Pascale Gehy-Andre  PA-C Diseases of Gallbladder & Bile Ducts
Anatomy of the Gallbladder <ul><li>A. A pickle shaped sac that is 8-10 cm long c a capacity of about 50 ml. </li></ul><ul>...
Biliary Anatomy <ul><li>Hepatocytes  canaliculi   biliary ductules    </li></ul><ul><li>L & R hepatic ducts   common h...
Bile Production <ul><li>A. Bile is an isotonic mixture consisting of  </li></ul><ul><ul><li>1. electrolytes </li></ul></ul...
Bile Production <ul><li>B. Cholate & chenodeoycholate which are bile salts are synthesized by hepatocytes from cholesterol...
Bile Acid Insufficiency <ul><li>1. Insufficient bile acids can result from a disorder at any step in enteropathic circulat...
Bile Acid Insufficiency (cont) <ul><li>2. Bile acids facilitate the absorption of dietary fat by the formation of intralum...
Cholelithiasis (Gallstones) <ul><li>Definition: presence of concretions in the gallbladder or bile ducts. </li></ul><ul><l...
GallStones (Cholelithiasis) <ul><li>2. Stone type (cont): </li></ul><ul><ul><li>B. pigment 30% </li></ul></ul><ul><ul><ul>...
Interrelation of gallbladder disease <ul><li>1. Cholecystitis is associated with cholelithiasis in 85%-90% of cases </li><...
Diagnostic Studies <ul><li>A. Chemistry, CBC, LFT’s, amylase </li></ul><ul><ul><li>1. CBC elevated in cholecystitis c slig...
Diagnostic Studies (cont) <ul><li>D. Ultrasound: </li></ul><ul><ul><li>Most sensitive and specific test for the detection ...
Treatment of Cholelithiasis (Gallstones) <ul><li>1. Pain relief </li></ul><ul><li>2. Cholecystectomy </li></ul><ul><ul><li...
Complications of Cholelithiasis (Gallstones) <ul><li>Colic </li></ul><ul><li>Acute cholecystitis </li></ul><ul><li>Cholang...
Acute Cholecystitis <ul><li>Types: </li></ul><ul><ul><li>1. Acute calculus cholecystitis </li></ul></ul><ul><ul><ul><li>In...
Acute Cholecystitis <ul><li>1. Key Symptoms: </li></ul><ul><ul><li>Pain in RUQ or epigastric area </li></ul></ul><ul><ul><...
Acute Cholecystitis (cont) <ul><li>4. Common in: </li></ul><ul><ul><li>Fat </li></ul></ul><ul><ul><li>Fertile </li></ul></...
Acute Cholecystitis <ul><li>6. Key Diagnostic Tests: </li></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><ul><li>Most ...
Acute Cholecystitis <ul><li>Key Diagnostic Tests: (continued) </li></ul><ul><ul><li>Oral cholecystogram (limited) </li></u...
 
Acute Cholecystitis (cont) <ul><li>Treatment: </li></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Antibiotics </li>...
Acute Cholecystitis (cont) <ul><li>Complications: </li></ul><ul><ul><li>Perforation </li></ul></ul><ul><ul><li>GB ileus </...
Gallbladder disease (cont) <ul><li>Biliary colic: </li></ul><ul><ul><li>Usually due to stones </li></ul></ul><ul><ul><li>P...
Choledocholithiasis <ul><li>Stones in the common duct which may cause the following symptoms: </li></ul><ul><ul><li>Biliar...
Cholangitis <ul><li>inflammation of CBD </li></ul><ul><li>Charcot’sTriad: </li></ul><ul><ul><ul><ul><li>RUQ pain (biliary ...
Cholangitis Mneumonic <ul><li>C harcot's triad/  C onjugated bilirubin increase H epatic abscesses/  H epatic (intra/extra...
Chronic  Cholecystitis <ul><li>Associated c GB stones in 95% of cases </li></ul><ul><li>Frequent attacks & GB empties poor...
Tumors of the Gallbladder <ul><li>Polyps: are rare </li></ul><ul><li>Carcinoma of GB: </li></ul><ul><ul><li>Uncommon </li>...
Review Gallbladder <ul><li>Gallstones ~ 70% cholesterol &  30% pigment stones </li></ul><ul><ul><li>May be asymptomatic (7...
Pancreas <ul><li>Anatomy </li></ul><ul><ul><li>Head: embraces the duodenal curve </li></ul></ul><ul><ul><li>Body: crosses ...
 
 
 
Pancreas Physiology <ul><li>1. Islets of Langerhans: responsible for the production of: </li></ul><ul><ul><li>A. Insulin <...
Pancreas Physiology (cont) <ul><li>2. Enzymes secreted from ducts: </li></ul><ul><ul><li>Amylase (CHO) </li></ul></ul><ul>...
Pancreas Physiology (cont) <ul><li>3. Pancreatic secretion stimulated by two hormones: </li></ul><ul><ul><li>Secretin : </...
Pancreas Physiology (cont) <ul><li>4. The pancreas secrets 1-4 Liters of fluid per day </li></ul><ul><li>5. The pancreatic...
Acute Pancreatitis <ul><li>Etiology: Alcohol & Gallstones  = 80-90% </li></ul><ul><ul><li>Other causes: </li></ul></ul><ul...
Pancreatitis Causes Mneumonic <ul><li>I GET SMASHED : </li></ul><ul><li>I diopathitic G allstones E thanol T rauma S teroi...
 
 
 
 
Acute Pancreatitis <ul><li>Symptoms: </li></ul><ul><ul><li>Epigastric pain severe, boring in nature </li></ul></ul><ul><ul...
Acute Pancreatitis <ul><li>Key Signs: </li></ul><ul><ul><li>Low grade fever, tachycardia, tachypnea </li></ul></ul><ul><ul...
