreotide, ceftriaxone)
*most common type of gallstone

Question 3

pigment gallstones - bilirubin

Answer 3

*black pigment stones
*associated with hemolytic conditions

Question 4

pigment gallstones - mixed

Answer 4

*brown pigment stones
*associated with biliary tract infection

Question 5

biliary sludge

Answer 5

*a crucial intermediate in the formation of gallstones
*facilitates crystal formation in both cholesterol and pigment stones

Question 6

cholelithiasis

Answer 6

*gallbladder stones
*only 25% of people with a gallstone will ever develop symptoms
*risk factors (5 F’s): female, fat, fertile, forty, fair

Question 7

pathophysiology of biliary colic & acute cholecystitis

Answer 7

*lodging of a gallstone in the neck of the gallbladder, causing obstruction of outflow from the gallbladder
*physiologic response = contraction of the gallbladder in an attempt to clear the obstruction
*this contraction causes severe RUQ pain

Question 8

biliary colic

Answer 8

*presents as severe RUQ pain (or epigastric pain) with possible radiation to R scapula; lasts < 6 hours
*the gallstone falls away from the neck back into the gallbladder, resulting in resolution of the obstruction & resolution of symptoms
*CBC & LFTs are NORMAL
*most pts will have recurrent episodes or develop complications

Question 9

acute cholecystitis

Answer 9

*presents as severe RUQ > 6 hours
*often associated with fever & presence of Murphy’s sign
*gallstone stays lodged in neck of gallbladder, resulting in inflammation
*ELEVATED WBCs; NORMAL LFTs
*treatment = antibiotics & cholecystectomy

Question 10

choledocholithiasis

Answer 10

*presence of gallstone(s) in COMMON BILE DUCT
*ELEVATED WBCs AND LFTs
*treatment = antibiotics & ERCP with eventual cholecystectomy
*possible complications: ascending cholangitis or acute gallstone pancreatitis

Question 11

ascending cholangitis

Answer 11

*infection of biliary tree, usually due to obstruction that leads to bacterial overgrowth
*presents with Charcot’s Triad:
1. RUQ pain
2. fever
3. JAUNDICE
*elevated WBCs and LFTs

Question 12

acute gallstone pancreatitis

Answer 12

*possible complication of choledocholithiasis that can occur if the stone migrates to the distal common bile duct, and especially if it passes through the ampulla of Vater, it can cause obstruction of pancreatic duct
*presents with: severe epigastric pain/RUQ pain radiating to the back, fever, JAUNDICE
*tx = supportive care, ERCP, and eventual cholecystectomy

Question 13

gallstone ileus

Answer 13

*large gallbladder stone erodes from gallbladder into duodenum and then gets stuck at the ileocecal valve, resulting in small bowel obstruction

Question 14

possible gallstone outcomes

Answer 14

1. asymptomatic stone (most common)
2. stone intermittently obstructing cystic duct, causing intermittent biliary pain
3. stone impacted in cystic duct, causing acute cholecystitis

Question 15

gallbladder cancer

Answer 15

*risk factors: gallstones, salmonella infection, gallbladder polyps
*dx: sx usually due to local metastases, advanced stage at time of dx
*treatment: surgical if discovered prior to metastasis; chemo/radiation
*prognosis usually poor

Question 16

porcelain gallbladder

Answer 16

*calcified gallbladder due to chronic cholecystitis
*usually found incidentally on imaging
*tx: prophylactic cholecystectomy generally recommended due to increased risk of gallbladder cancer

Question 17

gallbladder polyp management

Answer 17

*cholecystectomy is recommended for any polyp > 10 mm

Question 18

causes of biliary obstruction

Answer 18

1. gallstones
2. tumors (pancreas cancer, cholangiocarcinoma, ampullary carcinoma)

Question 19

functions of the exocrine pancreas

Answer 19

*digestion (via pancreatic enzymes)

