Pancreaticobiliary disease Flashcards
___ = gallstones
There are two types of gallstones: ___ (yellow) and ___ (brown)
Cholelithiasis = gallstones
There are two types of gallstones: cholesterol stones (yellow) and mixed/bilirubin stones (brown)
Normal bile comprises of a mixture of ___
How do cholesterol stones develop (i.e. what’s the starting mechanism and the rest of the pathway?)
Normal bile: mixture of bile, cholesterol and lecithin
Cholesterol stones form when there’s an event like supersaturation that disrupts this homeostasis
(supersaturation >> nucleation >> microstone formation >> gallstones)
Name the risk factors for cholesterol stones (name as many as you can recall)
Risk factors: obesity, Native American heritage, Crohn’s disease advanced age, multiparity, estrogen therapy (4 F’s – female , fat, fertile, forty)
**Crohn’s disease of the ileum (the ileum is what does bile salt absorption so if there’s diseased ileum, you won’t absorb bile salts and so you’ll have increased cholesterol)**
Black pigement stones occur from increased ___ bilirubin whereas brown pigment stones occur from ___
Black pigement stones occur from increased unconjugated bilirubin whereas brown pigment stones occur from infectious/bacterial cause
**black - radiopaque, brown - radiolucent**
Often occur w/ hemolysis
What is a major symptom of gallstones?
Name some of the complication of gallstones (5)
Major symptom of gallstones: biliary colic - pain
Complications of gallstones: cholestitis, common onstruction, acute pancreatitis, gallbladder cancer, gallstone ileus (happens if you pass a large gallstone)
A 52 year old male pt stops by your office for a 2nd opinion. He has recently been refered for cholecystectomy following a presentation with belching, bloating, fatty food intolerance and chronic pain for a month.
Would you refer this pt still for the cholecystectomy?
Nah.
Belching, bloating, fatty food intolerance, chronic pain are NOT attributed to gall stones
A 52 year old female pt comes to you for evaluation of her chest pain. She has been experiencing severe pain almost immediately after eating, typically foods like burgers and fries. The pain radiates to the chest, which makes her scared that she’s having a heart attack, and these symptoms occur at night.
What biliary disorder is on your differential?
Gallstones
*biliary colic - ass’d w/ nausea/vomiting + dull RUQ pain; neurohormonal activation triggers gallbladder contraction ?? stone into cystic duct*
What is shown below?
Ultrasound showing gallstones
**Gallstone testing: extracorporeal ultrasound w/ the pt fasting
There will be air in the gallbladder and since the sound waves can’t penetrate the gall stones (appear bright), there will also be post-acoustic shadowing**
___ occurs when a gallbladder gets stuck in the cystic duct, resulting in gallbladder inflammation and severe RUQ pain w/ nausea, vomiting, fever and jaundice
Acute cholecystitis occurs when a gallbladder gets stuck in the cystic duct, resulting in gallbladder inflammation and severe RUQ pain w/ nausea, vomiting, fever and jaundice
**can also be chronic**
A pt presents to your clinic with a 3 month history of fever, nausea, vomiting and severe RUQ pain. The patient also has mild scleral icterus and notes severe pain when taking a deep breath. The patient gets an ultrasound which shows gallbladder wall thickening and inflammation.
What is on your differential?
Acute cholecystitis
*calculous vs acalculous: former = most common; can produce secondary infection (hence leukocytosis); latter = due to gallbladder stasis, hypoperfusion or CMV infection
*Murphy’s sign: inspiratory arrest on RUQ palpation due to pain; may radiate to right shoulder due to phrenic nerve irritation*
Acute cholecystitis can be diagnosed using what 2 methods?
Ultrasound (shows wall thickening, fluid around gallbladder + tenderness >> sonographic Murphy’s sign)
HIDA scan (cholescintigraphy)
A pt is being evaluated for severe RUQ pain and inspiratory arrest upon palpation. The pt undergoes an ultrasound,shown below. What is the diagnosis and how do you know?
Acute cholecystitis - there’s wall thickening >3mm, fluid around the gallbladder, stones and the pt likely felt pain when pocked in the gallbladder
Describe how the HIDA scan works
Early phase: bile in the common duct
Normally, tracer is taken up to gallbladder and following fatty meal, secreted into duodenum
Tracer wouldn’t get to gallbladder if there’s obstruction
___ results from stone escaping gallbladder and lodging in common bile duct
What enzymes might be elevated? (4)
Choledocholithiasis results from stone escaping gallbladder and lodging in common bile duct
Elevated Alk phos, GGT, direct bilirubin, AST/ALTs
**pts present w/ jaundice, fever etc**
Below is MRCP imaging for a pt. What is the diagnosis?
Choledocholelithiasis
**
No contrast
Fluid – bright
Shows bile duct, pancreatic duct (next to bile duct), and 3 filling defects in bile duct (aka obstructions)
A pt presents w/ RUQ pain, jaundice and fever following a fatty meal. The pt also reports being more confused. Vital signs reveal hypotension, and the pt has abnormal liver tests and increased WBCs.
What is the diagnosis?
