Week 122 - Biliary/Pancreatic function Flashcards Preview

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Flashcards in Week 122 - Biliary/Pancreatic function Deck (62):
1

Week 122 Biliary/Pancreatic Function: What are the main causes of Chronic Pancreatitis?

• Mostly secondary to alcohol abuse in the western world.
• Other causes include hereditary, autoimmune and tropical causes.

2

Week 122 Biliary/Pancreatic Function: How does chronic pancreatitis normally present?

• Severe pain, weight loss, cachexia - this makes it difficult to differentiate from carcinoma.

3

Week 122 Biliary/Pancreatic Function: Which cells produce the exocrine function of the pancreas?

Acinar cells - produce digestive enzymes in the form of pro-enzymes (To protect the pancreas).

4

Week 122 Biliary/Pancreatic Function: What is the exocrine function of the pancreas?

• Pancreatic juice contains the following;
- Bicarbonate, Amylase, Lipase, Tyrpsinogen, Chymotrypsinogen, Phospholipase, Elastase, RNAase, DNAase, Carboxypeptidase.

5

Week 122 Biliary/Pancreatic Function: What causes the secretion of the pancreatic juice?

Pancreatic juice is secreted in response to cholecystokinin, which is produced in response to food entering the duodenum.

6

Week 122 Biliary/Pancreatic Function: What are the endocrine glands of the pancreas?

Islets of Langerhans.

7

Week 122 Biliary/Pancreatic Function: What are the two cell types in the Islets of Langerhans? What do they produce?

• Alpha cells - Glycogen
• Beta cells - Insulin
The Islets also produce somatostatin and pancreatic polypeptide.

8

Week 122 Biliary/Pancreatic Function: What are the two main causes of Acute Pancreatitis? What percentage of cases do these make up?

• Alcohol Abuse
• Gall Stones
• 80%

9

Week 122 Biliary/Pancreatic Function: Aside from Alcohol Abuse and Gallstones, what else can cause Acute Pancreatitis?

• Raised lipids or calcium, hereditary, Viral (mumps, Coxsackie virus), thiazide drugs, shock, trauma, vascular disease, Hypothermia.
• Also a complication of ERCP.

10

Week 122 Biliary/Pancreatic Function: What is the leading cause of Chronic Pancreatitis within the UK?

• Alcohol abuse with recurrent attacks of acute pancreatitis.

11

Week 122 Biliary/Pancreatic Function: Aside from alcohol abuse what other causes of chronic pancreatitis are there?

• Duct obstruction.
• Defective enzyme inhibitors.
• Tropical disease.
• 40% are idiopathic.

12

Week 122 Biliary/Pancreatic Function: What sign of chronic pancreas can make it visible on a radiograph?

The pancreas can calcify.

13

Week 122 Biliary/Pancreatic Function: What are the complications of chronic pancreatitis?

• Failure to produce digestive enzymes.
• Fat absorption is usually the first symptom, producing steatorrhoea and flatulence.
• Loss of endocrine function can finally cause diabetes.

14

Week 122 Biliary/Pancreatic Function: What causes jaundice in terms of pancreatic-biliary systems?

• Excess red cell destruction eg. haemolytic anaemia.
• Common bile duct- stone, stricture, tumour.
• Tumour of Ampulla of Vater
• Tumour Head of pancreas, chronic pancreatitis, stone.

15

Week 122 Biliary/Pancreatic Function: What is the double duct sign?

This is due to a cancer in the head of the pancreas causing strictures which result in dilatation of the common bile duct and the pancreatic duct.

16

Week 122 Biliary/Pancreatic Function: What is the most common type of gallstone?

• 80% are cholesterol or predominantly cholesterol.
• 20% bile pigment stones.

17

Week 122 Biliary/Pancreatic Function: What is the medical term for gallstones?

Cholelithiasis.

18

Week 122 Biliary/Pancreatic Function: What are the risk factors for cholesterol gall stones?

White, Age, High Cholesterol, Female (Fat,female, fair, over forty), Low fibre diet, Diabetes, Gall bladder stasis, Rapid weight reduction.

19

Week 122 Biliary/Pancreatic Function: What is the initial investigation for diagnosis of gallstones?

USS

20

Week 122 Biliary/Pancreatic Function: Describe the natural history of symptomatic gallstones that remain in the gall bladder.

• Acute cholecystitis.
- Which may resolve or develop into chronic cholecystitis.
- Chronic cholecystitis may lead to perforation or gangrene leading to peritonitis.
- Chronic cholecystitis can rarely form into carcinoma.

