Lecture 26

Question 1

What are cholestatic diseases of the liver?

Answer 1

Agents that directly damage hepatocytes or conditions where there is obstruction biliary outflow.

Question 2

What is intra-hepatic cholestatic disease of the liver?

Answer 2

The obstruction occurs to the bile ducts or bile canaliculi within the liver.

Question 3

What is extra-hepatic cholestatic disease of the liver?

Answer 3

Obstruction to the common bile duct (outside the liver).

Question 4

What are autoimmune cholangiopathies?

Answer 4

Autoimmune damage to either the bile ducts or bile canaliculi. These are uncommon but not rare disorders.

1) Primary biliary cirrhosis - autoimmune disorder leading to destruction of bile canaliculi.
2) Primary sclerosing cholangitis - autoimmune disorder leading to scarring of bile ducts.

Question 5

What occurs in cholestasis of sepsis?

Answer 5

Sepsis can affect the liver through:

1) Direct affects of intrahepatic infection e.g. liver abscess, bacterial cholangitis.
2) Ischaemia related to hypotension.
3) Circulating microbial products - aprticulary in context of gram-negative infection i.e. this is the most likely thing to lead to cholestatic picture.

Question 6

What happens when there is impaired blood inflow?

Answer 6

Portal vein obstruction, intra/extrahepatic thrombosis will cause:

1) varices
2) splenomegaly
3) intestinal congestion.

Question 7

What happens when there is impaired intrahepatic blood flow?

Answer 7

Cirrhosis, and sinusoid occlusion will cause:

1) Ascites (cirrhosis).
2) Oesophageal varices (cirrhosis).
3) Hepatomegaly.
4) Elevated aminotransferases.

Question 8

What happens when there is hepatic vein outflow obstruction?

Answer 8

Hepatic vein thrombosis (budd-chiari syndrome), sinusoidal obstructive syndrome will cause:

1) Ascites
2) Hepatomegaly
3) Elevated aminotransferases
4) Jaundice.

Question 9

What are benign neoplasms of the liver?

Answer 9

1) Cavernous haemangiomas

2) Hepatocellular adenomas.

Question 10

What are malignant neoplasms of the liver?

Answer 10

1) Hepatocellular carcinoma - see in patients with cirrhosis of the liver.
2) Hepatoblastoma
3) Cholangiocarcinoma
4) Hepatic metastases.

Question 11

What is the function of the pancreas?

Answer 11

Exocrine = 80-90%
Endocrine = 10-20%.

Question 12

What is the exocrine function of the pancreas composed of?

Answer 12

Composed of acing cells and ducts. Acing cells contain zymogen granules.

Question 13

What are zymogen granules?

Answer 13

Inactive enzyme precursors for trypsin, chymotrypsin, amylase, lipase, nuclease and elastase.

Question 14

What is the endocrine function of the pancreas composed of?

Answer 14

Islets of Langerhans. These secrete insulin, glucagon and other hormones.

Question 15

Describe pathology of the pancreas?

Answer 15

Congenital/genetic = cystic fibrosis.
Inflammatory/infective = acute and chronic pancreatitis.
Malignant = carcinoma of the pancreas.

Question 16

What is acute pancreatitis?

Answer 16

Inflammation of the pancreas - associated with acing cell injury.

Question 17

What is the spectrum of severity duration and severity of acute pancreatitis?

Answer 17

Mild = 60-70% cases, low mortality.
Severe = 30-40% of cases, 20-30% mortality.

Question 18

What are the four major categories of acute pancreatitis?

Answer 18

1) Metabolic - alcohol.
2) Mechanical - gallstones, trauma.
3) Vascular - shock, vasculitis.
4) Infection - mumps.

Question 19

How do the causes induce pancreatitis?

Answer 19

This is due to damage to acing cells. Releases pancreatic enzymes which damage the tissue and damage further acing cells. Secondary inflammatory response, with release of number of cytokines. This will induce massive reaction.

Question 20

What is the consequence of enzyme release?

Answer 20

1) Proteases - destruction of acini, ducts and islets.
2) Lipases - fat necrosis of pancreas and other sites.
3) Elastase - blood vessel destruction leading to intestinal haemorrhage.
4) Cell injury response - inflammation and oedema.

Question 21

What are the key events to trigger pancreatitis?

Answer 21

Obstruction of the pancreatic ducts or direct injury to acinar cells.

Question 22

Describe pancreatic duct obstruction by gallstones and ductal concretions present in alcoholics?