Acute pancreatitis <ul><li>Laboratory tests: </li></ul><ul><ul><li>Elevated serum amylase (>4x’s normal) </li></ul></ul><u...
Ranson’s criteria  on admission <ul><li>1. Age greater than 55 on admission? Yes  (1 points)  No  (0 points) </li></ul><ul...
Ranson’s criteria  within 48 hrs <ul><li>1. Hematocrit fall more than 10% within 48 hrs of admission? Yes  (1 points)  No ...
Ranson's criteria for pancreatitis mortality prediction <ul><li>Score Interpretation  </li></ul><ul><li>under 3 Predicted ...
 
Pancreatitis Ranson’s Criteria   On Admission  Mneumonic <ul><li>&quot; GA   LAW &quot; (GA is abbreviation for Georgia): ...
Pancreatitis Ranson’s Criteria Initial 48 hrs  Mneumonic <ul><li>&quot; C  &  HOBBS &quot; ( C alvin and  Hobb e s ): C al...
Acute Pancreatitis <ul><li>Radiology studies: </li></ul><ul><ul><li>Plain films of abdomen (upright) </li></ul></ul><ul><u...
Acute Pancreatitis <ul><li>Treatment: </li></ul><ul><ul><li>NPO </li></ul></ul><ul><ul><li>Nasogastric tube (rids acid) </...
Pancreatitis: Treatment Mneumonic <ul><li>MACHINES : M onitor vital signs A nalgesia/  A ntibiotics C alcium gluconate (if...
Acute pancreatitis <ul><li>Complications of pancreatitis </li></ul><ul><ul><li>1.  Pseudocysts </li></ul></ul><ul><ul><ul>...
Acute Pancreatitis <ul><li>Differential diagnosis </li></ul><ul><ul><li>Acute cholecystitis </li></ul></ul><ul><ul><li>Bil...
Chronic Pancreatitis <ul><li>Defined: </li></ul><ul><ul><li>Episodes of acute inflammation in a previously injured pancrea...
 
Chronic Pancreatitis <ul><li>Key Symptoms: </li></ul><ul><ul><li>1. Recurrent abdominal pain radiating to back, lasting hr...
Chronic Pancreatitis <ul><li>Key Sign: </li></ul><ul><ul><li>Epigastric tenderness </li></ul></ul><ul><li>Laboratory: </li...
 
 
Chronic Pancreatitis <ul><li>Treatment: </li></ul><ul><ul><li>1. pain relief: </li></ul></ul><ul><ul><ul><li>No alcohol </...
Pancreatic Carcinoma <ul><li>Most common is Ductal carcinoma accounts for more than 90% of all pancreatic carcinomas.  Thi...
Pancreatic Carcinoma <ul><li>Less common: Endocrine causes </li></ul><ul><ul><li>1. insulinoma </li></ul></ul><ul><ul><li>...
Pancreatic Carcinoma <ul><li>About  2/3 occur in the head  & usually spreads to the contiguous structures </li></ul><ul><l...
Pancreatic Carcinoma <ul><li>Classic findings: </li></ul><ul><ul><li>None in early stages </li></ul></ul><ul><ul><li>If co...
Pancreatic Carcinoma <ul><li>Laboratory Tests: </li></ul><ul><ul><li>Routine tests in early stages normal </li></ul></ul><...
 
Pancreatic Carcinoma <ul><li>Differential Diagnosis: </li></ul><ul><ul><li>Chronic pancreatitis </li></ul></ul><ul><ul><li...
Pancreatic Carcinoma <ul><li>Treatment: </li></ul><ul><ul><li>Prognosis is poor, with no survivors to 5 yrs </li></ul></ul...
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Gi Gallbladder & Pancreas

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Gi Gallbladder & Pancreas

  1. 1. Pascale Gehy-Andre PA-C Diseases of Gallbladder & Bile Ducts
  2. 2. Anatomy of the Gallbladder <ul><li>A. A pickle shaped sac that is 8-10 cm long c a capacity of about 50 ml. </li></ul><ul><li>B. Divided into: </li></ul><ul><ul><li>Neck: (has a small pouch called Hartmann’s pouch. This is the location of most of the pathology) </li></ul></ul><ul><ul><li>Body </li></ul></ul><ul><ul><li>Fundus </li></ul></ul><ul><li>C. Contracts after a fatty meal is ingested. </li></ul>Add a picture here.
