Gallstones

Question 1

What is cholelithiasis?

Answer 1

Gallstones

Formed from constituents of the bile:
cholesterol
calcium salts (phosphates, carbonates)
bilirubin (calcium bilirubinate)
Two main types
Cholesterol stones
Pigment stones

Question 2

What decreases bile acid causing gall stones?

Answer 2

Oestrogens
Excessive gut loss (terminal ileal disease eg Crohn’s)
Bile salts have been used to dissolve stones

Question 3

What causes pigmented gallstones?

Answer 3

Calcium bilirubinate
biliary infections
Abnormal red cell breakdown (haemolytic anaemia)

CAB

Question 4

what can gallstones cause?

Answer 4

“Chronic cholecystitis”
Obstruction
Predisposition to Carcinoma of the Gall Bladder and Biliary tract
Small minority of cases

Question 5

What is chronic cholecystitis?

Answer 5

Longstanding irritation of gall bladder
Thickening of gall bladder wall
Muscle hypertrophy
Low grade chronic inflammation
Fibrosis
Diverticula - misplacement of mucosa into wall
“Rokitansky-Aschoff sinuses”
Motility disorders
Dyspepsia
Right upper quadrant pain, often related to fatty foods

Question 6

What sinuses are mostly effected by gallstones?

Answer 6

Rokitansky-Aschoff sinuses

Question 7

Signs of cystic duct obstruction?

Answer 7

Acute (on chronic) cholecystitis
Secondary infection by bowel bacteria
Purulent bile
Empyema
Septicaemia
Perforation

Question 8

Tell me about acalculous cholecystitis?

Answer 8

5-10% of all acute cholecystitis
Usually a complication of some other critical illness
Sepsis, trauma, burns
Total parenteral nutrition
Due to increased bile viscosity and ischaemia
Poor prognosis

Question 9

Common duct stones?

Answer 9

Biliary colic
Obstructive jaundice
-Dilated bile ducts (ultrasound)
-Enlarged green stained liver

Question 10

Causes of obstructive jaundice?

Answer 10

Extrahepatic bile duct obstruction
Pale stools, dark urine
Conjugated hyperbilirubinaemia
Raised alkaline phosphatase
Mildly raised transaminases
Malabsorption of fat and vitamin K
Itching
Ascending cholangitis
Septicaemia
Liver abscess

Benign bile duct strictures
Instrumentation / surgery
Sclerosing cholangitis
HIV cholangiopathy (CMV, cryptosporidiosis)
Parasites (Clonorchis, Ascaris, Fasciola)
Carcinoma of
the bile duct
The duodenum (ampulla of Vater)
The pancreas
Compression of bile ducts by extrinsic masses

Question 11

Tell me about carcinoma of the gall bladder?

Answer 11

Adenocarcinoma
Preceded by dysplasia
Rare
Elderly women
90% have gall stones
Local structures (especially liver) usually invaded at presentation
Poor prognosis
Median survival 6 months

Question 12

Tell me about carcinoma of the bile duct?

Answer 12

Uncommon in West (but increasing)
Commoner in Orient
Associated with
Gall stones
Clonorchis sinensis
Inflammatory bowel disease (sclerosing cholangitis)
Congenital abnormalities (eg choledochal cyst)
Often multifocal
Painless obstructive jaundice, cholangitis
Poor prognosis

Question 13

How would you examine the gall bladder and pancreas?

Answer 13

Endoscopic retrograde cholangio-pancreatography

Question 14

Tell me about pancreatitis?

Answer 14

Common, incidence 0.1-1/1000 in West
Acute inflammation, haemorrhage and necrosis of pancreas
Liberation of digestive enzymes
Raised serum amylase

Fat necrosis
Secondary bacterial infection
May lead to pancreatic pseudocyst
Conversion of necrotic pancreas into a cyst filled with fluid and necrotic debris

Severe abdominal pain
Jaundice if CBD obstructed
Peritonitis - chemical, bacterial
Shock
Septicaemia
Adult respiratory distress syndrome
GI haemorrhage
Acute renal failure
10-15% mortality

Question 15

Causes of acute pancreatitis?

Answer 15

Alcohol
Gall stones
Iatrogenic
Abdominal trauma
Drugs
azathioprine, antibiotics, diuretics, NSAIDs
Infections
Mumps, EBV

Hereditary
Autosomal dominant
Hypercalcaemia
Tumours (obstruction)
Congenital anomalies
Hypothermia
Ischaemia
Idiopathic

Question 16

Tell me about chronic pancreatitis?

Answer 16

Localised or widespread
Chronic, irreversible inflammation of the pancreas
Fibrosis and calcification
Progressive destruction of acinar and endocrine tissue
Duct dilatation and strictures
Often indistinguishable from a tumour without histology

Signs:

Recurrent abdominal pain
Pancreatic exocrine insufficiency (malabsorption)
Pancreatic endocrine insufficiency (diabetes mellitus)
Serum amylase often normal
May be bouts of superimposed acute pancreatitis

Question 17

Causes of chronic pancreatitis?

Answer 17

Alcohol
Autoimmunity (IgG4)
Hereditary
Cystic fibrosis (duct obstruction by viscid mucus)
Autosomal dominant pancreatitis
Haemochromatosis
Tropical (India & Africa)
Biliary disease
Hypercalcaemia
Idiopathic

Question 18

Tumours of the pancreas?

Answer 18

Exocrine:
Benign - uncommon
Cystadenomas
Borderline - uncommon
Intraductal papillary mucinous tumours
Mucinous cystic tumours
Malignant - common
Ductal adenocarcinoma
Rarities

Endocrine (islet cell tumours)

Common, increasing incidence
Aetiology largely unknown
Smoking, diabetes, chronic pancreatitis
5% have a family history (incl. BRCA2)
Arises from ductal epithelium
K-ras, CDKN2A and p53 mutation common
Pre-invasive dysplasia recognised

60% head of pancreas
Progressive painless jaundice
Palpable dilatation of gall bladder (Courvoisier)
Duodenal erosion / bleeding
10% body, 10% tail
Ill defined upper abdominal pain radiating to back
Weight loss
Metastases - lymph nodes, liver
Migratory thrombophlebitis (Trousseau)

Question 19

How would you diagnose carcinoma of the pancreas?

Answer 19

Diagnosis:
Tumour markers - CA19-9
Imaging (CT, ERCP, endoscopic ultrasound)
Pancreatic juice cytology (? molecular diagnosis)
Biopsy
Needle core, aspiration cytology, operative

Prognosis
Poor 5 year survival 5%; (15-20% if operable)

Question 20

Tell me about pancreatic endocrine tumours?

Question 21

Name 5 functioning tumours?

Answer 21

Often very small
Insulinoma
Hypoglycaemic attacks, confusion, behavioural disturbance
Glucagonoma
Anaemia, diabetes, skin disease (necrolytic migratory erythema)
VIPoma
Watery diarrhoea
Gastrinoma
Zollinger-Ellison syndrome (high gastric acid output)
Somatostatinoma
Diarrhoea, diabetes, gall stones