21

Week 122 Biliary/Pancreatic Function: What are the complications of a gallstone in the bile duct?

• Colic
• Obstructive jaundice
• Pancreatitis

22

Week 122 Biliary/Pancreatic Function: What are the features of biliary colic?

• Usually due to gallstones.
• Sudden onset pain - Epigastric/RUQ
• May radiate to back, inter-scapular
• Nausea, vomiting
• Pain may fluctuate or persist

23

Week 122 Biliary/Pancreatic Function: What would an USS of acute cholecystitis show?

Thickened wall and shadows of gallstones.

24

Week 122 Biliary/Pancreatic Function: What is the treatment for acute cholecystitis?

Opiates and antibiotics.

25

Week 122 Biliary/Pancreatic Function: Describe the pathology of chronic cholecystitis.

• Wall thickens due to infiltration of inflammatory cells.
• Gall bladder becomes rigid and non-distensible.

26

Week 122 Biliary/Pancreatic Function: What is Courvoisiers law?

Jaundice with a palpable gallbladder cannot be due to gallstones (As in chronic cholecystitis the gallbladder becomes rigid and non-distensible.).

27

Week 122 Biliary/Pancreatic Function: Biliary obstruction will alter bowels and bladder in which way?

Pale stools and dark urine.

28

Week 122 Biliary/Pancreatic Function: What is a gall stone ileus?

• The inflamed gall bladder sticks to the bowel.
• A perforation forms and the stones migrate into the bowel.
• Large bowel obstructs the small intestine.

29

Week 122 Biliary/Pancreatic Function: What is the standard surgery for the Gallbladder?

• Endoscopic cholecystectomy
• >95% success.

30

Week 122 Biliary/Pancreatic Function: How does acute pancreatitis present?

• Severe epigastric pain.
• Nausea and vomitting.
• 'Shock'
• Elevation of serum amylase.

31

Week 122 Biliary/Pancreatic Function: What is the management of acute pancreatitis?

• I.V. analgesia
• Blood tests
• USS
• ICU/HDU
• CT scan 3-10 days

32

Week 122 Biliary/Pancreatic Function: What are the surgical options in acute pancreatitis?

• Gallbladder pancreatitis - Cholecystectomy.
• Pancreatic necrosectomy for infected necrosis.
• Surgery for complications e.g. bleeding, abscess.

33

Week 122 Biliary/Pancreatic Function: What is the management for chronic pancreatitis?

• Pain control.
• Replacement for deficiencies, Enzymes, insulin etc.
• Improvement of diet.

34

Week 122 Biliary/Pancreatic Function: What are the surgical options for chronic pancreatitis?

• Drainage of obstructed duct.
• Resection of diseased section.

35

Week 122 Biliary/Pancreatic Function: What are the three main types of pancreatic neoplasia?

• Adenocarcinoma
• Endocrine neoplasia - insulinomas, glucagonomas, gastrinomas.
• Cystic pancreatic neoplasia.

36

Week 122 Biliary/Pancreatic Function: What is the most common type of pancreatic neoplasia?

Adenocarcinoma, <1% 5 year survival.

37

Week 122 Biliary/Pancreatic Function: How does adenocarcinoma of the pancreas present?

• Obstructive jaundice
• Severe epigastric pain, radiating to the back.
• Weight loss, anorexia, cachexia
• Mass on imaging (CT,USS)

38

Week 122 Biliary/Pancreatic Function: What is ERCP?

Endoscopic retrograde cholangiopancreatography.
• An endoscope is passed down to the duodenum and a catheter is inserted into the Ampulla of Vater.
• A dye is injected to give a view of the biliary tree and pancreatic duct.
• It can be used for stone extraction/stenting/cytology/histology.

39

Week 122 Biliary/Pancreatic Function: What are the broad aspects of treatment for pancreatic adenocarcinoma?

• Surgery
• Oncology - Chemotherapy, Radiotherapy.
• Palliation

40

Week 122 Biliary/Pancreatic Function: What are the surgical options for treating pancreatic adenocarcinoma?

• Double bypass
• Resection

41

Week 122 Biliary/Pancreatic Function: What are the oncological treatments for pancreatic adenocarcinoma?

• Chemotherapy - Gemcitabine, Campeticabine
• Radiotherapy - Some use for locally invasive tumour, pre-operatively.

42

Week 122 Biliary/Pancreatic Function: What are the functions of the sphincter of Oddi?

• Regulates the release of bile and pancreatic juice into the duodenum.
• Prevents reflux of duodenal contents into common bile duct.

