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Digestive > 24 - Pancreatic and gall bladder pathology > Flashcards

24 - Pancreatic and gall bladder pathology Flashcards

1
Q

What do I need to know

A
  1. acute and chronic pancreatitis
  2. pancreatic adenocarcinoma
  3. cholelithiasis
  4. acute and chronic cholecystitis
  5. GB adenocarcinoma (rare)
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2
Q

What are the symptoms of pancreas injury like and why?

A

They are non-specific and tend to present late in disease progression as it is a hidden organ

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3
Q

What cells make up the exocrine pancreas?

A

Acinar cells and ductal cells

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4
Q

Acinar cells contain …

A

Zymogen granules that contain inactive enzyme precursors for trypsin, chymotrypsin, elastase, nuclease, amylase, lipase (proenzymes)

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5
Q

What does damage to cells cause?

A

Damage to acinar cells causes release of pancreatic digestive enzymes

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6
Q

What activates the pancreatic enzymes?

A

Trypsin (activated form trypsinogen by enterkinases)

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7
Q

Why is inflammation of the pancreas usually increased compared to other organs?

A

Initial injury can cause damage to acinar cells causing release and premature activation of pancreatic enzymes that further damage the pancreas

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8
Q

How much of the pancreas function does the endocrine component make up and what does it consist of?

A
  • Islets of Langerhan
  • secretes insulin and glucagon
  • pathology is diabetes
  • only 10-20% of liver
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9
Q

Main pathologies of the pancreas

A
  • pancreatitis
  • cystic fibrosis
  • carcinoma
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10
Q

Are most cases of acute pancreatitis fatal?

A

60-70% are mild and most recover

30-40% are severe and 20-30% mortality rate

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11
Q

What are the 4 main mechanisms of pancreatitis?

A
  1. Metabolic
  2. Mechanical
  3. Vascular
  4. Infection
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12
Q

Metabolic mechanism of pancreatitis?

A

Alcohol

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13
Q

Mechanical pancreatitis?

A

Gallstone (cholelitiasis) and trauma

Obstruct and damage the pancreatic duct

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14
Q

Vascular pancreatitis?

A

Shock - low BP and organ perfusion, sepsis, trauma

Vasculitis

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15
Q

Infection pancreatitis?

A

Especially viral i.e. mumps

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16
Q

Most common causes of pancreatitis?

A

Alcohol and gallstones

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17
Q

What is the pathology of pancreatitis?

A
  • initial injury stimulus and body’s inflammatory response/cytokines damage pancreatic glands and acinar cells
  • release of pancreatic enzymes
  • autodigestion of pancreatic tissue
  • further increases inflammatory response, cytokine release and ongoing tissue damage
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18
Q

Consequence of pancreatic enzymes release?

A

Proteases - proteolytic destruction of acini, ducts, islets
Lipases - fat necrosis and pancreas and other sites
Elastases - damage BVs leading to interstitial bleeding and bleeding into glands
Cell Injury response - inflammation, oedema, ischaemia

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19
Q

What are the 2 main initial injury events that occur in the pancreas?

A
  1. Obstruction of the pancreatic duct

2. Direct injury to acinar cells

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20
Q
  1. Obstruction of the pancreatic duct
A
  • i.e. gall stones and ductal concretions
  • block enzyme (and HCO3-) release
  • pressure increase in pancreas and ducts
  • increase pressure
  • interstitial oedema and local inflammation
  • oedema compromises local blood flow leading to ischemia
  • fat necrosis as lipase active
  • damage to acinar cells and enz release
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21
Q
  1. Direct injury to acinar cells
A
  • alcohol, drugs, trauma, viruses, ischemia
  • inflammatory response
  • enzyme release
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22
Q

Clinical features of pancreatitis?

A

Non-specific

  1. Acute epigastric pain (LUQ)
  2. Nausea and vomitting (close to stomach)
  3. Fever and tachycardia - cytokine response
  4. Abdominal tenderness
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23
Q

How is pancreatitis diagnosed?

A
  • high WBC (generic to all inflammation)
  • MAIN: high serum amylase/lipase due to enzyme release into peripheral blood
  • CT scan (edema, pseudocysts, necrosis)
  • rarely laparotomy
  • epigastric tenderness
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24
Q

Management of acute pancreatitis?

A
  • conservative to rest pancreas to stop further enz secretion and further inflammation so it can start to heal
  • may include IV and NG suction to avoid stimulation of enzyme secretion
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25
Q

Chronic pancreatitis definition

A

Repeated occurrences of pancreatic inflammation leading to chronic inflammation with damage and eventual loss of parenchymal tissue (pancreas functional cells) that is REPLACED by fibrous tissue

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26
Q

Most common cause of chronic pancreatitis?

A

Heavy alcohol intake (70-80% of cases)

27
Q

Features of pancreas in chronic pancreatitis?

A
  • Fibrotic and hard and calcification

- atrophy of exocrine acini while endocrine islets are spared

28
Q

Clinical features of chronic pancreatitis?

A
  • repeated attacks of abd pain often brought on by alcohol
  • if ongoing can get loss of exocrine function causing maldigestion and malabsorption
  • pseudocysts; NECROTIC pancreas surrounded by fibrosis
  • rarely get diabetes due to endocrine insufficiency
29
Q

Diagnosis of chronic hepatitis?

