Pathology of Biliary Tract and Pancreas Flashcards
Cholelithiasis
Gallstones
What are gallstones?
Hard, stone-like or gravel-like material formed in the biliary system, most commonly the gallbladder
Normal components of bile
Micelles of cholesterol, phospholipids, bile salts, bilirubin
Where is bile stored and concentrated?
Gallbladder
Bile is released by ___ into the 2nd part of the ___ through the ___ ___ ___ and the ___ __ ___
Bile is released by cholecystokinin into the 2nd part of the duodenum through the common bile duct and the Ampulla of Vater
Pathogenesis of cholesterol stones
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
Risk factors for cholesterol stones
Cholesterol excess in bile - female, obesity, diabetes, genetics
Pathogenesis of pigment stones
Excess bilirubin cannot be solubilised in bile salts
Risk factors for pigment stones
Excess bilirubin due to excess haemolysis
Pathogenesis of gallstones
Gallbladder pH and mucosal glycoproteins may be contributory factors, infection and inflammation of biliary lining
What can gallstones cause?
Acute and chronic cholecystitis, mucocoele, empyema, carcinoma, ascending cholangitis, obstructive jaundice, gallstone ileus, acute/chronic pancreatitis
Cholecystitis
Inflammation of the gallbladder
Acute cholecystitis:
- What causes it?
- What can it lead to?
- What is acute inflammation indicated by?
- 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
Chronic cholecystitis:
- What can cause it?
- Describe the gallbladder wall
- Histological features
- Associated with gallstones, may arise insidiously or after bouts of acute cholecystitis
- Thickened gallbladder wall
- Chronic inflammation and Rokitansky-Aschoff sinuses
Cholangiocarcinoma
Carcinoma of the bile ducts
Which conditions is cholangiocarcinoma associated with?
Ulcerative colitis and primary sclerosing cholangitis
How does cholangiocarcinoma present?
Jaundice, weight loss, anorexia, lethargy
Pancreatitis
Inflammation of the pancreas
Aetiology of acute pancreatitis
Cholelithiasis, alcohol, shock, mumps, hyperparathyroidism, hypothermia, trauma, iatrogenic
Pathogenesis of acute pancreatitis
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
Complications of acute pancreatitis
Death, shock, pseudocyst formation, abscess formation, hypoglycaemia, hyperglycaemia
Aetiology of chronic pancreatitis
Alcohol, cholelithiasis, cystic fibrosis, hyperparathyroidism, familial
Pathology of chronic pancreatitis
Replacement of pancreas by chronic inflammation and scar tissue, destruction of exocrine acini and islets
Carcinoma of the pancreas:
- What is it associated with?
- Prognosis
- Microscopic view
- Spread
- Smoking, diabetes, familial pancreatitis
- Poor prognosis
- Irregular abortive glands in a dense stroma
- Can spread directly, to local lymph nodes or haematogenous to liver
Risk factors for cholelithiasis
Age >40, female, high fat diet, obesity, pregnancy, hyperlipidaemia, bile salt loss, diabetes, dysmotility of gallbladder, prolonged fasting, TPN
Biliary colic
Symptomatic cholelithiasis
Biliary colic symptoms
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
Diagnosis of gallstones
Ultrasound, CT scan, MRCP/ERCP, HIDA, endoscopic ultrasound
Treatment for biliary colic
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
Diagnosis for acute cholecystitis
Ultrasound
Management of acute cholecystitis
IV antibiotics and IV fluids, nil by mouth, urgent cholecystectomy
Gallstone ileus
Small bowel obstruction caused by gallstones
Treatment for gallstone ileus
Urgent laparotomy - small bowel enterectomy to remove stone, interval cholecystectomy in 3 months
What can be used to help stage cholangiocarcinoma?
Duplex ultrasound, spiral CT/ECRP/PTC, MRI/MRCP/MRA
Treatment for cholangiocarcinoma
Surgical resection of bile duct and liver
What is ERCP treatment for?
Bile duct stones with obstruction
