Pancreas & Biliary Tract Diseases Flashcards
Cholesterol vs. Pigment gallstones
- cholesterol: most common in US (>80%), white or yellow
- pigment: black or brown
Symptoms of gallstones
- biliary colic, acute cholecystitis, choledocholithiasis w/ ascending cholangitis, gallstone pancreatitis
Biliary colic
- episodes of intense pain in RUQ or epigastrium, sometimes radiating to RIGHT SHOULDER BLADE
- last 30-60 mins, then subsides
- likely to RECUR
Biliary colic: physical exam, labs, treatment, diagnosis
- physical exam: afebrile, no peritoneal signs, may have RUQ gaurding
- labs: normal
- diagnosis: ultrasound
- treatment: cholecystectomy
Acute cholecystitis
- caused by persistent obstruction of cystic duct + chemicals from bile
- biliary colic persists for 4-6 hours or more
- physical exam: + murphy’s sign
- HIDA scan sometimes used to evaluate patency of cystic duct
- treatment: cholecytectomy
Imaging for gallstones and cholecystitis
- ultrasound: sensitive for stones and cholecystitis; NPO and no pain meds (sonographic murphy’s sign)
- CT: may show stones and cholecystitis
Ascending cholangitis
- obstruction of bile duct with superimposed bacterial infection
- CHARCOT’S TRIAD: fever, jaundice, RUQ pain
- labs: elevated WBC with left shift, elevated total bilirubin and alk phos ***may be confused with hepatitis
- ultrasound: dilation of bile ducts
Ascending cholangitis: treatment
- empiric antibiotics
- ERCP to establish biliary drainage, usually followed by cholecytectomy
ERCP: endoscopic retrograde cholangiopancreatography
- fluoroscopic image of duct system
- can then do a stone extraction
Biliary atresia
- congenital disorder: pediatric disease
- cause unknown
- most common cause of neonatal jaundice requiring surgery
- most common indication for liver transplant in pediatrics
Features of biliary atresia
- most affected children born at full term, normal weight
- important to exclude other causes
- physical exam: jaundice
- CHOLANGIOGRAM: gold standard to establish patency/continuity of bile duct from liver to duodenum
Biliary atresia treatment
- kasai procedure (hepatoportoenterostomy): small intestine anastomosed to the porta hepatis via Roux-en-Y
- most will eventually need liver transplant
Cholangiocarcinoma: cancer of biliary epithelium
- advanced at presentation
- PSC is man risk factor
- symptoms: jaundice, pruritis, acholic stools, dark urine, abd pain
- physical exam: jaundice, enlarged liver, palpable RUQ mass
Cholangiocarcinoma: ultrasound, staging, tumor markers
- ultrasound: dilated bile ducts, exclude stones
- cross sectional imaging used for staging
- tumor markers: CA19-1, CEA less useful for dx; may be helpful in monitoring for recurrence after Rx
Treatment of cholangiocarcinoma
- depends on location and stage
- early tumors treated with surgical resection, with 50% 5 year survival
- advanced tumors treated with systemic chemo
Gall bladder cancer: risks
- main risk factors: gallstones + infection
- risk increases with age, obesity, DM
- “Porcelain” gallbladder (intramural calcifications): increased risk
- gallbladder polyps increase cancer risk but don’t occur with stones
Gallbladder cancer and cholangiocarcinoma imaging
- mass at wall of duct or gallbladder
- may directly invade liver
- ultrasound to detect and visualize mass
- CT for staging and MR for unknown liver mass
Gallbladder cancer: symptoms, treatment
- symptoms: pain, anorexia, nausea, vomiting
- treatment: surgical resection sometimes with chemo and/or radiation
Acute pancreatitis: presentation, physical exam, labs
- presentation: acute onset, severe pain, radiating to back and relieved by SITTING UP or LEANING FORWARD
- physical exam: abdominal tenderness, decreased bowel sounds (ILEUS), hypotension, tachypnea, hypoxemia
- labs: elevated amylase/lipase, elevated WBC, elevated liver enzymes–cholangitis
Causes of acute pancreatitis
- GALLSTONES
- ALCOHOL
- scorpion, brown recluse
Management of acute pancreatitis
- ICU admission if severe
- if gallstones suspected, may need ERCP
- fluid resuscitation, pain management
- nutrition: enteral feeding preferred to parenteral nutrition
Complications of acute pancreatitis
- fluid collections: pseudocysts, pancreatic necrosis
- organ failure: SIRS, respiratory failure (ARDS), renal failure, shock
Chronic pancreatitis
- progressive fibrinoinflammatory condition
- main causes similar to acute pancreatitis
- rare causes: hereditary pancreatitis, autoimmune pancreatitis (increased IgG4)
Pathogenesis of chronic pancreatitis
- increased protein secretion, plugs small ducts, leading to stones
- obstruction by stones causes increased pressure
- increased pressure decreases vascular perfusion, causing ischemia
Features of chronic pancreatitis
- pain, exacerbated by meals
- amylase, lipase usually NORMAL
- clinical signs: pancreatic calcification, steatorrhea
Diagnosing exocrine insufficiency
- 72 hr fecal fat quantitation
- fecal elastase
- duodenal intubation with measurement of outputs of pancreatic enzymes after secretin stimulation is gold standard but rarely done
Treatment of chronic pancreatitis
- small meals, low fat
- STOP alcohol, smoking
- pancreatic enzyme supplements, vitamins, insulin if diabetic
- pain control
Gallstones
- prevelance increases with age, more common in women than men
- most are asymptomatic which don’t require treatment
Pancreatic cancer (exocrine): process
- adenocarcinoma arising from ductal epithelium: 95%
- neuroendocrine tumors less common
- 4th highest cause of cancer deaths: attributed to advanced disease at time of diagnosis
Risk factors for pancreatic cancer
- chronic pancreatitis, hereditary pancreatitis
- DM, smoking
- pancreatic cysts
Clinical features of pancreatic cancer
- symptoms: weight loss, epigastric pain, jaundice, back pain, steatorrhea, atypical DM, acute pancreatitis, trousseau’s syndrome: migratory superficial thrombophlebitis
- physical exam: jaundice, hepatomegaly, cachexia, RUQ/epigastric mass
Imaging of pancreatic cancer
- Ultrasound: biliary dilation and look for stones
- CT: for staging
- ERCP: diagnostic/therapeutic
Location of pancreatic cancer
- 2/3 occur in the head
- in the head it can cause biliary problems
Treatment of pancreatic cancer
- only 15-20 % deemed resectable at time of presentation
- 5 yr survival after putative curative surgery only 20%
- combo of chemo/radiation for unresectable disease
