Block 2 (Part 2-Pancreas/Gallbladder) Flashcards
(27 cards)
Acute Pancreatitis
inflammation of the pancreas
first 2 weeks: risk of SIRS (systemic inflammatory response syndrome), organ failure
after 2 weeks: risk of sepsis
Potential causes: most common= gallstones
risk: smoking, alcohol, hypertriglyceridemia over 1000, pancreas divisum, AIP
also can be caused by ERCP procedure
Genetic: PRSS1, CFTR, SPINK1, CTRC (all premature activation o pancreatic zymogens)
Intraductal papillary mucinous neoplasm
Early acute changes: intraacinar activation of enzymes, overwhelming defense mechanisms, microcirculatory injury, keukocytes, cytokines, ox stress, bacteria from gut
Sx: persistent severe abd pain, radiates to back, nausea/vomiting
Labs: elevated amylase and lipase
Dx: CT (ultrasound for stones)
Complications: acute peripancreatic fluid collection (pseudocysts), acute necrotic collection (walled-off necrosis)
Tx: IV fluids, pain control, nutrition, ERCP, cholecystectomy
Chronic Pancreatitis
risk: alcohol, smoking, obstruction, AIP
Genetic: SPINK1, CFTR, PRSS1(risk of cancer too)
Tropical pancreatitis: south india
pancreas divisum, biliary cysts
Progressive fibroinflammatory process, often asymptomatic, often patchy
ductal plugs, ischemia
abd pain after eating
pancreatic insuff (fat malabsorption, DM)
calcifications on imaging
Pancreatic function testing: fecal elastase and chymotrypsin
Increases risk of pancreatic cancer
Complications: pseudocyst, duct obstruction, fistula, splenic vein thrombo, pseudoaneurism
Tx: stop alcohol, smoking, pancreatic enzyme supplement, resection
Autoimmune Pancreatitis (AIP)
IgG4-related (plasma cells) can affect multiple organs can mimic cancer pancreatic duct strictures HISORt criteria (histology, imaging, serology, other organs, response to glucocorticoids) Tx: glucocorticoids
Acute Cholecystitis
gallbladder inflammation
assoc with gallstones (sometimes not, acalculous)
cystic duct obstruction- irritant- inflammation
Sx: prolonged steady RUQ pain, fever, guarding, Murphy’s sign +
Dx: abd untrasound (wall thickening), HIDA scan
Complication: gangrene, perforation, fistula
Tx: may abate w/o tx in 7-10d, antibiotics, pain control, gall drainage, surgery (cholecystectomy sooner rather than later)
Acalculous acute cholecystitis
gallbladder stasis and ischemia- inflammations- secondary infxn
Always very SICK patients
unexplained fever, liver test elevations,
Dx: abd untrasound, wall thickening, murphy’s sign, HIDA scan
Tx: antibiotics, draining(cholecystostomy), cholecystectomy
high mortality
Xanthogranulomatous cholecystitis
extravasation of bile into gallbladder wall
xanthoma cells
always gallstones
can mimic gall cancer
high rate of complications
Dx: ultrasound (nodules or bands in gall wall)
Tx: rule out cancer, cholecystectomy
Porcelain gallbladder
chronic cholecystitis with intramulral calcification of gall wall
uncommon, females
increased risk of gall cancer (incomplete calcification is worse)
asymptomatic
Tx: cholecystectomy
Gallbladder polyps
Cholesterol- most common
adenomyomatosis- thickening of muscle wall, intramural diverticula (assoc with gall stones, more women)
Inflammatory
Adenomas- potential for malignancy
Dx: ultrasound, CT
Tx: cholescystectomy if risk of cancer or sx
Acute (ascending) Cholangitis
fever, jaundice, abd pain result of stasis and infxn in biliary tract
bacteria from small intestine
colonic bacteria (e coli, klebsiella
Charcot’s triad: fever, abd pain, jaundice
Reynold’s pentad: + confusion, hypotension
cholestatic liver test elevations
Tx: antibiotics, drainage, ERCP
Biliary atresia