  3. 3. Biliary Anatomy <ul><li>Hepatocytes  canaliculi  biliary ductules  </li></ul><ul><li>L & R hepatic ducts  common hepatic duct </li></ul><ul><li>Common hepatic ducts & Cystic Duct  Common Bile Duct (CBD) </li></ul>
  4. 4. Bile Production <ul><li>A. Bile is an isotonic mixture consisting of </li></ul><ul><ul><li>1. electrolytes </li></ul></ul><ul><ul><li>2. Protein </li></ul></ul><ul><ul><li>3. bile salts </li></ul></ul><ul><ul><li>4. cholesterol </li></ul></ul><ul><ul><li>5. phospholipids- (phospholipids: contain phos. & on hydrolysis yield fatty acids, glycerol, lethicin, & cephalins. Phospholipase is the enzyme found in liver & pancrease) </li></ul></ul><ul><ul><li>6. bile pigment </li></ul></ul>
  5. 5. Bile Production <ul><li>B. Cholate & chenodeoycholate which are bile salts are synthesized by hepatocytes from cholesterol in a multi-step procedure. </li></ul><ul><li>C. Cholecystokinin (pancreatic enzyme) is released from the small bowel after a fatty meal, stimulates the GB to contract & sphincter of oddi to relax </li></ul><ul><li>D. Bile acids aid in the absorption of fat forming micelles which are absorbed in the small bowel. </li></ul><ul><li>E. The bile salts are reabsorbed in the small bowel & transported back to the liver. Averaging 9x’s/day. </li></ul>
  6. 6. Bile Acid Insufficiency <ul><li>1. Insufficient bile acids can result from a disorder at any step in enteropathic circulation </li></ul><ul><ul><li>A. liver disease with decreased production of acids </li></ul></ul><ul><ul><li>B. obstruction of the duct </li></ul></ul><ul><ul><li>C. Bacterial overgrowth </li></ul></ul><ul><ul><ul><li>(bile acids are conjugated before they can participate in fat absorption) </li></ul></ul></ul><ul><ul><li>D. Disorders of the terminal ileum which decrease the absorption of the bile salts. </li></ul></ul>
  7. 7. Bile Acid Insufficiency (cont) <ul><li>2. Bile acids facilitate the absorption of dietary fat by the formation of intraluminal micelles. </li></ul><ul><li>Therefore if absent will result in malabsorption of fat. </li></ul><ul><li>Treatment </li></ul><ul><ul><li>A. Tetracycline for small bowel overgrowth </li></ul></ul><ul><ul><li>B. Terminal ileum disorders should be treated </li></ul></ul><ul><ul><li>C. Use of medium chain triglycerides are helpful </li></ul></ul><ul><ul><li>Note: failure to correct allows bile acids to enter the large bowel producing diarrhea. </li></ul></ul>
  8. 8. Cholelithiasis (Gallstones) <ul><li>Definition: presence of concretions in the gallbladder or bile ducts. </li></ul><ul><li>1. Affects 20 million people/year </li></ul><ul><li>2. Stone type </li></ul><ul><ul><li>A. Cholesterol (70%) (most common) </li></ul></ul><ul><ul><ul><li>All ages </li></ul></ul></ul><ul><ul><ul><li>Mostly women </li></ul></ul></ul><ul><ul><ul><li>Use of estrogen </li></ul></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>Disease of small bowel & sphincter </li></ul></ul></ul>
  9. 9. GallStones (Cholelithiasis) <ul><li>2. Stone type (cont): </li></ul><ul><ul><li>B. pigment 30% </li></ul></ul><ul><ul><ul><li>(calcium bilirubinate) </li></ul></ul></ul><ul><ul><ul><li>Mostly bilirubin </li></ul></ul></ul><ul><ul><ul><li>Hemolytic states, cirrhosis & elderly </li></ul></ul></ul><ul><li>3. Mixed </li></ul>
  10. 10. Interrelation of gallbladder disease <ul><li>1. Cholecystitis is associated with cholelithiasis in 85%-90% of cases </li></ul><ul><li>2. Regurgitation of pancreatic acid causes non-bacterial cholecystitis </li></ul><ul><li>3. Bile stasis due to sphincter of oddi spasm or obstruction is a cause of inflammation </li></ul><ul><li>4. Gangrene of GB is due to chronic cholecystitis </li></ul><ul><li>5. A porcelain GB (heavily calcified) should be removed surgically because of increased risk of GB cancer </li></ul>
  11. 11. Diagnostic Studies <ul><li>A. Chemistry, CBC, LFT’s, amylase </li></ul><ul><ul><li>1. CBC elevated in cholecystitis c slight elevation of LFT’s </li></ul></ul><ul><ul><li>2. Biliary obstruction: bilirubin, alk phos & amylase may be elvated. </li></ul></ul><ul><li>B. Plain film of the abdomen is of poor value. </li></ul><ul><li>Only 15-20% of stones are radiopaque. </li></ul><ul><li>C. Oral Cholecystogram: </li></ul><ul><ul><li>Requires patient to take pills </li></ul></ul>
  12. 12. Diagnostic Studies (cont) <ul><li>D. Ultrasound: </li></ul><ul><ul><li>Most sensitive and specific test for the detection of gallstones </li></ul></ul><ul><ul><li>Limited in obese patients </li></ul></ul><ul><ul><li>Simple to do & safe </li></ul></ul><ul><ul><li>No preparation needed </li></ul></ul><ul><ul><li>May show thinkened wall in acute cholecystitis </li></ul></ul><ul><li>E. HIDA scan: </li></ul><ul><ul><li>Used if acute cholecystitis is suspected. The nuclear material is normally taken up in the GB. If obstructed no GB will be seen. </li></ul></ul><ul><li>F. CT scan </li></ul>