43

Week 122 Biliary/Pancreatic Function: The sphincter of Oddi relaxes in response to which hormone?

• Cholecystokinin

44

Week 122 Biliary/Pancreatic Function: There are three things that inhibit the relaxation of the spincter of Oddi, what are they?

• Tramadol
• Glucagon
• Somatostatin

45

Week 122 Biliary/Pancreatic Function: What is the main sensory organ for pancreatic secretion?

The duodenum.

46

Week 122 Biliary/Pancreatic Function: The duodenum is the main sensory organ for pancreatic secretion, it contains endocrine cells which secrete which two hormones in response to what?

• Secretin in response to luminal acid.
• Cholecystokinin (CKK) in response to proteins or fats.

47

Week 122 Biliary/Pancreatic Function: Secretin is released by the duodenum into the blood in response to luminal acid, when it binds to secretin receptors in pancreas what effect does it have?

• Causes the secretion of pancreatic bicarbonate.

48

Week 122 Biliary/Pancreatic Function: Increased cholecystokinin has what effect on the gall bladder and the pancreas?

• Pancreas - Causes the secretion of pancreatic juice.
• Gall bladder - Causes Gallbladder emptying.
(• Also causes relaxation of the sphincter of Oddi).

49

Week 122 Biliary/Pancreatic Function: Which cells in the pancreas are responsible for the secretion of bicarbonate?

Duct Cells.

50

Week 122 Biliary/Pancreatic Function: What is the basic structure of triglyceride?

• A glycerol backbone with three fatty acids attached by ester bonds.

51

Week 122 Biliary/Pancreatic Function: What are the four lipolytic enzymes?

• Lipase, Colipase, phospholipase A2 and cholesterol esterase.

52

Week 122 Biliary/Pancreatic Function: What is the process by which lipids are digested?

• Colipase attaches to the emulsion droplet, which acts as an anchor for lipase. The lipase breaks the droplet into fatty acids and glycerol.
• Phospholipase A2 then acts on the phospholipids to break them into fatty acids and lysolecithin.
• Cholesterol esterase then breaks down the cholesterol and fatty acids.
• The insoluble lipolytic products are made soluble by transferring to bile acid micelles.

53

Week 122 Biliary/Pancreatic Function: Describe the process by which heme is converted into bilirubin.

• The degradation and oxidation of heme is takes place over two stage, catalysed by the enzyme heme oxygenase to produce the green biliverdin.
• The Biliverdin is then reduced to bilirubin by the enzyme biliverdin reductase.

54

Week 122 Biliary/Pancreatic Function: How is bilirubin transported around the body?

Bound to albumin, as it is not soluble.

55

Week 122 Biliary/Pancreatic Function: How is bilirubin excreted into bile and how does liver damage affect this process?

• Bilirubin is converted into bilirubin diglucuronide in hepatocytes.
• This is then actively transported into the bile canalculi.
• As this active transport requires energy it is prone to impairment in liver damage.

56

Week 122 Biliary/Pancreatic Function: Bilirubin diglucuronide is converted into what in the gut?

Urobilinogen - by bacteria in the gut.

57

Week 122 Biliary/Pancreatic Function: Urobilinogen is excreted in two ways, what are they?

• Most is excreted in stool as stercobilin (Which gives stool it's colour)
• Some is excreted in the urine as urobilins (this gives urine it's colour)

58

Week 122 Biliary/Pancreatic Function: Summarise the metabolism of bilirubin.

1) Heme is broken down to bilirubin in macrophages (Liver + spleen).
2) It is transported in the blood with albumin.
3) Conjugated in the liver.
4) Secreted into the intestine as bilirubin diglucuronide, the glucuronic acid is removed and it is converted into urobilinogen.
5) Some is resorbed by kidneys to form urobilins, most is reduced to stercobilin and is excreted in stool.

59

Week 122 Biliary/Pancreatic Function: Which blood test is most useful for diagnosis of acute pancreatitis?

Serum Amylase - If it is greater than 3x the normal limit and is accompanied with severe upper abdominal pain it is acute pancreatitis.

60

Week 122 Biliary/Pancreatic Function: What is the tumour marker for pancreatic cancer? What else can it be raised in?

• CA19-9
• Also raised in gallstones, jaundice and ascites.

61

Week 122 Biliary/Pancreatic Function: What is bile composed of?

• Water
• Bile salts
• Lecithin
• Cholesterol
• Bilirubin

62

Week 122 Biliary/Pancreatic Function: What are the three mechanims of gallstone formation?

1) Supersaturation
2) Nucleation
3) Stone growth