Pancreas & Biliary Disease Flashcards
3 types of gallstones
*cholesterol stones
*pigment stones
*biliary sludge
cholesterol gallstones
*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
pigment gallstones - bilirubin
*black pigment stones
*associated with hemolytic conditions
pigment gallstones - mixed
*brown pigment stones
*associated with biliary tract infection
biliary sludge
*a crucial intermediate in the formation of gallstones
*facilitates crystal formation in both cholesterol and pigment stones
cholelithiasis
*gallbladder stones
*only 25% of people with a gallstone will ever develop symptoms
*risk factors (5 F’s): female, fat, fertile, forty, fair
pathophysiology of biliary colic & acute cholecystitis
*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
biliary colic
*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
acute cholecystitis
*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
choledocholithiasis
*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
ascending cholangitis
*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
acute gallstone pancreatitis
*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
gallstone ileus
*large gallbladder stone erodes from gallbladder into duodenum and then gets stuck at the ileocecal valve, resulting in small bowel obstruction
possible gallstone outcomes
- asymptomatic stone (most common)
- stone intermittently obstructing cystic duct, causing intermittent biliary pain
- stone impacted in cystic duct, causing acute cholecystitis
gallbladder cancer
*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
porcelain gallbladder
*calcified gallbladder due to chronic cholecystitis
*usually found incidentally on imaging
*tx: prophylactic cholecystectomy generally recommended due to increased risk of gallbladder cancer
gallbladder polyp management
*cholecystectomy is recommended for any polyp > 10 mm
causes of biliary obstruction
- gallstones
- tumors (pancreas cancer, cholangiocarcinoma, ampullary carcinoma)
functions of the exocrine pancreas
*digestion (via pancreatic enzymes)
proenzymes secreted by pancreas
*require ACITIVATION in duodenum (enterokinases on enterocytes activate them)
-trypsinogen
-chymotrypsinogen
-proelastase
-procarboxypeptidase
-prophospholipase A2
active enzymes secreted by the pancreas
*amylase
*lipase
3 major causes of acute pancreatitis
- gallstones (small stones more likely to cause pancreatitis) - MOST COMMON CAUSE
- alcohol
- idiopathic
most common cause of acute pancreatitis
gallstones
causes of drug-induced pancreatitis
*valproic acid
*azathioprine
risk factors for severe pancreatitis
*age > 55
*obesity (BMI > 30)
diagnosis of acute pancreatitis
2 of 3 criteria:
1. acute epigastric pain, often radiating to the back
2. elevated serum amylase and/or lipase to 3x upper limit of normal
3. characteristic imaging findings (ultrasound is helpful for determining if this is gallstone pancreatitis)
acute pancreatitis
*inflammation of the pancreas
*autodigestion of pancreas by pancreatic enzymes
treatment of acute pancreatitis
*aggressive hydration for all patients
*NO antibiotics recommended
*immediate oral feeding (low residue, low fat, soft diet)
*remove gallbladder if caused by gallstone
causes of CHRONIC pancreatitis
*ALCOHOL (most common cause of chronic pancreatitis)
*smoking
*idiopathic
*genetic: CFTR, SPINK1, hereditary pancreatitis PRSS1
*cystic fibrosis
*autoimmune pancreatitis
*obstructive (benign or malignant stricture)
autoimmune pancreatitis
*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
chronic pancreatitis
*chronic inflammation, atrophy, calcification of the pancreas
*clinical presentation:
-chronic abdominal pain
-exocrine pancreatic insufficiency (malabsorption, chronic diarrhea, weight loss)
diagnosis of chronic pancreatitis
*imaging: CT, MRI, ultrasound, EUS
*lab tests:
-NOT serum amylase or lipase
-FECAL ELASTASE-1 (spot stool)
-quantitative fecal fat (72 hour collection)
what is the fecal elastase diagnostic test used for
*chronic pancreatitis
*fecal elastase is an enzyme secreted by the pancreas that remains relatively stable during transport through the GI tract
treatment for chronic pancreatitis
*pain management (analgesics, celiac plexus block)
*pancreatic enzyme replacement therapy (pancrelipase)
adenocarcinoma of the pancreas
*clinical presentation:
-PAINLESS JAUNDICE (head of pancreas tumors) [especially in older patients]
-weight loss
-epigastric pain radiating to the back
diagnosis of adenocarcinoma of the pancreas
*cross-sectional imaging (CT, MR, US) - double duct sign
*lab: CA 19-9
*endoscopic ultrasound with fine needle aspiration (EUS/FNA)
treatment of adenocarcinoma of the pancreas
*surgical resection (Whipple procedure) (only hope for long-term survival)
*chemo & radiation
neuroendocrine tumors of the pancreas
*insulinoma
*gastrinoma (ZE syndrome)
*VIPoma
*glucagonoma
*somatostatinoma