  13. 13. Treatment of Cholelithiasis (Gallstones) <ul><li>1. Pain relief </li></ul><ul><li>2. Cholecystectomy </li></ul><ul><ul><li>Emergent for cholecystitis </li></ul></ul><ul><ul><li>Scheduled if symptomatic cholelithiasis s/ cholecystitis </li></ul></ul><ul><li>3. Dissolution with </li></ul><ul><ul><li>Ursidiol, </li></ul></ul><ul><ul><li>chenodeoxycholic acid (actigall) </li></ul></ul><ul><ul><li>Contraindicated in: </li></ul></ul><ul><ul><ul><li>Liver ds </li></ul></ul></ul><ul><ul><ul><li>large stones </li></ul></ul></ul><ul><ul><ul><li>Pregnant women </li></ul></ul></ul><ul><ul><ul><li>Severe sx </li></ul></ul></ul><ul><ul><ul><li>**It takes 2 yrs to work </li></ul></ul></ul><ul><ul><li>Indications: elderly? </li></ul></ul><ul><li>4. Lithotripsy </li></ul>
  14. 14. Complications of Cholelithiasis (Gallstones) <ul><li>Colic </li></ul><ul><li>Acute cholecystitis </li></ul><ul><li>Cholangitis </li></ul><ul><li>Perforation </li></ul><ul><li>Fistulization </li></ul><ul><li>Gallstone ileus </li></ul>
  15. 15. Acute Cholecystitis <ul><li>Types: </li></ul><ul><ul><li>1. Acute calculus cholecystitis </li></ul></ul><ul><ul><ul><li>Inflammation of GB in association with stones </li></ul></ul></ul><ul><ul><ul><li>Stones are in the GB, cystic duct, or in CBD </li></ul></ul></ul><ul><ul><li>2. Acute Acalculus cholecystitis </li></ul></ul><ul><ul><ul><li>Acute inflammation of the GB without the presence of stones </li></ul></ul></ul><ul><ul><ul><li>High incidence of gangrene, necrosis, & perforation </li></ul></ul></ul><ul><ul><ul><li>High mortality rate because more common in elderly & debilitated c absence of oral intake & GB stasis </li></ul></ul></ul><ul><ul><ul><li>Early intervention (consider drainage first) </li></ul></ul></ul><ul><ul><ul><li>Large doses of IV antibiotics </li></ul></ul></ul>
  16. 16. Acute Cholecystitis <ul><li>1. Key Symptoms: </li></ul><ul><ul><li>Pain in RUQ or epigastric area </li></ul></ul><ul><ul><li>Possible radiation to shoulder, back, tip of R scapula, or flank </li></ul></ul><ul><ul><li>Nausea & vomiting </li></ul></ul><ul><ul><li>Fever, tachycardia, tachypnea </li></ul></ul><ul><ul><li>Jaundice (represents obstruction) </li></ul></ul><ul><ul><ul><li>Urine turns dark (acolic stool-Bilirubin) </li></ul></ul></ul><ul><li>2. Key Signs: </li></ul><ul><ul><li>RUQ (or epigastric) tenderness </li></ul></ul><ul><ul><li>+Murphy’s sign </li></ul></ul><ul><li>3. Laboratory: </li></ul><ul><ul><li>Leukocytosis </li></ul></ul><ul><ul><li>Alk Phos & bilirubin </li></ul></ul><ul><ul><ul><li>(c obstruction & pathology of GB) </li></ul></ul></ul><ul><ul><li>SGOT ^, SGPT ^ (if cholangitis present) </li></ul></ul>
  17. 17. Acute Cholecystitis (cont) <ul><li>4. Common in: </li></ul><ul><ul><li>Fat </li></ul></ul><ul><ul><li>Fertile </li></ul></ul><ul><ul><ul><li>(OCP use) </li></ul></ul></ul><ul><ul><li>Forty </li></ul></ul><ul><ul><li>Females </li></ul></ul><ul><li>5. Differential Diagnosis: </li></ul><ul><ul><li>Peptic ulcer </li></ul></ul><ul><ul><li>Appendicitis </li></ul></ul><ul><ul><li>Hepatitis </li></ul></ul><ul><ul><li>Pyelonephritis </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>Renal colic </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Cholangitis </li></ul></ul>
  18. 18. Acute Cholecystitis <ul><li>6. Key Diagnostic Tests: </li></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><ul><li>Most sensitive and specific test for the detection of gallstones </li></ul></ul></ul><ul><ul><ul><li>GB wall thickening and the presence of pericholecystic fluid are radiographic signs of acute cholecystitis </li></ul></ul></ul><ul><ul><li>HIDA Scan (dimethyl iminodiacetic acid) </li></ul></ul><ul><ul><ul><li>great when bilirubin elevated </li></ul></ul></ul><ul><ul><ul><li>Does not detect gallstones </li></ul></ul></ul><ul><ul><ul><li>Identifies an obstructed GB </li></ul></ul></ul><ul><ul><ul><li>The most sensitive and specific test for cholecystitis (especially acalculus cholecystitis) </li></ul></ul></ul>
  19. 19. Acute Cholecystitis <ul><li>Key Diagnostic Tests: (continued) </li></ul><ul><ul><li>Oral cholecystogram (limited) </li></ul></ul><ul><ul><li>CT scan </li></ul></ul><ul><ul><ul><li>most accurate for differential of intra- & extrahepatic obstruction with 95% accuracy. </li></ul></ul></ul><ul><ul><ul><li>Often used in the workup of abdominal pain without specific localizing signs & symptoms </li></ul></ul></ul><ul><ul><ul><li>CT scan is not a first line study for detection of gallstones because of greater cost & invasive nature of the test </li></ul></ul></ul><ul><ul><ul><li>When present gallstones usually are observed on CT </li></ul></ul></ul>
  20. 21. Acute Cholecystitis (cont) <ul><li>Treatment: </li></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><li>Analgesics </li></ul></ul><ul><ul><ul><li>( No morphine- theories of sphincter of Oddi spasm) </li></ul></ul></ul><ul><ul><li>Cholecystectomy </li></ul></ul><ul><ul><ul><li>Open vs. laparoscopic surgery </li></ul></ul></ul>