Ascending cholangitis/choledocholithiasis cholangitis:
Charcot’s triad: RUQ pain, jaundice and fever
Reynold’s pentad: Charcot’s triad + hypotension/shock + altered mental status (which is what this pt has)
How do gallstones lead to pancreatitis? (2)
At the common passage of the bile and pancreatic ducts, gallstones can lead to bile reflux into the pancreas or otherwise activation of the pancreatic enzymes >> acinar cell damage
*elevated ALT + alk Phos >> improve w/ obstruction removal*
How do you treat Cholelithiasis? (4)
How do you treat choledocholithiasis? (1)
Surgery, oral dissolution, contact dissolution, extracorporial lithotripsy
ERCP for choledocholithiasis
___ is characterized by autodigestion of the pancreas by pancreatic enzymes
Acute pancreatitis is characterized by autodigestion of the pancreas by pancreatic enzymes
**presents w/ epigastric abdominal paincoming from the back + increased serum amylase, lipase
The primary causes of acute pancreatitis are (2)
What are some other causes? (I GET SMASHED)
Primary causes of acute pancreatitis = alcohol + gallstones
(from First Aid:
Idiopathic
Gallstones
Ethanol (alcohol)
Trauma
Steroids
Mumps
Autoimmune disease
Scorpion sting
Hypercalcemia/Hypertriglyceridemia
ERCP
Drugs (sulfa drugs, NRTIs, protease inhibitors)
Review the systemic effects of pancreatitis/pancreas enzymes
Review the clinical features of pancreatitis below
*note that the lab tests aren;t specific (FA says lipase is more specific)
How do you treat pancreatitis? (3)
Mainly supportive care and try to reduce inflammation
Also treat complications
One of the complications of acute pancreatitis is fluid accumulation, which can be ___, later developing into a ___ (hint: literally fake cyst)
One of the complications of acute pancreatitis is fluid accumulation, which can be extrapancreatic, later developing into a pseudocyst*
*Pseudocyst: lined by granulation, not epithelial lining; complication of severe acute pancreatitis*
___ is characterized by chronic inflammation, atrophy and calcification of the pancreas
Chronic pancretitis is characterized by chronic inflammation, atrophy and calcification of the pancreas
**complications: pancreatic insifficiency - presents w/ steatorrhea, fat-soluble vitamin -, diabetes mellitus**
+/- amylase, lipase elevation
The major causes of chronic pancreatitis are (2)
The major causes of chronic pancreatitis alcohol use + idiopathic (first aid says genetic predisposition)
**
High triglycerides: >1000
Autoimmune IgG4 related pancreatitis – mimics pancreatic mass; treat w/ steroids and goes away
What are the effects of alcohol in chronic pancreatitis? (6)
Don’t really know but:
cytotoxic lymphocytes
calcification
fibrosis
altered protein synthesis
decreased blood flow
direct effects
Describe pancreas divisum
Pancreas divisum – failure of fusion of pancreatic buds; mostly drained thru minor papilla instead of major papilla (usually no consequence but might cause pancreatitis)
Review the slide on hereditary pancreatitis
Steatorrhea in chronic pancreatitis develops due to lack of __ and __
Steatorrhea in chronic pancreatitis develops due to lack of lipase and duodenal bicarbonate
**Fat malabsorption (no absorption of fat soluble vitamins); presents as loose stool w/ excessive fat**
Describe the graph below
Fecal fat absorbed until lipase output drops below < 10% of normal
Replaced w/ exogenous lipase
How do pts w/ chronic pancreatitis develop diabetes?
Due to loss of insulin and glucagon
**
Brittle – hard to control
Don’t usually develop diabetic ketoacidosis
How do you diagnose chronic pancreatitis? (based on 2 things)
Dx based on structure or function
**see below for deetz**
If calcification present: end stage, but also diagnostic
Can also measure glucose but if that is off, its also an end stage feature
Pts with pancreatitis can also develop cysts. What are 3 types of cystic pancreatic lesions?
Pseudocyst - inflammatory
Serous cystadenoma
Mucinous cyst: mucinous cystadenoma or intra papillary mucinous neoplasm (IPMN)
A ___ develops following a history of severe pancreatitis and is anechoic, thick walled w/ rare septations
A pseudocyst develops following a history of severe pancreatitis and is anechoic, thick walled w/ rare septations
*see below*
What is shown by the imaging below? (hint: this pt had pancreatitis)
Pseudocyst
An imaging evaluation for a pt shows a microcyst w a honey comb appearance, central calcification, thin + clear fluid, that stains +ve for glycogen
What is the diagnosis?
Serous cystadenoma
What is indicated by the imaging below?
Serous cystadenoma
The difference between serous cystadenomas and mucinous cystadenomas is that ___ are pre-malignant and contain viscous fluid. Can also cause symptoms if large
The difference between serous cystadenomas and mucinous cystadenomas is that mucinous cystadenomas are pre-malignant and contain viscous fluid. Can also cause symptoms if large.
*see below*
Name the types of intraductal papillary mucinos neoplasms (3)
Main duct - has dilated main duct w/ thick fluid + mucin
Branch type, and Mixed
*see slide for deetz*
Which type of IPMN is indicated below?
IPMN branch type
Which IPMN is indicated below?
IPMN main duct
*Fishmouth deformity – pathognomonic for IPMN main duct*
How does pancreatic cancer present?
Depends on the location
(see slide)
Risk factors: smoking, chronic pancreatitis, diabetes, +50 yoa, Jewish + AA males
**double duct sign**
