Pancreatic and Gallbladder Disorders Flashcards
Bile
- Isosmotic w/ plasma
-
Composition:
- Water (82%)
- Bile acids (12%)
- Phospholipids (4%)
- Cholesterol (0.7%)
- Bilirubin (0.3%)
-
Bile acids formation
- Primary bile acids: synthesized in the liver from cholesterol
- Secondary bile acids: formed from bacterial action in the colon
- Bile salts are absorbed in the ileum and majority go back to the liver
-
Bile pool = 2-4 grams
- 500-600 ml of hepatic bile secreted/day
- Bile circulates 2-3x per meal
- 90-95% of bile enters the enterohepatic circulation
Gallbladder
Histology
- Mucosa is columnar and thrown into folds
-
Rokitansky-Aschoff sinuses: outpouchings of gallbladder mucosa that penetrate into muscle wall
- May represent acquired herniations
Gallbladder
Motility
- Neural control by parasympathics
- Most potent physiologic stimulator is cholecystokinin (CCK)
- Stimulated by long-chain fatty acids, amino acids and carbs
- Causes gallbladder contraction, relaxation of the Sphincter of Oddi
Gallbladder
Diseases
- Cholelithiasis (gallstones)
- Cholecystitis (inflammation)
- Cholesterolosis (cholesterol deposits)
- Cancer (gallbladder adenocarcinoma)
Cholelithiasis
Overview
“Gallstones”
- 10-20% of adults in U.S. and western Europe
- Most are clinically silent (> 80%)
- Most stones in the U.S (90%) are cholesterol stones
Cholelithiasis
Epidemiology
- 20 million per year in U.S.
- 98-99% asymptomatic
- 1-2% develop sx (biliary colic) per year
- 50% of those will be asymptomatic in the next year
- 50% will have another episode within 1 year
- 1-2% of those will develop complications per year
Types of Gallstones
Cholesterol Gallstones
Characteristics
- 75% of gallstones
-
Composition:
- Pure cholesterol stones ⇒ large and white
- Mixed cholesterol stones (> 50% cholesterol) ⇒ small and multiple
- Other components are calcium carbonate, calcium phosphate and calcium bilirubinate
- Most stones are: radiolucent, 1-3 cm, yellow and multifaceted
-
Formation:
- Bile supersaturated w/ cholesterol
- Concentration exceeds capacity of bile salts and lecithin’s to disperse it
- Cholesterol nucleates into solid crystals
- Delayed emptying favors further precipitation of crystals around nidus
Cholesterol Gallstones
Risk Factors
- Age: most common in the later part of life
-
Female sex: estrogenic factors predispose
- ↑ Risk w/ OCPs and pregnancy
- Obesity
-
Genetics
- Pima Indians, Scandinavians, those w/ 1st degree relatives affected
- Genes encoding hepatocyte proteins that transport biliary lipids have association w/ gallstone formation
-
Underlying conditions
- Crohn’s disease, DM, hypertriglyceridemia
- Changes in biliary excretion of cholesterol
-
Clofibrate: drug used to lower cholesterol
- ↓ Cholesterol → bile acids ⇒ ↑ biliary secretion of cholesterol ⇒ ↑ stone risk
- Rapid weight change: ass. w/ ∆ biliary excretion of bile
- Conditions of stasis: autonomic neuropathy (DM)
Pigment Gallstones
Overview
- Predominant gallstone worldwide
- 10-25% of gallstones in the US but higher % in Asians
- Usually < 1cm, many may be present
- Seen in conditions w/ ↑ concentration of unconjugated bilirubin in bile
- Chronic hemolytic anemias (overwhelm deconjugation in biliary tree)
- Severe ileal dysfunction or bypass
- Bacterial/parasitic contamination of the biliary tree
- Infection ⇒ release of microbial Beta-glucuronidases ⇒ hydrolysis of bilirubin glucuronides ⇒ ↓ conjugation in the biliary tree
Black Pigment Stones
- Increased production of unconjugated bilirubin which complexes w/ calcium
-
Content:
- Pure calcium bilirubinate or complexes w/ calcium, mucin, glycoproteins, and copper
-
Association:
- Chronic hemolytic conditions
- Cirrhosis
- Sclerosing Cholangitis
Brown Pigment Stones
- Colonization of bile by enteric organisms
- Soft and Flaky
- Common in Asia
-
Association:
- Biliary Stasis
- Infection
Cholelithiasis
Clinical Manifestations
- 70-80% asymptomatic
-
Symptomatic stones complications:
- Biliary colic
- Cholecystitis
- Empyema, perforation, fistulas
- Pancreatitis
- Ascending cholangitis
- Gallstone ileus: erosion of stone through GB wall and into ileum w/ subsequent intestinal obstruction