  21. 22. Acute Cholecystitis (cont) <ul><li>Complications: </li></ul><ul><ul><li>Perforation </li></ul></ul><ul><ul><li>GB ileus </li></ul></ul><ul><ul><li>Biliary colic </li></ul></ul><ul><ul><li>Biliary Dyskinesia </li></ul></ul><ul><ul><li>Choledocholithiasis </li></ul></ul><ul><ul><li>Chronic Cholecystitis </li></ul></ul><ul><ul><li>Tumors of GB </li></ul></ul>
  22. 23. Gallbladder disease (cont) <ul><li>Biliary colic: </li></ul><ul><ul><li>Usually due to stones </li></ul></ul><ul><ul><li>Pain due to GB distention </li></ul></ul><ul><ul><li>Nausea/ Vomiting </li></ul></ul><ul><ul><li>Relief of pain suddenly </li></ul></ul><ul><li>Biliary Dyskinesia: </li></ul><ul><ul><li>Symptoms without stones </li></ul></ul><ul><ul><li>GB doesn’t empty properly </li></ul></ul>
  23. 24. Choledocholithiasis <ul><li>Stones in the common duct which may cause the following symptoms: </li></ul><ul><ul><li>Biliary colic </li></ul></ul><ul><ul><li>Obstructive jaundice </li></ul></ul><ul><ul><li>Intermittent jaundice </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Cholangitis (inflammation of CBD) </li></ul></ul><ul><ul><li>Hemobilia </li></ul></ul><ul><ul><ul><li>Fever </li></ul></ul></ul><ul><ul><ul><li>Pain </li></ul></ul></ul><ul><ul><ul><li>Blood (in the intrahepatic system) </li></ul></ul></ul>
  24. 25. Cholangitis <ul><li>inflammation of CBD </li></ul><ul><li>Charcot’sTriad: </li></ul><ul><ul><ul><ul><li>RUQ pain (biliary pain) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Jaundice </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fever </li></ul></ul></ul></ul>
  25. 26. Cholangitis Mneumonic <ul><li>C harcot's triad/ C onjugated bilirubin increase H epatic abscesses/ H epatic (intra/extra) bile ducts O bstruction L eukocytosis A lkaline phosphatase increase N eoplasms G allstones I nflammatory bowel disease (ulcerative colitis) T ransaminase increase I nfection S clerosing </li></ul>
  26. 27. Chronic Cholecystitis <ul><li>Associated c GB stones in 95% of cases </li></ul><ul><li>Frequent attacks & GB empties poorly </li></ul><ul><li>Fever unusual </li></ul><ul><li>Pain usually several hrs after eating </li></ul><ul><li>Bloating, belching, and flatus </li></ul><ul><li>Murphy’s sign absent </li></ul><ul><li>Labs : CBC, Amylase, bilirubin, enzymes normal </li></ul><ul><li>HIDA scan positive </li></ul>
  27. 28. Tumors of the Gallbladder <ul><li>Polyps: are rare </li></ul><ul><li>Carcinoma of GB: </li></ul><ul><ul><li>Uncommon </li></ul></ul><ul><ul><li>Mostly women </li></ul></ul><ul><ul><li>Usually diagnosed too late </li></ul></ul><ul><ul><li>Spread by direct invasion </li></ul></ul><ul><ul><li>Adenocarcinoma </li></ul></ul><ul><ul><li>Courvoisier’s sign (palpable GB) </li></ul></ul><ul><li>Carcinoma of Bile Duct: </li></ul><ul><ul><li>Usually adenocarcinoma </li></ul></ul><ul><ul><li>Symptoms: </li></ul></ul><ul><ul><ul><li>Painless jaundice </li></ul></ul></ul><ul><ul><ul><li>Mass palpable </li></ul></ul></ul>
  28. 29. Review Gallbladder <ul><li>Gallstones ~ 70% cholesterol & 30% pigment stones </li></ul><ul><ul><li>May be asymptomatic (70%) </li></ul></ul><ul><ul><li>May cause biliary colic (20%) </li></ul></ul><ul><ul><li>May cause cholecystitis (10%) </li></ul></ul><ul><li>Biliary colic- steady cramplike pain in epigastrium (RUQ) </li></ul><ul><ul><li>Pain subsides over 30-60 min </li></ul></ul><ul><li>Cholecystitis - steady cramplike pain in epigastrium (RUQ) & + Murphy’s sign </li></ul><ul><ul><li>Pain does not subside spontaneously </li></ul></ul><ul><li>Cholangitis - triad= </li></ul><ul><ul><li>1. biliary pain (RUQ) 2. jaundice 3. fever </li></ul></ul><ul><ul><li>Sclerosing cholangitis- autoimmune inflammation of the bile ducts. A rare complication of ulcerative colitis </li></ul></ul>
  29. 30. Pancreas <ul><li>Anatomy </li></ul><ul><ul><li>Head: embraces the duodenal curve </li></ul></ul><ul><ul><li>Body: crosses the vertebral column </li></ul></ul><ul><ul><li>Tail: in the hilum of the spleen </li></ul></ul>
  30. 34. Pancreas Physiology <ul><li>1. Islets of Langerhans: responsible for the production of: </li></ul><ul><ul><li>A. Insulin </li></ul></ul><ul><ul><li>B. Glucagon: </li></ul></ul><ul><ul><ul><li>A hormone that is produced by the alpha cells of langerhan that produces glucose from glycogen. </li></ul></ul></ul><ul><ul><li>C. Gastrin </li></ul></ul><ul><ul><li>D. Somatostatin </li></ul></ul><ul><ul><ul><li>Gastrin and somatostatin are mostly in stomach, but also in pancreas, stimulates HCL stopping agents. </li></ul></ul></ul>
  31. 35. Pancreas Physiology (cont) <ul><li>2. Enzymes secreted from ducts: </li></ul><ul><ul><li>Amylase (CHO) </li></ul></ul><ul><ul><li>Lipase (Fats) </li></ul></ul><ul><ul><li>Trypsinogen (Protein) </li></ul></ul><ul><ul><ul><li>Is converted to trypsin in the duodenum so as not to cause autodigestion </li></ul></ul></ul><ul><ul><ul><li>NOTE: Liver produces alpha trypsin to protect against autodigestion </li></ul></ul></ul>
