Lecture 74_75 - Diseases and pathology of Pancreas, GB Flashcards
(42 cards)
Describe the anatomy of the biliary tree?
Right Hepatic duct and left hepatic duct converge to form the common hepatic duct (RHD branches more quickly than the left)
Cystic Duct (from GB) converges with the CHD to form the Common bile duct
Pancreatic duct and CBD converge at the Major Papilla (of Vater) (of the second part of the Duodenum), which is controlled by the Sphicter of Oddi
what is ERCP?
Endoscopic Retrograde Cholangeo-pancrea-tography
Imaging technique designed to specifically look at biliary architecture
what is a HIDA scan?
§ HIDA Scan – aka Liver/Spleen Scan
□ Radio tracer injected into the vein which follows the course of bile (taken up in liver and excreted into biliary tree)
® Liver should be dark; excreted to bile duct
® If stone in the Cystic Duct – no tracer will enter the gall bladder
what are the different types of gall stones?
etiologies
1) Cholesterol stones – Comes from endogenous cholesterol when there is an imbalance between cholesterol, bile salts, and phospholipids, the cholesterol comes out of solution
2) Pigment Stones –
black – increased unconjugated bile (such as hemolysis of sickle cell disease)
brown – usually due to infection; common in asian populations (liver flukes)
Treatment of Gall stones;
Symptomatic
asymptomatic
Asymptomatic – observation; unless the patient needs prophylaxis (eg sickle cell patients or porcelien GB patients)
Symptomatic – Threapuetic intervention is necessary due to increase complication rate
Symptoms of Gall STones / impaction of a gall stones
(where can the pain radiate to?)
what symptoms should you not attribute to gall stones?
Symptoms: Biliary Cholic (episodic and crampy pain due to a stones transient impaction in the cystic duct)
pain is usually in the RUQ/Epigastrium but can radiate to the chest or R scapula
Never attribute Chronic pain, belching, bloating, fatty food intolerance or chronic pain to gall stones
Pirmary method for dx of gall stones?
Ultrasound
Complications of cholelithiasis?
what pattern of LFTs is observed
- Acute cholecystitis –
- Choledocholithiasis – (Choledocholithiasis Cholangitis vs Choledocholithiasis Pancreatitis)
LFTs- – elevated BR / elevated ALP
• Acute cholecystitis –
where is the stone?
typical presentation
eponymous physical exam finding
diagnostic techniques
Treatment
gall stone stuck in the cystic duct, leading to inflammation of the GB wall, due to bacteria in the now static media
resentation – RUQ pain with N/V, Fever, Luekocytosis, Jaundice,
Murphy’s Sign (palpate the gall bladder and have inspiratory arrests)
dx: RUQ pain, US, HIDA
Tx: Abx + surgical management
Choledocholithiasis Cholangitis — where is the stone
what is charcot’s triad?
Choledocholithiasis Pancreatitis
Cholangitis – § Common bile Duct Obstruction leading to bacterial infection and inflammation
§ Charcot's Tirad -- pain, jaundice, fever
Pancreatitis – Inflammation of the pancreas due to gallstone obstruction in the pacnreatic duct/ampulla of vater
Treatments for choliolithiasis
○ Surgery – laproscopic cholecystectomy
Oral dissolution – bile salts over many month
Contact Dissolution — infuse ether , and solubilizes stones instantly, but lots of side effects
○ Extracorporial lithotripsy
ERCP – § Preferred method for removal of common bile duct stones
• Primary Sclerosisng Cholangitis
what is it?
histo pattner?
commonly associated with?
how does it present on imaging?
Idiopathic fibrosing d/o of the intra and extra hepatic biliary ducts
○ Associated with IBD (Crohns, Ulcerative Colitis)
onion skinning of bile ducts
imaging: “chain of links”
what is acute pancreatitis?
what is the a necessary symptom to make the dx?
Acute inflammation of the pancreases manifested by abdominal pain and increased amylase and lipase (atuodigestion of the pancreas by pancreatic enzymes)
PAIN is an absolutely necessary symptom to make the dx
what kind of pain can manifest in acute pancreatitis?
what levels of amylase and lipase are seen on labs?
○ PAIN – epigastric, central and radiates to the back (bc the pancreas is retroperionteal)
§ Some of the worst pain a patient can have
○ Enzymes Amlyase and Lipase – 3x upper limits of normal
what are some etiologies of acute pancreatitis (GET SMASHED)
Gall-stones Alcohol Trauma Steroids/sulfonamides, other durgs such as 6MP Mumps Auto-immune disease Scorpion sting Hypercalcemia/Hypertriglyceridemia ERCP Drugs (sulfa drugs)
what are some effcts (local and systemic) of increased trypsin and lipase ?
○ Activation of multiple cascades
§ Capillary leak
§ Peripheral white cell response
§ DIC
§ Local Fat Necrosis - -autodigestion of the pancrease
§ Coagulopathy
Renal failure
can lead to pancreatic psuedocyst which can rupture and hemorrhage
Complications of acute pancreatitis?
how may it present
Psuedocysts – Extrapancreatic Fluid in the retroperitoneal space; a rind can form around it
§ Pseudocysts – form 3-6 weeks after sever acute pancreatitis
Severe pain, obstruction duodenum, dissection, bleeding of the cyst (hemosucus pancreaticus), infection, erosion into other structures, pleural effusion with high amylase and lipase
Treatment goals of Chronic pancreatitis
Supportive care – clinical surveillance, NPO, aggressive IV fluid replacement (helps perfuse the pancreas and mitigates renal dysfunction), pain relief , nutritional support , (+/- IV abx of necrosis)
○ Reduce inflammation ○ Assess and treatment complications
• Chronic Pancreatitis –
What is it ?
• Presentation ?
Long standing inflammation in abnormal gland, usually after repeat bouts of acute pancreatis which has caused gland scarring
○ Chronic pain ○ Calcificaitons of the pancrease ○ Pancreating endo and exocrine insufficiency
Major etiologies of chronic pancreatitis?
Alcohol's CF, herediatary pancreatitis, hypertriglyceridemia autoimmune Idiopathic
Pancreas Divisum
Presentation and symptoms of chronic pancreatitis?
Pain (which may die down as the disease progresses)
exocrine insufficienies
Steatorrhea (if alcohol related) (lipase < 10%)
endocrine insufficiencies:
DMT1 – loss of insulin and glucagon
Risk of DKA
what dx test can be made for chronic pancreatitis?
ERCP, CT, US – look for stones, ductal dilation
□ Calcifications in the gland —
§ Function -- Secretin tests (enzymes, bicarb), fecal chymotrypsin, or fat
- acute cholecystitis vs chronic
Gross path
symptoms
acute: GB appears red or hemorrhagic
RUQ pain, N, Fever, anorexia
Chronic:
The GB wall is thick and fibrotic
RUQ Pain, N, Fever, anorexia — but usually a more indolent course
May be asymptomatic
Biliary Atresia:
what is it?
etiology?
pathology?
prognosis?
Hypoplasia or narrowing of biliary tract in infancy;
Pathology — Cholestasis; bile tries to found other routes of the liver; biliary cirrhosis; bile duct obliterated by inflammation
* Etiology unknown * Most important cause of liver disease in early childhood -- frequent and severe
Prognosis – ○ Cirrhosis develops by 3-6 months (8 weeks) of age without treatment