progressive, fibro-obliterave disease of extrahepatic biliary tree
NEONATAL
small %: biliary atresia splenic malformation (BASM): other anomalies
Jaundice at birth-8weeks
Dx: abd untrasound
Tx: Kasai procedure promptly, most will eventually req liver txplant
Biliary cysts
most assoc with abnormal pancreaticobiliary junction (APBJ)- ducts join outside duodenal wall
also assoc with risk of gall cancer- cholangiocarcinoma
More common in asian women
usually present before age 10, jaundice, chronic intermittent abd pain
Dx: ultrasound
Primary Sclerosing Cholangitis (PSC)
progressive inflammation, stricturing of intrahepatic and extrahepatic bile ducts
assoc with IBD- ulcerative colitis,, men
immune activation
Sx: asymptomatic, pruritis, jaundice
Dx: cholangiography
Complications: cirrhosis, steatorrhea, osteoporosis, biliary strictures, cholangiocarcinoma, colon cancer
Tx: ERCP for strictures, surgery or liver txplant
AIDS cholangiopathy
biliary obstruction from infection related (cryptospordium parvum) seen in AIDS with CD4 less than 100 cholestatic enzymes up Dx: ultrasound, ERCP if positive Tx: biliary sphincterotomy
Biliary parasitosis
Ascaris lumbricoides: roundworm, ERCP and drugs
Echinococcus granulosis: tapeworm, rupture of cyst, resection, drugs
Clonorchis sinensis: chinese liver fluke, chronic infxn-cholangiocarcinoma
Opisthorchiasis- liver fluke, southeast asia, similar to Clonorchis
Fasciola hepatica- sheep liver fluke, ERCP, drugs
Recurrent pyogenic cholangitis
pigment stone formation in intrahepatic biliary system, recurrent bouts of cholangitis
Exclusively in southeast asia
Increased risk of cholangiocarcinoma and cirrhosis
Cholelithiasis
stones in gallbladder
often asymptomatic
risk: estrogen, fat, fertile, female, age, octreotide, rapid weight loss
Sx: biliary colic (intermittent duct obstruction) pain less than 4hrs after eating fatty foods
Dx: ultrasound
Tx: cholecystectomy if risk factors or sx
Choledocholithiasis
stones in common bile duct
usually secondary to passage of gallstones
Sx: asymptomatic, intermittent, more prolonged than biliary colic
Dx: Endoscopic ultrasound
Tx: ERCP
Mirizzi syndrome
common bile duct obstruction from extrinsic compression from impacted stone in cystic duct Sx: jaundice, fever Assoc with gall cancer Dx: cholangiography Tx: cholecystectomy
Pancreatic cystic neoplasms (PCN)
pancreatic cyst with malignant potential serous cystadenoma mucinous cystic neoplasm intraductal papillary mucinous neplasm (IPMN) solid pseudopapillary neoplasm
PCN: serous cystadenoma
lined by glycogen rich cells can be anywhere in pancreas women over 60yo malignant transform is very rare Central scar, microcystic asymptomatic, conservative management
PCN: mucinous cystic neoplasm
exclusively women, over 40yo ovarian-like stroma that secretes mucin in body or tail of pancreas NO communication with duct Tx: resect due to malignant potential
PCN: Intraductal papillary mucinous neoplasm (IPMN)
mucin producing papillary neoplasm
Pancreatic DUCT
age 50 or more, equal sex, anywhere in pancreas
Sx: asymptomatic, chronic pancreatitis
Tx: resect due to malignancy (Whipple procedure)
side branch has lower risk than main duct
PCN: solid pseudopapillary neoplasms
young women
body and tail of pancreas
Sx: asymptomatic or abd pain
Tx: resect due to malignant potential
Exocrine pancreatic cancer
more males and blacks many genetic predispositions risk: smoking, obesity, chronic pancreatitis usually ductal adenocarcinoma Sx: weight loss, painless jaundice, steatorrhea, pain Dx: ultrasound, CA 19-9, then CT Tx: surgery, chemo poor prognosis