  32. 36. Pancreas Physiology (cont) <ul><li>3. Pancreatic secretion stimulated by two hormones: </li></ul><ul><ul><li>Secretin : </li></ul></ul><ul><ul><ul><li>Produced in the duodenum & stimulated by acid </li></ul></ul></ul><ul><ul><ul><li>Inhibits gastric acid </li></ul></ul></ul><ul><ul><ul><li>Stimulates pancreas to produce bicarb & chloride </li></ul></ul></ul><ul><ul><li>Cholecystokinin : </li></ul></ul><ul><ul><ul><li>A pancreozymin which is released in response to fat & amino acids in the duodenum </li></ul></ul></ul><ul><ul><ul><li>Stimulates pancreas to produce amylase, lipase, & trypsin </li></ul></ul></ul>
  33. 37. Pancreas Physiology (cont) <ul><li>4. The pancreas secrets 1-4 Liters of fluid per day </li></ul><ul><li>5. The pancreatic juice is usually alkaline. </li></ul><ul><ul><li>Food in duodenum causes secretion of secretin (due to high acid content). Secretin releases H2O & bicarb. </li></ul></ul><ul><li>6. In pancreatitis we use foods low in fat & protein because they stimulate secretion from the pancreas. CHO is a weaker stimulant. </li></ul><ul><li>7. Pancreatic enzymes inhibit gastric secretion of its enzymes. </li></ul>
  34. 38. Acute Pancreatitis <ul><li>Etiology: Alcohol & Gallstones = 80-90% </li></ul><ul><ul><li>Other causes: </li></ul></ul><ul><ul><ul><li>Complications of ERCP (endoscopic retrograde cholangiopancreatography) </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>Infections (mumps/ viral) </li></ul></ul></ul><ul><ul><ul><li>Hyperlipidemia: TG > 1000 mg </li></ul></ul></ul><ul><ul><ul><li>Hypercalemia </li></ul></ul></ul><ul><ul><ul><li>Drugs (thiazides, lasix) </li></ul></ul></ul><ul><ul><ul><li>Idiopathic </li></ul></ul></ul>
  35. 39. Pancreatitis Causes Mneumonic <ul><li>I GET SMASHED : </li></ul><ul><li>I diopathitic G allstones E thanol T rauma S teroids M umps A utoimmune (PAN) S corpion stings H yperlipidemia/ H ypercalcemia E RCP D rugs (including azathioprine and diuretics) </li></ul><ul><li>Note: 'Get Smashed' is slang in some countries for drinking, and ethanol is an important pancreatitis cause. </li></ul><ul><li>Note: Shortest answer is gallstones for women, and ethanol for men. </li></ul>
  36. 44. Acute Pancreatitis <ul><li>Symptoms: </li></ul><ul><ul><li>Epigastric pain severe, boring in nature </li></ul></ul><ul><ul><li>Radiation to back </li></ul></ul><ul><ul><li>Nausea & vomiting </li></ul></ul><ul><ul><li>Aggravated by eating </li></ul></ul><ul><ul><li>Feels better leaning forward </li></ul></ul><ul><ul><li>Possible + peritoneal signs </li></ul></ul>
  37. 45. Acute Pancreatitis <ul><li>Key Signs: </li></ul><ul><ul><li>Low grade fever, tachycardia, tachypnea </li></ul></ul><ul><ul><li>Pleural effusions or basal consolidation of lung (left) </li></ul></ul><ul><ul><li>Bowel sounds are feeble or absent </li></ul></ul><ul><ul><li>Low blood pressure, thready pulse, diaphoretic (shock) </li></ul></ul><ul><ul><li>Rare findings are: </li></ul></ul><ul><ul><ul><li>Jaundice due to common bile duct compression </li></ul></ul></ul><ul><ul><ul><li>Cullen sign : discoloration of the periumbilical area </li></ul></ul></ul><ul><ul><ul><li>Grey turner sign : flank discoloration </li></ul></ul></ul><ul><ul><ul><ul><li>These two are specific for pancreatitis </li></ul></ul></ul></ul>
  38. 46. Acute pancreatitis <ul><li>Laboratory tests: </li></ul><ul><ul><li>Elevated serum amylase (>4x’s normal) </li></ul></ul><ul><ul><ul><li>Goes down within 48 hrs </li></ul></ul></ul><ul><ul><ul><li>Urine amylase neither specific nor sensitive </li></ul></ul></ul><ul><ul><ul><li>If normal needs to be confirmed by CT </li></ul></ul></ul><ul><ul><li>Serum lipase </li></ul></ul><ul><ul><ul><li>delayed but more specific </li></ul></ul></ul><ul><ul><li>CBC usually abnormal </li></ul></ul><ul><ul><ul><li>Elevated WBC </li></ul></ul></ul><ul><ul><ul><li>If hgb/hct fall means poor prognosis </li></ul></ul></ul><ul><ul><li>Chemistry </li></ul></ul><ul><ul><ul><li>Hyperglycemia </li></ul></ul></ul><ul><ul><ul><li>hypocalcemia </li></ul></ul></ul><ul><ul><li>LFT’s </li></ul></ul><ul><ul><ul><li>Abnormal if biliary tree involved </li></ul></ul></ul><ul><ul><li>**Excessive fluid loss </li></ul></ul>
  39. 47. Ranson’s criteria on admission <ul><li>1. Age greater than 55 on admission? Yes (1 points) No (0 points) </li></ul><ul><li>2. WBC greater than 16K on admission? Yes (1 points) No (0 points) </li></ul><ul><li>3. Blood glucose greater than 200 mg% on admission? Yes (1 points) No (0 points) </li></ul><ul><li>4. Serum LDH greater than 350 IU/L on admission? Yes (1 points) No (0 points) </li></ul><ul><li>5. Serum SGOT (AST) greater than 250 SF units on admission? Yes (1 points) No (0 points) </li></ul>
