Pancreas & Biliary Tract Diseases

Question 1

Cholesterol vs. Pigment gallstones

Answer 1

• cholesterol: most common in US (>80%), white or yellow

- pigment: black or brown

Question 2

Symptoms of gallstones

Answer 2

• biliary colic, acute cholecystitis, choledocholithiasis w/ ascending cholangitis, gallstone pancreatitis

Question 3

Biliary colic

Answer 3

• episodes of intense pain in RUQ or epigastrium, sometimes radiating to RIGHT SHOULDER BLADE
• last 30-60 mins, then subsides
• likely to RECUR

Question 4

Biliary colic: physical exam, labs, treatment, diagnosis

Answer 4

• physical exam: afebrile, no peritoneal signs, may have RUQ gaurding
• labs: normal
• diagnosis: ultrasound
• treatment: cholecystectomy

Question 5

Acute cholecystitis

Answer 5

• 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

Question 6

Imaging for gallstones and cholecystitis

Answer 6

• ultrasound: sensitive for stones and cholecystitis; NPO and no pain meds (sonographic murphy’s sign)
• CT: may show stones and cholecystitis

Question 7

Ascending cholangitis

Answer 7

• 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

Question 8

Ascending cholangitis: treatment

Answer 8

• empiric antibiotics

- ERCP to establish biliary drainage, usually followed by cholecytectomy

Question 9

ERCP: endoscopic retrograde cholangiopancreatography

Answer 9

• fluoroscopic image of duct system

- can then do a stone extraction

Question 10

Biliary atresia

Answer 10

• congenital disorder: pediatric disease
• cause unknown
• most common cause of neonatal jaundice requiring surgery
• most common indication for liver transplant in pediatrics

Question 11

Features of biliary atresia

Answer 11

• 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

Question 12

Biliary atresia treatment

Answer 12

• kasai procedure (hepatoportoenterostomy): small intestine anastomosed to the porta hepatis via Roux-en-Y
• most will eventually need liver transplant

Question 13

Cholangiocarcinoma: cancer of biliary epithelium

Answer 13

• 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

Question 14

Cholangiocarcinoma: ultrasound, staging, tumor markers

Answer 14

• 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

Question 15

Treatment of cholangiocarcinoma

Answer 15

• depends on location and stage
• early tumors treated with surgical resection, with 50% 5 year survival
• advanced tumors treated with systemic chemo

Question 16

Gall bladder cancer: risks

Answer 16

• 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

Question 17

Gallbladder cancer and cholangiocarcinoma imaging

Answer 17

• 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

Question 18

Gallbladder cancer: symptoms, treatment

Answer 18

• symptoms: pain, anorexia, nausea, vomiting

- treatment: surgical resection sometimes with chemo and/or radiation

Question 19

Acute pancreatitis: presentation, physical exam, labs

Answer 19

• 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

Question 20

Causes of acute pancreatitis

Answer 20

• GALLSTONES
• ALCOHOL
• scorpion, brown recluse

Question 21

Management of acute pancreatitis

Answer 21

• ICU admission if severe
• if gallstones suspected, may need ERCP
• fluid resuscitation, pain management
• nutrition: enteral feeding preferred to parenteral nutrition

Question 22

Complications of acute pancreatitis

Answer 22

• fluid collections: pseudocysts, pancreatic necrosis

- organ failure: SIRS, respiratory failure (ARDS), renal failure, shock

Question 23

Chronic pancreatitis

Answer 23

• progressive fibrinoinflammatory condition
• main causes similar to acute pancreatitis
• rare causes: hereditary pancreatitis, autoimmune pancreatitis (increased IgG4)

Question 24

Pathogenesis of chronic pancreatitis

Answer 24

• increased protein secretion, plugs small ducts, leading to stones
• obstruction by stones causes increased pressure
• increased pressure decreases vascular perfusion, causing ischemia

Question 25

Features of chronic pancreatitis

Answer 25

• pain, exacerbated by meals
• amylase, lipase usually NORMAL
• clinical signs: pancreatic calcification, steatorrhea

Question 26

Diagnosing exocrine insufficiency

Answer 26

• 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

Question 27

Treatment of chronic pancreatitis

Answer 27

• small meals, low fat
• STOP alcohol, smoking
• pancreatic enzyme supplements, vitamins, insulin if diabetic
• pain control

Question 28

Gallstones

Answer 28

• prevelance increases with age, more common in women than men
• most are asymptomatic which don’t require treatment

Question 29

Pancreatic cancer (exocrine): process

Answer 29

• adenocarcinoma arising from ductal epithelium: 95%
• neuroendocrine tumors less common
• 4th highest cause of cancer deaths: attributed to advanced disease at time of diagnosis

Question 30

Risk factors for pancreatic cancer

Answer 30

• chronic pancreatitis, hereditary pancreatitis
• DM, smoking
• pancreatic cysts

Question 31

Clinical features of pancreatic cancer

Answer 31

• 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

Question 32

Imaging of pancreatic cancer

Answer 32

• Ultrasound: biliary dilation and look for stones
• CT: for staging
• ERCP: diagnostic/therapeutic

Question 33

Location of pancreatic cancer

Answer 33

• 2/3 occur in the head

- in the head it can cause biliary problems

Question 34

Treatment of pancreatic cancer

Answer 34

• 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