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Clin Med- GI > Gallbladder/Pancreatic Lecture > Flashcards

Gallbladder/Pancreatic Lecture Flashcards

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1
Q

Bile storage site

Concentrates bile

Contracts in response to cholecystokinin (CCK)

Filled when spincter or Oddi is closed

A

Gallbladder

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2
Q
A
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3
Q

Helps break up fats (for digestion in sm intestine, terminal ileum
and recycled to liver for re-excretion)

500-1500 mL secreted from liver each day!

A

Bile

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4
Q

Made up of:

  1. Bile salts (from cholesterol)
  2. Bilirubin (waste product from old worn out RBCs)
  3. Alkaline fluid
A

Bile

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5
Q

Cholecystic

A

Referring to gallbladder

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6
Q

Cholecystectomy

A

Removal of gallbladder

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7
Q

Cholecystalgia

A

Pain from gall bladder (aka biliary colic)

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8
Q

Acute cholecystitis

A

Inflammation (can be chronic)

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9
Q

What percentage of gallstones are cholesterol?

What percentage are calcium bilirubinate/ Ca salts?

A

Cholesterol 75%

Calcium 25%

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10
Q

“Pigmented” black/brown stones

A

Calcium bilirubiante stones

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11
Q
  1. Cholesterol supersaturation (bile gets supersaturated with cholesterol)
  2. Nucleation (Microscopic cholesterol comes together and crystallizes. Over time, additional layers of cholesterol added on)
  3. Gallbladder hypomotility (Slower emptying=more time for stone formation, ie pregnancy)
A

Causes of gallstones

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12
Q

Age (traditionally, over 40y/o)

Obesity (or rapid weight loss)

Sex: Female

Race (example: Native Americans)

(Female, Fat, Forty, Fair, and Fertile)

A

Risk factors for stones

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13
Q

Cholelithiasis

A

Stones in GB

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14
Q

Choledocholithiasis

A

Stone in bile duct

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15
Q

Oral contraceptives, Pregnancy, Diabetes/Insulin use, Hemolysis, Biliary parasites, Cirrhosis, Crohn’s, Hyperparathyroid Dz.

A

Contributing factors for gallstones

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16
Q

What % of ppl have gallstones and are asymptomatic

A

50-60% (most are never symptomatic)

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17
Q

Biliary colic (aching pain in the RUQ/epigastric)

Referred pain: to back, scapula, or R shoulder area

A

Symptoms of cholelithiasis

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18
Q

Best diagnostic (especially initial) for cholelithiasis

A

Ultrasound (95%)

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19
Q

Cystic ducts become blocked due to:

  • gallstones
  • sludge, infection cancer (less common)
A

Acute cholecystitis

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20
Q

Gallbladder blockage –> distention/edema –> ischemia

..this causes?

A

RUQ pain

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21
Q

RUQ and epigastric pain

R scapula/shoulder pain

N/V

Fever/Chills

A

Acute cholecystitis symptoms

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22
Q

Tenderness RUQ/epigastric area

+ Murphy’s sign

Possibe jaundice (late sign)

A

Acute cholestitits

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23
Q

Are plain radiographs good diagnostic images of gallstones?

A

NO..can only see about 25% (Ca containing stones are only about 25%)