Answer 22

1) Increased intrapancreatic ductal pressure.
2) Accumulation of enzyme rich interstitial fluid.
3) fat necrosis as lipase already active.
4) Promotes oedema and local inflammation.
5) Oedema compromises blood flow.

Question 23

Describe primary acinar cell injury?

Answer 23

Viruses, drugs, trauma and iscahamia can be cause the release of enzymes.

Question 24

What are the clinical features of acute pancreatitis?

Answer 24

1) Acute abdominal pain - usually upper abdominal and will show in the epigastric region.
2) Nausea and vomiting.
3) Fever, tachycardia.
4) Marked abdominal tenderness - may have ileum and rarely will be shock.

Question 25

How do you make the diagnosis of acute pancreatitis?

Answer 25

1) High white cell count - increase in the cells involved in acute inflammatory response, however not specific. 2) Elevated serum amylase (lipase) - measure enzymes that are released from the pancreas, these will be significantly elevated. 3) CT scan - oedema, necrosis and pseudocysts of the pancreas. . 4) Rarely may need laparotomy to confirm diagnosis.

Question 26

How do you manage an acute pancreatitis?

Answer 26

"Rest the pancreas" 1) IV fluids - nil by mouth, not eating food. 2) NG suction - nasogastric tube to remove the secretions from gastric. 3) Analgesia. 4) Close monitoring - looking for the complications that may arise with pancreatitis.

Question 27

What is chronic pancreatitis?

Answer 27

Defined as repeated bouts of pancreatic inflammation its loss of pancreatic parenchyma and replacement by fibrous tissue. Majority have heavy alcohol intake (60-70%).

Question 28

What is the pathology of chronic pancreatitis?

Answer 28

1) Fibrotic organ - very hard. 2) Atrophy of the exocrine component but relative sparing of the islets. 3) Mild chronic inflammatory infiltrate. 4) Calcification.

Question 29

What causes chronic pancreatitis?

Answer 29

1) 60-70% have heavy alcohol intake - intraductal plugs (proteins, cell debris). 2) Previous acute pancreatitis, severe malnutrition and hereditary/CFTR mutations.

Question 30

What are the clinical features of chronic pancreatitis?

Answer 30

1) Repeated attacks of abdominal pain - often bought on by alcohol. 2) Can be more persistent pain. 3) If ongoing: loss of exocrine function (malabsorption), pseudocysts, and rarely diabetes mellitus.

Question 31

How do you make the diagnosis of chronic pancreatitis?

Answer 31

1) Clinical suspicion. 2) Serum amylase - may not be elevated. 3) CT imaging.

Question 32

Describe pancreatic carcinoma?

Answer 32

4th most common cause of cancer death. Males slight > Females. Most aged >50 (peak aged 60-80). Prognosis remains poor (

Question 33

What are the risk factors for pancreatic carcinoma?

Answer 33

1) Tobacco smoking - smokers have a higher incidence. 2) Havy alcohol intake. 3) High BMI. 4) Rare hereditary cases. 5) Alcohol and coffee suggested but not confirmed.

Question 34

Where do adenocarcinoma (of the pancreas) form?

Answer 34

1) 60-70% will occur in the head of the pancreas. 2) 5-10% will occur in the body of the pancreas. 3) 10-15% will occur in the tail. 3) 20% will diffuse.

Question 35

What happens when there is an adenocarcinoma in the head of the pancreas?

Answer 35

The tumour will invade the ampulla and biliary obstruction will occur.

Question 36

What happens when there is an adenocarcinoma in the body and tail of the pancreas?

Answer 36

It will remain silent, often large and disseminated at presentation, spread to nodes, adjacent organs, liver, bones and lungs.

Question 37

What are the clinical features of pancreas adenocarcinoma?

Answer 37

1) Obstructive jaundice. 2) Pain. 3) Weight loss. 4) Pancreatitis. 5) Thrombophlebitis/venous thrombosis.

Question 38

How do you make the diagnosis of pancreas adenocarcinoma?

Answer 38

Made on imaging - followed by CT or Ultrasound guided FNA and core biopsy. No tumour marker identified.

Question 39

Describe pancreatic endocrine tumours?

Answer 39

Can get tumours arising from the islet cells. These are rare and can secrete pancreatic hormones.

Question 40

What are endocrine tumours? (examples)

Answer 40

Insulinoma - the tumour will secrete insulin. The patient will present with hypoglycaemia. Most benign, 10% malignant. Treat with resection.