Question 20

proenzymes secreted by pancreas

Answer 20

*require activation in duodenum (enterokinases on enterocytes activate them)
-trypsinogen
-chymotrypsinogen
-proelastase
-procarboxypeptidase
-prophospholipase A2

Question 21

active enzymes secreted by the pancreas

Answer 21

*amylase
*lipase

Question 22

3 major causes of acute pancreatitis

Answer 22

1. gallstones (small stones more likely to cause pancreatitis) - MOST COMMON CAUSE
2. alcohol
3. idiopathic

Question 23

most common cause of acute pancreatitis

Answer 23

gallstones

Question 24

causes of drug-induced pancreatitis

Answer 24

*valproic acid
*azathioprine

Question 25

risk factors for severe pancreatitis

Answer 25

*age > 55
*obesity (BMI > 30)

Question 26

diagnosis of acute pancreatitis

Answer 26

2 of 3 criteria:
*acute epigastric pain, often radiating to the back
*serum amylase and/or lipase to 3x upper limit of normal
*characteristic imaging findings (ultrasound is helpful for determining if this is gallstone pancreatitis)

Question 27

acute pancreatitis

Answer 27

*inflammation of the pancreas
*autodigestion of pancreas by pancreatic enzymes

Question 28

treatment of acute pancreatitis

Answer 28

*aggressive hydration for all patients
*NO antibiotics recommended
*immediate oral feeding (low residue, low fat, soft diet)
*remove gallbladder if caused by gallstone

Question 29

causes of CHRONIC pancreatitis

Answer 29

*ALCOHOL (most common cause of chronic pancreatitis)
*smoking
*idiopathic
*genetic: CFTR, SPINK1, hereditary pancreatitis PRSS1
*cystic fibrosis
*autoimmune pancreatitis
*obstructive (benign or malignant stricture)

Question 30

autoimmune pancreatitis

Answer 30

*clinical presentation: obstructive jaundice, acute pancreatitis
*typically seen in males 60-70 years old
*diagnosis: serum IgG4; imaging (SAUSAGE-SHAPED PANCREAS; diffuse irregular stricturing of the pancreatic duct)
*treatment = glucocorticoids

Question 31

chronic pancreatitis

Answer 31

*chronic inflammation, atrophy, calcification of the pancreas
*clinical presentation:
-chronic abdominal pain
-exocrine pancreatic insufficiency (malabsorption, chronic diarrhea, weight loss)

Question 32

diagnosis of chronic pancreatitis

Answer 32

*imaging: CT, MRI, ultrasound, EUS
*lab tests:
-NOT serum amylase or lipase
-FECAL ELASTASE-1 (spot stool)
-quantitative fecal fat (72 hour collection)

Question 33

what is the fecal elastase diagnostic test used for

Answer 33

*chronic pancreatitis
*fecal elastase is an enzyme secreted by the pancreas that remains relatively stable during transport through the GI tract

Question 34

treatment for chronic pancreatitis

Answer 34

*pain management (analgesics, celiac plexus block)
*pancreatic enzyme replacement therapy (pancrelipase)

Question 35

adenocarcinoma of the pancreas

Answer 35

*clinical presentation:
-PAINLESS JAUNDICE (head of pancreas tumors) [especially in older patients]
-weight loss
-epigastric pain radiating to the back

Question 36

diagnosis of adenocarcinoma of the pancreas

Answer 36

*cross-sectional imaging (CT, MR, US) - double duct sign
*lab: CA 19-9
*endoscopic ultrasound with fine needle aspiration (EUS/FNA)

Question 37

treatment of adenocarcinoma of the pancreas

Answer 37

*surgical resection (Whipple procedure) (only hope for long-term survival)
*chemo & radiation

Question 38

neuroendocrine tumors of the pancreas

Answer 38

*insulinoma
*gastrinoma (ZE syndrome)
*VIPoma
*glucagonoma
*somatostatinoma