- Gallbladder carcinoma (association, not necessarily causal)
Biliary Colic
- Can follow a fatty meal
-
Intermittent obstruction of cystic duct by stones
- ↑ Pressure in gallbladder
- No inflammation of gallbladder mucosa
-
Symptoms:
- Severe, epigastric or RUQ pain increasing over 30 mins and constant for 1-5 hrs
- ± Radiation to right shoulder/scapula
- Normal labs if uncomplicated
- Up to 50%/yr will have another episode
- 1-2%/yr will have a complication
Cholecystitis
Overview
-
Inflammation of the gallbladder
- Acute
- Chronic
- Acute superimposed on chronic
- Common indication for abd surgery in the US
- Usually associated w/ gallstones
Cholecystitis
Pathogenesis
-
Chemical injury:
- Obstruction ⇒ ↑ level of bile salt or acids ⇒ hydrolyzed to lecithin and lysolecithin ⇒ ↑ inflammation
-
Microbials:
-
Bacteria (usu. E. coli or Enterococcus) are present in 80% of acute and 30% of chronic cholecystitis
- Usually secondary rather than precipitating colonization
- Protozoa (e.g. cryptosporidium) may be causal in cases of acalculous cholecystitis, particularly in the immunosuppressed
-
Bacteria (usu. E. coli or Enterococcus) are present in 80% of acute and 30% of chronic cholecystitis
Acute Calculous Cholecystitis
90% of acute cholecystitis
-
Impacted stone in cystic duct or GB neck
-
GB chemical irritation
- Disrupt protective glycoprotein mucus,
- Exposes epithelium to detergent action of bile salts
-
Acute inflammation of gallbladder mucosa:
- Prostaglandins released
- ↑ inflammation of wall w/ edema
- ↑ intraluminal pressure w/ compromised blood flow
- Eventually, may develop bacterial contamination
-
GB chemical irritation
- 75% preceded by biliary colic
-
Symptoms:
- Progressive RUQ or epigastric pain, > 6 hrs
- Murphy’s sign (bedside or sonographic)
- Fever, anorexia, N/V
- Leukocytosis, ± mild ↑ LFTs
- Thick gallbladder wall > 3 mm
- Can require surgery, have spontaneous resolution, or become chronic
Acute Cholecystitis
Morphology
-
Gross:
- Enlarged, tense, blotchy
- Covered w/ fibrinous/fibrinopurulent exudate
- Often identify obstructing stone in GB neck or cystic duct
- Bile may contain pus (empyema)
-
Micro:
- Neutrophilic infiltrate
- Vascular congestion / edema
- Hemorrhage / ulceration
- Fibrin
-
Mucosal/mural necrosis
- Day 3-5
-
Myofibroblastic proliferation
- Day 5-10
-
If very severe:
- ± Necrosis (gangrenous cholecystitis)
- ± Perforation
Acute Acalculous Cholecystitis
5-10% of acute cholecystitis w/o obstruction from a stone
- Pathogenesis involves ischemia
- See inflammation and edema of wall
- Further compromises blood flow
- Bile, mucus and ‘sludge’ may accumulate and block cystic duct
- Often is insidious
- Need a high index of suspicion in these pts
- Males > females (slight effect)
-
Precipitating factors include:
- Burns
- Trauma
- Shock, vasculitis/ischemia
- Critical/chronic illness (ICU pt)
- Diabetes, long term TPN
- Immunosuppression
Gangrenous Cholecystitis
- Gallbladder so inflamed that tissue ischemia results
- Gas forming organisms
- Can lead to gallbladder perforation
- 30% mortality
Empyema of the Gallbladder
Pus around the gallbladder
More severe than traditional cholecystitis
Choledocholithiasis
- Obstruction of CBD which obstructs bile flow out of liver and gallbladder
- Different from cholecystitis in that bilirubin and liver enzymes will be significantly elevated
- AST/ALT usually < 1,000
- Bilirubin spills into urine
- ± Pruritus and acholic stools
- No urobilinogen (usually malignancy only)
- Stone removal is key before cholangitis occurs
Cholangitis
Impacted stone in CBD causing bile stasis and bacterial superinfection
- Charcot’s triad: pain, jaundice and fever
- May become septic
- Fever, hypotension, higher mortality
- Reynolds’ Pentad: Charcot’s triad plus hypotension and AMS
- Need urgent decompression of bile duct
Porcelain Gallbladder
- Intramural calcification of the gallbladder
- Risk factor for carcinoma of the gallbladder
- Plain abdominal film can detect
- Treatment is prophylactic cholecystectomy
Gallstone Ileus
