What is cholelithiasis?
Formed from constituents of the bile:
calcium salts (phosphates, carbonates)
bilirubin (calcium bilirubinate)
Two main types
What decreases bile acid causing gall stones?
Excessive gut loss (terminal ileal disease eg Crohn’s)
Bile salts have been used to dissolve stones
What causes pigmented gallstones?
Abnormal red cell breakdown (haemolytic anaemia)
what can gallstones cause?
Predisposition to Carcinoma of the Gall Bladder and Biliary tract
Small minority of cases
What is chronic cholecystitis?
Longstanding irritation of gall bladder
Thickening of gall bladder wall
Low grade chronic inflammation
Diverticula - misplacement of mucosa into wall
Right upper quadrant pain, often related to fatty foods
What sinuses are mostly effected by gallstones?
Signs of cystic duct obstruction?
Acute (on chronic) cholecystitis
Secondary infection by bowel bacteria
Tell me about acalculous cholecystitis?
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
Common duct stones?
-Dilated bile ducts (ultrasound)
-Enlarged green stained liver
Causes of obstructive jaundice?
Extrahepatic bile duct obstruction
Pale stools, dark urine
Raised alkaline phosphatase
Mildly raised transaminases
Malabsorption of fat and vitamin K
Benign bile duct strictures
Instrumentation / surgery
HIV cholangiopathy (CMV, cryptosporidiosis)
Parasites (Clonorchis, Ascaris, Fasciola)
the bile duct
The duodenum (ampulla of Vater)
Compression of bile ducts by extrinsic masses
Tell me about carcinoma of the gall bladder?
Preceded by dysplasia
90% have gall stones
Local structures (especially liver) usually invaded at presentation
Median survival 6 months
Tell me about carcinoma of the bile duct?
Uncommon in West (but increasing)
Commoner in Orient
Inflammatory bowel disease (sclerosing cholangitis)
Congenital abnormalities (eg choledochal cyst)
Painless obstructive jaundice, cholangitis
How would you examine the gall bladder and pancreas?
Endoscopic retrograde cholangio-pancreatography
Tell me about pancreatitis?
Common, incidence 0.1-1/1000 in West
Acute inflammation, haemorrhage and necrosis of pancreas
Liberation of digestive enzymes
Raised serum amylase
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
Adult respiratory distress syndrome
Acute renal failure
Causes of acute pancreatitis?
azathioprine, antibiotics, diuretics, NSAIDs
Tell me about chronic pancreatitis?
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
Recurrent abdominal pain
Pancreatic exocrine insufficiency (malabsorption)
Pancreatic endocrine insufficiency (diabetes mellitus)
Serum amylase often normal
May be bouts of superimposed acute pancreatitis
Causes of chronic pancreatitis?
Cystic fibrosis (duct obstruction by viscid mucus)
Autosomal dominant pancreatitis
Tropical (India & Africa)
Tumours of the pancreas?
Benign - uncommon
Borderline - uncommon
Intraductal papillary mucinous tumours
Mucinous cystic tumours
Malignant - common
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
Metastases - lymph nodes, liver
Migratory thrombophlebitis (Trousseau)
How would you diagnose carcinoma of the pancreas?
Tumour markers - CA19-9
Imaging (CT, ERCP, endoscopic ultrasound)
Pancreatic juice cytology (? molecular diagnosis)
Needle core, aspiration cytology, operative
Poor 5 year survival 5%; (15-20% if operable)
Tell me about pancreatic endocrine tumours?
Name 5 functioning tumours?
Often very small
Hypoglycaemic attacks, confusion, behavioural disturbance
Anaemia, diabetes, skin disease (necrolytic migratory erythema)
Zollinger-Ellison syndrome (high gastric acid output)
Diarrhoea, diabetes, gall stones