  40. 48. Ranson’s criteria within 48 hrs <ul><li>1. Hematocrit fall more than 10% within 48 hrs of admission? Yes (1 points) No (0 points) </li></ul><ul><li>2. BUN rise more than 5 mg/dl within 48 hrs of admission? Yes (1 points) No (0 points) </li></ul><ul><li>3. Serum calcium less than 8 mg% within 48 hrs of admission? Yes (1 points) No (0 points) </li></ul><ul><li>4. Arterial pO2 less than 60 mmHg within 48 hrs of admission? Yes (1 points) No (0 points) </li></ul><ul><li>5. Base deficit less than 4 mEq/L within 48 hrs of admission? Yes (1 points) No (0 points) </li></ul><ul><li>6. Fluid sequestration more than 6L within 48 hrs of admission? Yes (1 points) No (0 points) </li></ul>
  41. 49. Ranson's criteria for pancreatitis mortality prediction <ul><li>Score Interpretation </li></ul><ul><li>under 3 Predicted mortality about 1% </li></ul><ul><li>3-4 Predicted mortality of 15% </li></ul><ul><li>5-6 Predicted mortality of 40% </li></ul><ul><li>> 6 Predicted mortality of 100% </li></ul>
  42. 51. Pancreatitis Ranson’s Criteria On Admission Mneumonic <ul><li>&quot; GA LAW &quot; (GA is abbreviation for Georgia): G lucose >200 A ST >250 L DH >350 A ge >55 y.o. W BC >16000 </li></ul><ul><li>Or </li></ul><ul><li>LEGAL : L eukocytes > 16.000 E nzyme AST > 250 G lucose > 200 A ge > 55 L DH > 350 </li></ul>
  43. 52. Pancreatitis Ranson’s Criteria Initial 48 hrs Mneumonic <ul><li>&quot; C & HOBBS &quot; ( C alvin and Hobb e s ): C alcium < 8 H ct drop > 10% O xygen < 60 mm B UN rise > 5 B ase deficit > 4 S equestration of fluid > 6L </li></ul>
  44. 53. Acute Pancreatitis <ul><li>Radiology studies: </li></ul><ul><ul><li>Plain films of abdomen (upright) </li></ul></ul><ul><ul><ul><li>Helps r/o perforation (free air) or intestinal obstruction </li></ul></ul></ul><ul><ul><li>Abdominal sonogram identifies: </li></ul></ul><ul><ul><ul><li>GB, CBD size, stones </li></ul></ul></ul><ul><ul><li>CT scan </li></ul></ul><ul><ul><ul><li>Size of pancreas </li></ul></ul></ul><ul><ul><ul><li>Extent of necrosis </li></ul></ul></ul><ul><ul><ul><li>Fluid collection </li></ul></ul></ul><ul><li>Prognosis: most recover within 48-72 hrs </li></ul><ul><ul><li>Mortality average is about 10% </li></ul></ul>
  45. 54. Acute Pancreatitis <ul><li>Treatment: </li></ul><ul><ul><li>NPO </li></ul></ul><ul><ul><li>Nasogastric tube (rids acid) </li></ul></ul><ul><ul><li>IV fluids (electrolytes, calcium) </li></ul></ul><ul><ul><li>Parenteral analgesics (Demerol) </li></ul></ul><ul><ul><li>Antibiotics in severe biliary pancreatitis </li></ul></ul><ul><ul><li>Removal of stones from ampulla if needed. </li></ul></ul><ul><ul><li>High CHO, low fat & protein </li></ul></ul>
  46. 55. Pancreatitis: Treatment Mneumonic <ul><li>MACHINES : M onitor vital signs A nalgesia/ A ntibiotics C alcium gluconate (if necessary) H 2 blockers I V access/ I V fluids N il by mouth E mpty gastric contents S urgery if required/ S enior review </li></ul>
  47. 56. Acute pancreatitis <ul><li>Complications of pancreatitis </li></ul><ul><ul><li>1. Pseudocysts </li></ul></ul><ul><ul><ul><li>Due to necrosis of cells causing accumulation of blood, pancreatic juices, fat </li></ul></ul></ul><ul><ul><ul><li>Resolve spontaneously </li></ul></ul></ul><ul><ul><li>2. Pancreatic Abscess </li></ul></ul><ul><ul><ul><li>Infected cysts </li></ul></ul></ul><ul><ul><li>3. Others </li></ul></ul><ul><ul><ul><li>Fat necrosis </li></ul></ul></ul><ul><ul><ul><li>ARDS (respiratory distress syndrome) </li></ul></ul></ul><ul><ul><ul><li>Acute tubular necrosis </li></ul></ul></ul><ul><ul><ul><li>DIC, hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Pancreatic insufficiency </li></ul></ul></ul>
  48. 57. Acute Pancreatitis <ul><li>Differential diagnosis </li></ul><ul><ul><li>Acute cholecystitis </li></ul></ul><ul><ul><li>Biliary colic </li></ul></ul><ul><ul><li>Cholangitis </li></ul></ul><ul><ul><li>Peptic ulcer </li></ul></ul><ul><ul><li>Hepatitis </li></ul></ul><ul><ul><li>Intestinal obstruction </li></ul></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul>
  49. 58. Chronic Pancreatitis <ul><li>Defined: </li></ul><ul><ul><li>Episodes of acute inflammation in a previously injured pancreas </li></ul></ul><ul><li>Causes: </li></ul><ul><ul><li>Alcoholic abuse </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Pancreas divisum: failure of the ventral & dorsal pancreatic ducts to fuse </li></ul></ul><ul><ul><li>Most common cause in children is cystic fibrosis </li></ul></ul>
  50. 60. Chronic Pancreatitis <ul><li>Key Symptoms: </li></ul><ul><ul><li>1. Recurrent abdominal pain radiating to back, lasting hrs to days, precipitated by alcohol. </li></ul></ul><ul><ul><li>2. Steatorrhea when 90% of pancreas is destroyed. Increase protein in diet without complications. Increased fat intake will cause further increase in diarrhea. </li></ul></ul><ul><ul><li>3. CHO malabsorption is rare </li></ul></ul><ul><ul><li>4. Vitamin B12 malabsorption: due to decreased secretion of trypsin. B12 combines with a R-protein in the stomach. If not cleaved by trypsin, it will not bind with IF. Then can not be absorbed in the terminal ileum </li></ul></ul><ul><ul><li>5. Diabetes mellitus </li></ul></ul>