- Inflammation from cholecystitis causes a fistula from gallbladder directly to small intestine
- Stone travels through fistula
- Causes small bowel obstruction at ileocecal valve
- Plain x-ray shows air in biliary tree and SBO
Mirizzi’s Syndrome
Stone impacted in cystic duct mimics choledocholithiasis in presentation and labs
Chronic Cholecystitis
-
Multiple attacks of acute cholecystitis
- May appear as if it is an acute attack
- ± Prior dx/sx of acute cholecystitis
- 90% of pts have stones
-
Morphology:
- Fibrosis w/ ↑ wall thickness, mucosa usually preserved
- Mononuclear cells: lymphocytes, plasma cells and MΦ
- ± Dystrophic calcification in GB wall ⇒ ‘porcelain gallbladder’
- ↑ Incidence of GB cancer
- Hydrops: resorption of bile solids and mucin secretion
Biliary Tract Disorders
Diagnostic Tests
- Labs
- Ultrasound
- CT scan
- HIDA (hepatobiliary scintigraphy)
- MRI/MRCP
- EUS (endoscopic ultrasound)
- ERCP (endoscopic retrograde cholangiopancreatography)
Liver Labs
- Liver Associated Enzymes (LAE’s) ⇒ Alk phos, GGT, ALT, AST
- Liver function tests ⇒ Bilirubin, INR, albumin
-
Stages of biliary obstruction:
- ALT elevation ⇒ within hrs
- Bilirubin elevation ⇒ within one to several days (CA 19-9)
- Duct dilation ⇒ within several days
-
Liver labs (LAE and bilirubin) often lag behind
- Reflect clinical status of pt 6-24 hours before drawn
- ALT and LAE first to improve, then bili then duct dil, then CA 19-9
Biliary Tract Disorders
Ultrasound
- Stones appear as mobile, dependent echogenic foci in gallbladder lumen w/ shadowing
- Sludge appears as layering echogenic material w/o shadows
- Sensitivity > 95% for stones > 2 mm
- Stones seen in CBD in 50%
Biliary Tract Disorders
CT scan
Not great for detecting uncomplicated stones
Excellent test for detecting complications such as:
Abscess, gallbladder perforation, CBD stone, and pancreatitis
Biliary Tract Disorders
Hepatobiliary Scintigraphy (HIDA)
- Assessment of cystic duct patency
- Normal scan: radioactivity in gallbladder, CBD, and small bowel in 30–60 min
- Positive scan (abnormal): non-visualization of gallbladder w/ preserved excretion into CBD or small bowel
- Sensitivity 95%, specificity 90% for acute cholecystitis
- Do not use if bilirubin very high
Biliary Tract Disorders
MRI/MRCP
- Does not require contrast for stones but does for masses
- Can’t give contrast w/ GFR < 30 due to Derm condition
- Best at high stones/common hepatic duct
- Very sensitive and specific but institution dependent
- Still lots of false pos and neg’s ⇒ only use if changes management
- Takes time (1-1.5hr)
- Does not see stents, calcifications well
- Can be hard to get/read at night and on weekends
- Pt cooperation a problem
- Movement obscures
- Claustrophobia
Biliary Tract Disorders
EUS (Endoscopic Ultrasound)
- Sometimes used pre-ERCP
- Not available at all centers
- Invasive (sedation) but low risk, much lower than ERCP
- May be better than MRCP at distal stones
- Allows for fine needle aspiration if tumor suspected
- Much better at ampullary visualization than MRCP
- Can rule out ampullary tumors
Biliary Tract Disorders
Endoscopic Retrograde Cholangiopancreatography (ERCP)
- Gold standard test for choledocholithiasis
- Sensitivity and specificity rates 95%
-
Ability to extract stones (or drain infected bile)
- Lifesaving in severe cholangitis
- Complication rate as high or higher than cholecystectomy
Cholesterolosis of Gallbladder
- Accumulation of cholesterol esters and TAGs in MΦ within lamina propria
- Common, and usually asymptomatic
-
Pathogenesis theories:
- Supersaturation of bile w/ cholesterol
- Abnormal lipid transport
- No association w/ elevated blood cholesterol
-
Gross appearance:
-
Strawberry Gallbladder
- Yellow color on mucosa
-
Strawberry Gallbladder
-
Microscopic:
- Cholesterol esters and triglycerides accumulate in subepithelial “foamy MΦ” and gallbladder epithelium
Gallbladder Carcinoma
Epidemiology and Associations
-
Demographics:
- F:M ratio is 2:1
- Affects older population
- ↑ incidence in Southwest US
-
Associations:
- Gallstones: present in 95% of cases, BUT only 1-2% of pts w/ gallstones develop GB cancer