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24
Q

Hepatobiliary IminoDiacetic Acid Scan

Radioactive tracer injected, followed thru liverGB

Best test, but usually not necessary

A

HIDA scan

..expensive! only use if odd presentation

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25
**CBC w/ diff:** Elevated WBC count (leukocytosis) 12-15k **Hepatic function tests:** LFT’s: elevated, sometimes **Alkaline phosphatase:** usually elevated (at least a little) **Gamma-glutamyl transpeptidase (GGT):** elevated **Bilirubin:** elevated, especially in common duct stone Amylase: elevated, sometimes
Labs in acute cholecystitis
26
Stone in common bile duct - usually migrates from gallbladder - less common: form in GBD
Choledocholithiasis
27
Can be asymptomatic (30-40%) Biliary colic Jaundice, pancreatitis, maybe cholangitis **ERCP (endoscopic retrograde cholangiopancreatography) can be used to DIAGNOSE and TREAT**
Choledocholithiasis
28
Contraindication of ERCP?
Pancreatitis
29
ERCP is diagnosis and treatment ONLY if the stone is..
in common bile duct | (Choledocholithiasis)
30
Infection and inflammation of biliary tract Due to obstruction, then infection (retrograde infection: E.coli, Enterococcus, Klebsiella and Enterobactor)
Acute cholangitis
31
Potentially life threatning- can lead to sepsis/shock Most often caused by choledocholithiasis **Signs/symptoms: RUQ pain, jaundice, fever (\*\*Charcot's triad)**
Acute cholangitis
32
1. Abdominal pain (RUQ) 2. Jaundice 3. Fever
Charcot's triad | (pathognomonic for **Acute Cholangitis**)
33
How many blood cultures do you need for Acute Cholangitis?
TWO! different locations
34
**Labs:** CBC: leukocytosis Hyperbilirubinemia Alkaline Phosphatase: elevated / increasing _Blood cultures X 2_ **Tx:** Abx (to cover for gm negs, anaerobes, enterococci) Removal of obstruction via ERCP
Acute cholangitis
35
sits in retroperitoneum Head near duodenum Tail posterior to stomach, near spleen During development two ‘buds’ get together and fuse
Pancreas
36
2 portions of Pancreas
Exocrine and Endocrine portions
37
Ducts --\> duodenum Acinar cells (95% of pancreas) Lipase Ductal epithelial cells
Part of **exocrine portion** or pancreas
38
Secretes: 1. Proteolytic enzymes (trypsinogen, chymotrypsinogen, procarboxypeptidase)..**protein digestion** 2. Amylase...**carbohydrate digestion** 3. Lipase...**fat digestion** (more sensitive on test)
Acinar cells (make up 95% of pancreas)
39
Fat digestion is done by...
Lipase
40
Amylase digests...
Carbohydrates
41
Secretes: Alkaline solution- water, electrolyes, sodium bicarb (NaHCO3) - majority of what pancreas secretes - 1-2 L a day
Ductal epithelial cells
42
Where does the **exocrine** portion of the pancreas empty into?
Duodenum
43
Where does the **endocrine** portion of the pancreas empty into?
Bloodstream
44
Secretion --\> bloodstream Consists of: Islets of Langerhans (1-2%) Beta-Cells Alpha Cells Delta Cells
**Endocrine** portion of the pancreas
45
These cells are responsible for **insulin synthesis/secretion**
Beta cells
46
These cells produce **glucagon**
Alpha cells
47
These cells produce **somatostatin**, serves to inhibit several processes including GH and TSH secretion
Delta cells
48
1. Digestion 2. regulation of pH in intestines 3. blood sugar regulation
Role of pancreatic secretions
49
Pancreatitis usually results in _______ cell injury
Acinar (can be acute or chronic)
50
Can be related to an obstruction of the pancreatic duct (due to several different things, including stones & failure of the 2 parts of the pancreas to fully join during development: “pancreas divisum”)- 5-10% pop.
Pancreatitis
51
The inactive proenzymes (like Trypsinogen) are activated early, while still in pancreas Fat necrosis Pancreatic enzymes digest itself
Possible causes of pancreatitis
52
Gallstones (45%) Alcohol (35%) Together they make up about 80% Idiopathic **MC: cholelithiasis or alcohol abuse**
Causes of **acute pancreatitis**
53
Trauma (ie MVA) Drugs Infections (mumps, EBV, CMV, HIV) Peptic ulcer disease Metabolic issues (hyperlipid, hyperCa) Toxins (methyl alcohol) Scorpion stings Autoimmune ERCP
Other causes of pancreatitis
54
Valproic acid Tetracycline Metronidazole Furosemide Nitrofurantoin Estrogens Thiazides
Drugs that can cause pancreatitis
55
If a gallstone is blocking the common bile duct and the pancreatic duct, what might happen?
Acute pancreatitis
56
Upper abdominal pain/epigastric pain..may radiate to back Rapid onset **Worse supine** **Better leaning forward** N/V Fever, chills
Acute pancreatitis
57
PE: most tender epigastric maybe distention, guarding vitals: tachycardic, fever
Acute pancreatitis
58
If gallstone is obstructing common bile duct in acute pancreatitis, what might develop?
Jaundice
59
1. Cullen's sign= periumbilical ecchymosis 2. Grey-Turner sign= flank ecchymosis
Signs of **hemorrhagic pancreatitis** | (these signs are rare, \<1%)
60
What is more sensitive and specific for acute pancreatitis ..amylase or lipase?
Lipase
61
* *increased** WBCs * *increased** amylase and lipase * *increased** LFTs in severe dz..**elevated** glucose, **decreased** calcium
Acute pancreatitis
62
Image of choice for acute pancreatitis?
CT!!!
63
Bilirubin ALT and AST Alk-Phos (ALP) Albumin Prothrombin time
LFTs
64
Helps assess severity of acute pancreatitis
Ranson's criteria
65
Age \>55 WBCs \>16 Glucose \>200 ALT \> 250 (6x norm) LDH \>350 (2x norm)
Ranson's criteria ## Footnote **higher scores= more severe dz and increased chance of death**
66
Ranson's score of 0-2 3-5 6+
0-2: low mortality. ~1% 3-5: 10-20% mortality 6+: 50% mortality
67
Acute pancreatitis tx
NPO (esp NO ALCOHOL!) Supportive..fluid, pain, nutrition Correct electrolyte imbalance
68
Inflammatory disease Irreversible changes Can lead to permanent loss of function
Chronic pancreatitis
69
Causes of chronic pancreatitis
1. Non obstructive (**#1 cause is alcohol!!)** 2. Obstructive - benign..sphincter of oddi dysfunction - neoplasm
70
Do gallstones cause chronic pancreatitis?
NO! only acute
71
Epigastric/LUQ pain (episodic or continuous) Diarrhea Steatorrhea (as damage **decreases lipase production**) diabetes (very late sign, as islets are damaged)
Chronic pancreatitis
72
Gold standard of pancreatic function | (can dz early chronic pancreatitis)
Secretin stimulation test
73
4th leading cancer death 5 year survival rate= 4% s/s: wt loss, **painless jaundice**, pale stool, dark urine, Virchow's node, Trousseau's sign (migratory thrombophlebitis)
Pancreatic cancer
74
Image of choice for pancreatic cancer
CT scan dual phase helical- head of pancreas
75
Pancreatic cancer tumor marker?
CA 19-9 (75-85%)
76
What happens to direct bili and alk phos levels in pancreatic cancer?
Increase!
77
Tx= chemo/radiation (poor response) Whipple surg Palliative care
Pancreatic cancer

Clin Med- GI (8 decks)

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