Biliary Tree, Gallbladder and Pancreas

Question 1

list risk factors for cholesterol stones

Answer 1

• common in Western/developed countries
• advancing age
• female gender
  
  • estrogen (OCP, pregnancy)
• obesity
• rapid weight reduction
• gall bladder stasis
• inborn error of bile salt metabolism
• hyperlipidemima

Question 2

list risk factors for pigment stones

Answer 2

• common in Asians
• rural > urban
• chronic hemolysis
• biliary infections
• GI disorders
  
  • ileal diseases
    
    • Crohns or ileal resection or bypass
• CF

Question 3

the clinical presentation of cholelithiasis is mainly ___ but can also present with ____ pain

Answer 3

the clinical presentation of cholelithiasis is mainly asymptomatic but can also present with colicky pain

Question 4

list the complications of cholelithiasis

Answer 4

• complications:
  
  • empyema
  • perforation
  • fistulas
  • cholangitis
  • pancreatitis
  • gallstone ileus
  • increased risk of carcinoma

Question 5

describe the pathogenesis of gallstones

Answer 5

• bile is supersaturated with cholesterol
• GB hypomotility promotes nucleation (precipitation from bile into vesicles)
• cholesterol nucleation in bile is accelerated
• mucus hypersecretion traps the crystal, permitting aggregation into stones (acts like glue)

Question 6

describe the pathogenesis of acute cholecystitis

Answer 6

1. chemical irritation and inflammation in setting of obstruction to flow
2. mucosal phospholipase convert lecithin to lysolecithin
3. damage to glycoprotein layer of mucosa
4. further release of PGs from mucosa
5. cumulatively leads to mucosal and mural inflammation
6. gallbladder dysmotility and increased intraluminal pressure
7. superimposed bacterial contamination

Question 7

describe chronic cholecystitis

Answer 7

• sequel of repeated acute cholecystitis
• rarely extensive dystrophic calcification aka porcelain gallbladder (increased association with cancer)

Question 8

in chronic cholecystitis, there could be extensive dystrophic calcification aka ____ which has an increased association with ___

Answer 8

in chronic cholecystitis, there could be extensive dystrophic calcification aka porcelain gallbladder which has an increased association with cancer

Question 9

Answer 9

Question 10

describe carcinoma of the gallbladder

Answer 10

• most common in 7th decade of life
• slightly more -common in females
• gallstones in 60-90% of patients
• other risk factors:
  
  • pyogenic and parasitic infections of the biliary tract
• carcinogenic derivatives of bile may play a role
• mostly adenocarcinoma
• most have invaded or spread to liver at diagnosis

Question 11

other risk factors for carcinoma of the gallbladder include ___ and ___ infections of the biliary tract

Answer 11

other risk factors for carcinoma of the gallbladder include pyogenic and parasitic infections of the biliary tract

Question 12

describe the image

Answer 12

gallbladder adenocarcinoma

malignant glands are seen infiltrating a densely fibrotic gallbladder wall

Question 13

the most common causes of pancreatic insufficiency are ___ and ____

Answer 13

the most common causes of pancreatic insufficiency are pancreatitis and CF

Question 14

describe exocrine dysfunction seen in pancreatic insufficiency

Answer 14

• exocrine dysfunction
  
  • fat malabsorption (steatorrhea)
    
    • lipolytic activity decreases faster than proteolysis
    • loose greasy foul-smelling stool
    • fat-soluble vitamins (ADEK and B12) not absorbed

Question 15

describe endocrine dysfunction seen in pancreatic insufficiency

Answer 15

• endocrine dysfunction
  
  • glucose intolerance, diabetes mellitus

Question 16

80% of acute pancreatitis cases are associated with ___ and ___

Answer 16

80% of acute pancreatitis cases are associated with gallstones and alcohol

Question 17

list the clinical features of acute pancreatitis

Answer 17

• leukocytosis
• DIC
• hemolysis
• peripheral vascular collapse
• shock with acute tubular necrosis (ATN), ARDS
• hypocalcemia, tetany
• raised amylase levels in first 24 hours
• followed by lipase within 72-96 hours

