Pathology of Pancreas, Gallbladder and Extrahepatic biliary tree

Question 1

What are gallstones made of?

Answer 1

Cholesterol
Bile pigment
Mostly they are mixed
- calcium

Question 2

How are gallstones diagnosed?

Answer 2

10% have enough calcium for X-Ray

Most are seen on ultrasound

Question 3

What are the components of bile?

Answer 3

97% water
Cholesterol
Bile acids
Phospholipids
Bile pigment (bilirubin)

Question 4

How are gallstones formed?

Answer 4

Bile becomes lithogenic for cholesterol if there is excessive secretion of cholesterol or decreased secretion of bile salts
Excessive secretion of bilirubin (e.g. haemolytic anaemia) can cause precipitation in concentrated bile in the gallbldder

Question 5

What is acute cholecystitis?

Answer 5

Inflammation of the gallbladder

- normally caused when a gallstone blocks the cystic duct causing supersaturation of bile and chemical irritation

Question 6

What are the signs and symptoms of acute cholecystitis?

Answer 6

Severe RUQ pain
Tenderness
Fever (sepsis)
Leucocytosis
Normal serum amylase

Question 7

What is the outcome for cholecystitis?

Answer 7

Usually resolves spontaneously but can progress to empyema. gangrene and rupture

Question 8

What is the pathophysiology of chronic cholecystitis?

Answer 8

A sequel to repeated attacks of acute cholecystitis
This damages the wall, making it thick and fibrotic
The inflammation is secondary to chemical damage (supersaturated bile) rather than a bacterial infection

Question 9

What is a gallbladder mucocele?

Answer 9

Overdisteneded gallbladder with an epithelial lining filled with mucoid or clear and water content

Question 10

What is the pathophysiology of a gallbladder mucocele?

Answer 10

Usually non-inflammatory
Results in outlet obstruction of the gallbladder (commonly an impacted stone in the neck or cystic duct)
The wall becomes pale, smooth and fibrotic

Question 11

Name some of the causes of acute pancreatitis.

Answer 11

Gallstones
Alcohol abuse (main)
Post-ERCP
Hypercalcaemia
Drugs (azothioprine)
Mumps

Question 12

How does acute pancreatitis present?

Answer 12

Severe upper abdominal pain
- pain not just localised to the gallbladder
Fever
Leucocytosis
Rasied serum amylase

Question 13

What is the pathophysiology of acute pancreatitis?

Answer 13

Blockage of the bile duct (e.g. gallstone at the hepatopancreatic ampulla of Vater)
The causes bile reflux back into the pancreatic duct
The digestive enzymes irritate the cells of the pancreas = pancreatitis

Question 14

What is acute hemorrhagic pancreatitis?

Answer 14

Acute inflammation and necrosis of pancrease parenchyma, focal enzymic necorisis of the pancreatic fat and vessel necrosis (haemorrhage)

• digestion of the vascular walls results in thrombosis and haemorrhage
• lipase activation produces necrosis of fat tissue in the pancreatic interstitium and peri-pancreatic spaces

Question 15

What is a pancreatic abscess?

Answer 15

A potential complication of acute pancreatitis

When pancreatic necrosis becomes infected (an avascular haemorrhagic pancreas is a good culture medium)

Question 16

How is a pancreatic abscess treated?

Answer 16

Drainage or necrosectomy plus antibiotics

Question 17

What is the pathophsyiology of chronic pancreatitis?

Answer 17

Long-standing inflammation of the pancreas
- either episodes of acute inflammation or
- chronic damage with persistent pain or malabsorption
Caused by ductal obstruction
Progressive, irreverisble fibrotic destruction of the pancreatic secretory parenchyma and areas of ductal dilation and stricture

Question 18

What are the signs and symptoms of chronic pancreatitis?

Answer 18

Episodic, epigastric abdominal pain
- episodes stop once the acinar cells have been destroyed (6-10 years)
No pain and malabsorption 
Steatorrhoea 
Diabetes

Question 19

What is the difference between a cyst and a pseudocyst?

Answer 19

Cysts have epithelial linings

- can’t tell the difference on imaging

Question 20

What is a pseudocyst?

Answer 20

Potential complication of acute pancreatitis
Commonly arises in the lesser sac
Contains a high concentration of pancreatic enzymes
May resolve by itself or require draining into the stomach (transmural drainage)

Question 21

What are the possible differentials when you see a pancreatic cyst?

Answer 21

Mucinous cystic neoplasm
- benign, but has an invasive component
Intraductal papillary mucinous neoplasm
- in continuity with the main pancreatic duct or side branch duct
- dysplastic papillary lining, secreting mucin
- risk of malignancy
Serous cystadenoma
- no mucin production
- benign

Question 22

What are the signs and symptoms of carcinoma of the pancreas?

Answer 22

Painless obstructive jaundice
- if in head of pancreas
- painless as it occurs slowly and the gallbladder isn’t contracting forcefully against the blockage
Abdominal pain due to pancreatic insufficiency or nerve invasion
Radiology may show the double duct sign (tumour in the head of the pancreas obstructing the bile and pancreatic ducts)
- you would also see duct dilation with no gallstone presence

Question 23

What is a Whipple’s resection?

Answer 23

When a tumour of the head of the pancreas is removed
- curative intent
Can’t have any metastases
- as most people present late, only 10% of patients are suitable
75% of tumours are incompletely excised
20 month survival rate after operation

Question 24

What is neo-adjuvant therapy?

Answer 24

Chemotherapy

• the administration of a therapeutic agent before the main treatment
• e.g. trying the shrink the tumour before surgery

Question 25

Give some examples of neo-adjuvant therapy for carcinoma of the pancreas?

Answer 25

Folfirinox chemotherapy

- limited improvement in metastatic disease

Question 26

What is a pancreatic endocrine tumour?

Answer 26

A tumour of the islets in the pancreas
- some secrete hormones (functional)
- most common function tumour is an insulinoma, which presents with hypoglycaemia
Rare
Most insulinomas are bengin
Malignant endocrine tumours have better prognosis than pancreatic carcinoma

Question 27

What is carcinoma of the ampulla of Vater?

Answer 27

A malignant tumour in the last 2cm of the common bile duct, where it passes through the duodenal wall
Presents early due to bile obstruction
May arise from a pre-existing adenoma (intestinal)

Question 28

How is carcinoma of the ampulla of Vater treated?

Answer 28

Whipple’s resection

- 25% 5 year survival

Question 29

What is a Cholangiocarcinoma?

Answer 29

A tumours of the connective tissues of the bile ducts

Classified as wither intra- or extra-hepatic depending on the origin

Question 30

Why is it hard to diagnose a Cholangiocarcinoma?

Answer 30

Has a similar histology to metastitic adenocarcinoma
In the same organ are hepatocellular carcinoma
Extrahepatic carcinoma’s have similar morphology and prognosis to pancreatic carcinoma

Question 31

What is the treatment of a Cholangiocarcinoma?

Answer 31

Whipple’s operation to remove the common bile duct and involved pancreas and duodenum
No chemotherapy as of yet

Question 32

Describe a carcinoma of the gallbladder.

Answer 32

Rare
Gallstones are present in 80% of cases
Adenocarcinoma
Bad prognosis unless found incidentally in a gallbladder removed for chronic cholecystitis
- complete excision