A

Mainly via clinical suspicion

Can also include serum amylase but may not be elevated and CT

30
Q

Pancreatic carcinoma

A
  • usually adenoC
  • older (50+ 60-80)
  • poor prognosis due to anatomy/positioning as a hidden organ
  • males slightly > female
  • only 15-20% operable
31
Q

What is the survival rate of pancreatic carcinoma at 5 years

A

less than 5%

32
Q

What are the risk factors for pancreatic cancer

A

smoking, alcohol, diet/lifestyle/bmi, rare genetic diseases

not well associated risks

33
Q

Where do most pancreatic cancers occur

A
  • 60-70% in head
  • 10-15% tail
  • 5-19% body
  • 20% diffuse/throughout pancreas
34
Q

Compare and contrast cancer in the head and body/tail

A

head - can invade ampulla causing biliary obstruction and jaundice
- body and tail can remain silent until they present and by then large and disseminated/spread to nodes, adjacent organs, liver, bones so has poor prognosis

35
Q

Does cancer in the head or body have poorer prognosis

A

Body/tail

36
Q

Where do most pancreatic cancers occur

A

the head

37
Q

What are clinical features of pancreatic cancer

A
  • if in head and affecting ampulla then obstructive jaundice
  • pain
  • weight loss
  • pancreatitis
  • venous thrombosis
38
Q

How is an unprovoked DVT related to pancreatic cancer

A

Pancreatic cancer is a risk factor for venous thrombosis. Therefore if someone presents with a sudden unprovoked thrombosis should investigate to see if there is an underlying pancreatic malignancy

39
Q

How is diagnosis of pancreatic cancer made?

A
  • usually made on imaging; CT or US followed by a biopsy of the tumour as guided by imaging
40
Q

Endocrine tumours?

A
  • rare
  • increase or decrease pancreatic tumours
  • insulinoma will secrete insulin and can result in hypoglycaemia
  • most are benign
41
Q

Gallstone also called

A

Cholelithiasis

42
Q

Is cholelithiasis common?

A

Yes. 10-20% of people have gallstones BUT 80% of these don’t cause symptoms or problems or risk

43
Q

What kind of gallstones are most?

A

Cholesterol stones

44
Q

What do cholesterol stones contain

A

Crystalline cholesterol monohydrate

45
Q

What are gallstones?

A

Saturated bile fluids that form crystals and stones

46
Q

What are the less common type of gallstones, when do they usually occur and what are they made of

A

Pigement stones
Made of bilirubin and calcium salts
Usually occurs when there is abnormal amounts of breakdown of RBCs

47
Q

Why do cholesterol stones occur

A
  • are lifestyle related
  • bile becomes super-saturated with cholesterol
  • stasis favours crystal formation
  • if the crystals are then stasis in the GB for too long then stones are formed
48
Q

Are gallstones more likely in women or men

A

WOMEN

49
Q

Risk factors for gallstones?

A
  • women and older people
  • estrogen i.e. the pill or pregnancy
  • obesity
  • rapid weight loss
  • GB stasis
  • family history
  • lifestyle disease
50
Q

What is reason to believe that gallstones are lifestyle related

A

Gallstones are uncommon in developing and underdeveloped societies

51
Q

What are the 2 major clinical consequences of gallstones

A
  1. Cholecystitis (inflammation of the GB - acute/chronic)

2. Biliary colic (due to choledocolithiasis and pain from continuing persistalsis trying to clear bile duct)

52
Q

What are other clinical consequences as a result of cholecystitis and biliary colic

A
  • cholangitis (inflammed bile duct - often due to bacteria in a closed off environment)
  • obstructive cholestasis > jaundice
  • pancreatitis (esp if blockage at ampulla)
53
Q

Inflammation of GB

A

cholecystitis

54
Q

Why do you normally see cholecystitis

A

Usually do not see without gallstones

Usually occurs due to obstruction at the neck of the GB or the cystic duct

55
Q

Why do gallstones cause cholecystitis

A
  • obstruction in neck or cystic duct
  • stasis of bile
  • FIRST this causes chemical irritation of the mucosa
  • secondary the stasis of bile and protection from outside world allows for bacterial infection
56
Q

Clinical features of acute cholecystitis

A
  • RUQ pain and tenderness post fatty meal as GB stimulated
  • non-specific inflam response/symptoms
  • neutrophil leucocytosis/increased WBC (non-specific)
  • if stone in CBD and inflam here then increased bilirubin, ALP, GGT
  • image GB via ultrasound
57
Q

What does chronic cholecystitis result from?

A

Results from longterm association of gallstones and subsequent inflammation or may have a history of repeated acute cholecystitis

58
Q

How does a chronically infammed GB present compared to an acutely inflammed GB

A

Long term inflammation causes it to be…

  • thickened walls
  • contracted
  • fibrotic and scarred
  • shrunken (OR may be enlarged or normal)

An acutely inflamed GB will be red, inflamed, swollen/oedema, dilated BVs

59
Q

Management of cholecystitis

A

Like in pancreas is mostly conservative trying to decrease activity - IV fluid, pain relief - to allow it to settle and cope with the inflam itself
Possibly anti-biotics
25% require surgery but this is avoided as carries more risks when inflamed

60
Q

What if long-term the inflammation doesn’t settle?

A

Surgery - cholecystectomy

Quick recovery time as not open surgery

61
Q

Choledocolithiasis

A
  • stones in CBD
  • risk of obstructed ampulla and so pancreatic enzymes leading to pancreatitis
  • can lead to biliary obstruction
  • colicky abdominal pain
  • obstructive jaundice
  • cholangitis (inflam)
    i. e. symptoms due to obstruction, stasis of bile and accumulation of bacteria (infection)
62
Q

Cancers of the biliary system?

A
  1. Cancer of the GB
  2. Cancer of the biliary ducts

BOTH are rare and usually adenocarcinomas (glandular tissue)

63
Q

Who do biliary system cancers occur in?

A

Older (70)
females more than males
usually late presentation with VERY poor prognosis (1% after 5 years)
often invade the liver hence poor prognosis

Digestive (24 decks)

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