Question 18

in acute pancreatitis, ___ levels are increased in the first ____ hours, followed by ___ levels within ____ hours

Answer 18

in acute pancreatitis, amylase levels are increased in the first 24 hours, followed by lipase levels within 72-96 hours

Question 19

list the 3 possible complications of acute pancreatitis

Answer 19

• ARDS
• acute tubular necrosis (ATN)
• pancreatic abscess

Question 20

describe the image

Answer 20

Question 21

chronic pancreatitis is caused by repeated bouts of mild to moderate pancreatic inflammation with loss of ____ and replacement by ____

Answer 21

chronic pancreatitis is caused by repeated bouts of mild to moderate pancreatic inflammation with loss of pancreatic parenchyma and replacement by fibrous tissue

Question 22

describe the image

Answer 22

chronic pancreatitis

extensive fibrosis and atrophy has left only residual islets (left) and ducts (right) with a sprinkling of chronic inflammatory cells and a few islands of acinar tissue

Question 23

list the stroma-rich vs. stroma-poor pancreatic tumors

Answer 23

• solid, stroma-rich
  
  • ductal adenocarcinoma
• solid, stroma-poor
  
  • neuroendocrine tumors (islet cell tumors)
  • acinar cell carcinoma
  • solid pseudopapillary tumor
  • pancreatoblastoma

Question 24

describe pancreatic adenocarcinoma

Answer 24

Question 25

pancreatic adenocarcinoma is associated with ____ sign (migratory \_\_\_\_) explain this

Answer 25

pancreatic adenocarcinoma is associated with **Trousseau's** sign (migratory **thrombophlebitis**) * release of platelet activating factors and procoagulants from tumor

Question 26

there is no single specific marker for pancreatic adenocarcinoma, but sometimes there is raised \_\_\_\_

Answer 26

there is no single specific marker for pancreatic adenocarcinoma, but sometimes there is raised **CA 19-9**

Question 27

\_\_\_\_ is the usually the first symptom of pancreatic adenocarcinoma (because of invasion of \_\_\_\_\_)

Answer 27

**pain** is the usually the first symptom of pancreatic adenocarcinoma (because of invasion of **the posterior abdominal wall and nerves**)

Question 28

describe pancreatic neuoendocrine tumors (NET)

Answer 28

Question 29

describe insulinoma

Answer 29

**pancreatic neuroendocrine tumor** * arise from B-cells * hypoglycemia * accentuated by fasting, relieved with intake of glucose * clinically may manifest as Whipple triad * low blood glucose * presence of symptoms * resolution with the blood glucose is normalized * insulin levels are increased

Question 30

describe Whipple triad and what it is seen in

Answer 30

seen in **insulinomas** * low blood glucose * presence of symptoms * resolution when the blood glucose is normalized

Question 31

describe gastrinomas

Answer 31

**seen in pancreatic neuroendocrine tumors** * gastrin-producing neuroendocrine tumors * result in ZE syndrome * multiple duodenal peptic ulcers * prominent gastric rugal folds due to increased oxyntic gland mass * steatorrhea * associated with Multiple Endocrine Neoplasia (MEN-1)

Question 32

gastrinomas are associated with \_\_\_\_

Answer 32

gastrinomas are associated with **Multiple Endocrine Neoplasia (MEN-1)**

Question 33

describe intraductal papillary mucinous neoplasm (IPMN)

Answer 33

* arise within the ductal system * majority in the head * dilated duct filled with mucin * cysts can be multiloculated; lined by tall columnar mucin-secreting cells

Question 34

mucinous cystic neoplasms (MCN) are not connected to ____ and its characteristic feature is the ____ stroma

Answer 34

mucinous cystic neoplasms (MCN) are not connected to **the ductal system** and its characteristic feature is the **ovarian-type stroma**

Question 35

describe the image

Answer 35

the ovarian-like stroma seen in MCN