Pathology of Biliary Tract and Pancreas

Question 1

Cholelithiasis

Answer 1

Gallstones

Question 2

What are gallstones?

Answer 2

Hard, stone-like or gravel-like material formed in the biliary system, most commonly the gallbladder

Question 3

Normal components of bile

Answer 3

Micelles of cholesterol, phospholipids, bile salts, bilirubin

Question 4

Where is bile stored and concentrated?

Answer 4

Gallbladder

Question 5

Bile is released by ___ into the 2nd part of the ___ through the ___ ___ ___ and the ___ __ ___

Answer 5

Bile is released by cholecystokinin into the 2nd part of the duodenum through the common bile duct and the Ampulla of Vater

Question 6

Pathogenesis of cholesterol stones

Answer 6

Gallstones form when there is an imbalance between the ratio of cholesterol to bile salts disrupting micelle formation and there is free crystallisation of cholesterol on micelle surface

Question 7

Risk factors for cholesterol stones

Answer 7

Cholesterol excess in bile - female, obesity, diabetes, genetics

Question 8

Pathogenesis of pigment stones

Answer 8

Excess bilirubin cannot be solubilised in bile salts

Question 9

Risk factors for pigment stones

Answer 9

Excess bilirubin due to excess haemolysis

Question 10

Pathogenesis of gallstones

Answer 10

Gallbladder pH and mucosal glycoproteins may be contributory factors, infection and inflammation of biliary lining

Question 11

What can gallstones cause?

Answer 11

Acute and chronic cholecystitis, mucocoele, empyema, carcinoma, ascending cholangitis, obstructive jaundice, gallstone ileus, acute/chronic pancreatitis

Question 12

Cholecystitis

Answer 12

Inflammation of the gallbladder

Question 13

Acute cholecystitis:

• What causes it?
• What can it lead to?
• What is acute inflammation indicated by?

Answer 13

• Gallstones obstructing the flow of bile, initially sterile then becomes infected
• Causes intense adhesions within 2-3 days, may cause empyema, rupture, peritonitis
• Acute inflammation is indicated by neutrophils

Question 14

Chronic cholecystitis:

• What can cause it?
• Describe the gallbladder wall
• Histological features

Answer 14

• Associated with gallstones, may arise insidiously or after bouts of acute cholecystitis
• Thickened gallbladder wall
• Chronic inflammation and Rokitansky-Aschoff sinuses

Question 15

Cholangiocarcinoma

Answer 15

Carcinoma of the bile ducts

Question 16

Which conditions is cholangiocarcinoma associated with?

Answer 16

Ulcerative colitis and primary sclerosing cholangitis

Question 17

How does cholangiocarcinoma present?

Answer 17

Jaundice, weight loss, anorexia, lethargy

Question 18

Pancreatitis

Answer 18

Inflammation of the pancreas

Question 19

Aetiology of acute pancreatitis

Answer 19

Cholelithiasis, alcohol, shock, mumps, hyperparathyroidism, hypothermia, trauma, iatrogenic

Question 20

Pathogenesis of acute pancreatitis

Answer 20

Pancreatic duct epithelial injury → loss of protective barrier allowing autodigestion of pancreatic acini → release of lytic pancreatic enzyme proteases and lipase → intra- and peripancreatic fat necrosis → tissue destruction and haemorrhage

Question 21

Complications of acute pancreatitis

Answer 21

Death, shock, pseudocyst formation, abscess formation, hypoglycaemia, hyperglycaemia

Question 22

Aetiology of chronic pancreatitis

Answer 22

Alcohol, cholelithiasis, cystic fibrosis, hyperparathyroidism, familial

Question 23

Pathology of chronic pancreatitis

Answer 23

Replacement of pancreas by chronic inflammation and scar tissue, destruction of exocrine acini and islets

Question 24

Carcinoma of the pancreas:

• What is it associated with?
• Prognosis
• Microscopic view
• Spread

Answer 24

• Smoking, diabetes, familial pancreatitis
• Poor prognosis
• Irregular abortive glands in a dense stroma
• Can spread directly, to local lymph nodes or haematogenous to liver

Question 25

Risk factors for cholelithiasis

Answer 25

Age >40, female, high fat diet, obesity, pregnancy, hyperlipidaemia, bile salt loss, diabetes, dysmotility of gallbladder, prolonged fasting, TPN

Question 26

Biliary colic

Answer 26

Symptomatic cholelithiasis

Question 27

Biliary colic symptoms

Answer 27

Stone impacts in cystic duct causing a gradual build-up of pain in the RUQ that radiates to the back/shoulder. Associated with indigestion and nausea. May last 2-6 hours

Question 28

Diagnosis of gallstones

Answer 28

Ultrasound, CT scan, MRCP/ERCP, HIDA, endoscopic ultrasound

Question 29

Treatment for biliary colic

Answer 29

Painkillers, low fat diet/lose weight if obese, if recurrent episodes pain/colic then consider referral for surgery - cholecystectomy, ursodeoxycholic acid 10mg/kg/day if unfit

Question 30

Diagnosis for acute cholecystitis

Answer 30

Ultrasound

Question 31

Management of acute cholecystitis

Answer 31

IV antibiotics and IV fluids, nil by mouth, urgent cholecystectomy

Question 32

Gallstone ileus

Answer 32

Small bowel obstruction caused by gallstones

Question 33

Treatment for gallstone ileus

Answer 33

Urgent laparotomy - small bowel enterectomy to remove stone, interval cholecystectomy in 3 months

Question 34

What can be used to help stage cholangiocarcinoma?

Answer 34

Duplex ultrasound, spiral CT/ECRP/PTC, MRI/MRCP/MRA

Question 35

Treatment for cholangiocarcinoma

Answer 35

Surgical resection of bile duct and liver

Question 36

What is ERCP treatment for?

Answer 36

Bile duct stones with obstruction