Pathology of the Biliary Tree and Pancreas

Question 1

What is cholelithiasis?

Answer 1

Gallstones

Question 2

Normal components and release of bile?

Answer 2

Micelles of cholesterol, phospholipid, bile salts and bilirubin

Stored and conc. in the gallbladder and released by CCK into the 2nd part of the duodenum, through the CBD and ampulla of Vater

Question 3

Pathogenesis of gallstones?

Answer 3

Imbalance between the ratio of cholesterol : bile salts, disrupting micelle formation

Question 4

Causes of excess cholesterol in bile, i.e: cholesterol gallstones?

Answer 4

5 Fs:
Female
Fat 
Fair (caucasian) 
Fertile
Forty (>40 years)

Question 5

What are pigment gallstones?

Answer 5

Excess bilirubin cannot be solubilised in bile salts, e.g: due to excess haemolysis in haemolytic anaemia

Question 6

What is cholecystitis?

Answer 6

Inflammation of the GALLBLADDER that is usually assoc. with gallstones; it can be acute or chronic and is very common

Question 7

Pathogenesis of acute cholecystitis?

Answer 7

Gallstones obstruct the outflow of bile; initially, the gallbladder is sterile but then is infected, causing:
Empyema
Rupture
Peritonitis

It can also cause adhesions within a few days

Question 8

Histopathology of acute cholecystitis?

Answer 8

Acute inflammation is indicated by neutrophils

Question 9

Pathogenesis of chronic cholecystitis?

Answer 9

Assoc. with gallstones; this may develop insidiously or after episodes of acute cholesytitis

The gallbladder wall is THICKENED but not distended

Question 10

Histopathology of chronic cholecystitis?

Answer 10

Chronic inflammation and Rokitansky-Aschoff sinuses (outpouchings of gallbladder mucosa into the gallbladder muscle layer)

Question 11

Occurence of gallbladder carcinoma?

Answer 11

Rare but are adenocarcinomas; they are assoc. with gallstones

Can locally invade into the liver

Question 12

Occurence and presentation of cholangiocarcinoma (carcinoma of bile ducts)?

Answer 12

Rare and is an adenocarcinoma that is assoc. with UC and PSC; presents with obstructive jaundice

Question 13

What is a gallstone ileus?

Answer 13

Fistula forms between the inflamed gallbladder and the duodenum; the stone passes until it becomes trapped in the ileo-caecal junction

Question 14

What is pancreatitis?

Answer 14

Acute/chronic inflammation of the pancreas

Question 15

Presentation of acute pancreatitis?

Answer 15

Tends to occur in adults; there is sudden onset, severe abdominal pain (epigastric/umbilical) and patients can be in shock

Question 16

Ix for acute pancreatitis?

Answer 16

Elevated serum amylase

Question 17

Causes of acute pancreatitis?

Answer 17

Idiopathic

Gallstones
Ethanol (alcohol)
Trauma

Steroids
Mumps (other infections/malignancy)
Autoimmune 
Scorpion stings/spider bites
Hyperlipidaemia / hypercalcaemia / hyperparathyroidism (metabolic disorders)
ERCP
Drugs

Question 18

Pathogenesis of acute pancreatitis?

Answer 18

Causes of acute pancreatitis cause epithelial injury of the pancreatic duct; there is a loss of the protective barrier, allowing auto-digestion of the pancreatic acini

Lytic pancreatic enzymes (proteases, lipases) are released:
Intra- and peri-pancreatic fat necrosis due to lipases
Tissue destruction and haemorrhage due to proteases

Question 19

Complications of pancreatitis?

Answer 19

Pseudocyst formation 
Abscess formation
Hypocalcaemia
Hyperglycaemia
Shock and death

Question 20

Aetiology of chronic pancreatitis?

Answer 20

Alcohol
Cholelithiasis
Cystic fibrosis
Hyperparathyroidism
Familial tendency

Question 21

Pathogenesis of chronic pancreatitis?

Answer 21

Chronic inflammation and replacement of pancreas with fibrous tissue; there is destruction of the exocrine acinar cells and of the endocrine Islets (of Langerhan)

Question 22

Aetiology of pancreatic carcinoma?

Answer 22

Unknown aetiology but usually adenocarcinomas

Question 23

Risk factors for pancreatic carcinoma?

Answer 23

Smoking
Diabetes
Familial pancreatitis

Question 24

Spread of carcinomas of the pancreas, depending on location?

Answer 24

Carcinoma of the head can lead to invasion into the duodenal wall OR the tumour can constrict the CBD

Carcinoma of the tail can spread by direct invasion of the spleen

Question 25

Spread of adenocarcinomas of the pancreas?

Answer 25

Direct spread to other organs, e.g: duodenum, stomach and spleen

Spread to local lymph nodes

Haematogenous spread to liver