  51. 61. Chronic Pancreatitis <ul><li>Key Sign: </li></ul><ul><ul><li>Epigastric tenderness </li></ul></ul><ul><li>Laboratory: </li></ul><ul><ul><li>Blood tests not useful: serum amylase often normal ; amylase & lipase only ^ in acute states </li></ul></ul><ul><ul><li>Secretin test: to estimate the volume of fluid & bicarb. </li></ul></ul><ul><ul><li>Radiology tests: </li></ul></ul><ul><ul><ul><li>Flat plate (AXR) may reveal calcifications </li></ul></ul></ul><ul><ul><ul><li>ERCP showing a dilated CBD </li></ul></ul></ul><ul><ul><ul><li>CT scan showing calcifications , pseudocysts, ductal abnormalities </li></ul></ul></ul>
  52. 64. Chronic Pancreatitis <ul><li>Treatment: </li></ul><ul><ul><li>1. pain relief: </li></ul></ul><ul><ul><ul><li>No alcohol </li></ul></ul></ul><ul><ul><ul><li>Analgesics (narcotics- careful c addicts) </li></ul></ul></ul><ul><ul><ul><li>Pancreatic extracts </li></ul></ul></ul><ul><ul><li>2. Steatorrhea: </li></ul></ul><ul><ul><ul><li>use of oral enzymes with meals, low fat diet, low protein, medium chain triglycerides. </li></ul></ul></ul><ul><ul><li>Diabetes: </li></ul></ul><ul><ul><ul><li>Calorie restriction </li></ul></ul></ul><ul><ul><ul><li>Small doses of insulin </li></ul></ul></ul>
  53. 65. Pancreatic Carcinoma <ul><li>Most common is Ductal carcinoma accounts for more than 90% of all pancreatic carcinomas. This is exocrine. </li></ul><ul><li>Most are adenocarcinoma of ampulla area = no cure </li></ul><ul><li>More frequent in males over 40 yo </li></ul><ul><li>Smoking increases incidence </li></ul><ul><li>Top ranked cancers: </li></ul><ul><ul><li>Men Women </li></ul></ul><ul><ul><li>Lung breast </li></ul></ul><ul><ul><li>Colon colon </li></ul></ul><ul><ul><li>Prostate lung </li></ul></ul><ul><ul><li>Pancreas ovary </li></ul></ul><ul><ul><li>pancreas </li></ul></ul>
  54. 66. Pancreatic Carcinoma <ul><li>Less common: Endocrine causes </li></ul><ul><ul><li>1. insulinoma </li></ul></ul><ul><ul><li>2. gastrinoma </li></ul></ul><ul><ul><li>3. glucagonoma </li></ul></ul><ul><ul><li>4. somatostatinoma inhibits all islet cell fxn </li></ul></ul><ul><ul><li>5. VIPoma (pancreatic polypeptide) causes severe diarrhea & hypokalemia (pancreatic diarrhea) </li></ul></ul>
  55. 67. Pancreatic Carcinoma <ul><li>About 2/3 occur in the head & usually spreads to the contiguous structures </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Vague discomfort </li></ul></ul><ul><ul><li>More toward back </li></ul></ul><ul><ul><li>Worse on lying down </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Jaundice is characteristic </li></ul></ul><ul><ul><li>Glucose intolerance can be an early sign </li></ul></ul><ul><ul><li>N/V weakness on occasion </li></ul></ul><ul><ul><li>Pruritis </li></ul></ul><ul><ul><li>Pain can be early if the tail is involved because of splanchnic nerve </li></ul></ul><ul><ul><li>Note: painless, non-pruritic, jaundice if head involved </li></ul></ul><ul><ul><li>but painful if tail is involved </li></ul></ul>
  56. 68. Pancreatic Carcinoma <ul><li>Classic findings: </li></ul><ul><ul><li>None in early stages </li></ul></ul><ul><ul><li>If common duct obstructed due to head tumor = jaundice & icterus </li></ul></ul><ul><ul><li>GB can be palpable (Courvoisier’s sign) </li></ul></ul><ul><ul><li>Ascites & peripheral edema may be a sign of portal hypertension </li></ul></ul><ul><ul><li>Superficial thrombophlebitis (Trousseau’s sign) occurs. </li></ul></ul>
  57. 69. Pancreatic Carcinoma <ul><li>Laboratory Tests: </li></ul><ul><ul><li>Routine tests in early stages normal </li></ul></ul><ul><ul><li>Alk phos & transaminases (AST/ALT) are slightly elevated </li></ul></ul><ul><ul><li>Ultrasound: the best in the initial diagnosis </li></ul></ul><ul><ul><li>CT scan is better at staging the tumor </li></ul></ul><ul><ul><li>Angiography (helpful if tumor is resectable) </li></ul></ul><ul><ul><ul><li>Stages: </li></ul></ul></ul><ul><ul><ul><ul><li>I. Confined to pancreas </li></ul></ul></ul></ul><ul><ul><ul><ul><li>II. Involving only the neighboring structures </li></ul></ul></ul></ul><ul><ul><ul><ul><li>III. Involving regional lymph nodes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>IV. Metastatic to liver & distant spread </li></ul></ul></ul></ul>
  58. 71. Pancreatic Carcinoma <ul><li>Differential Diagnosis: </li></ul><ul><ul><li>Chronic pancreatitis </li></ul></ul><ul><ul><li>Cholecystitis </li></ul></ul><ul><ul><li>Causes of jaundice: hepatitis </li></ul></ul><ul><ul><li>Irritable bowel syndrome </li></ul></ul><ul><ul><li>Carcinoma of duodenum </li></ul></ul><ul><ul><li>Common bile duct stones </li></ul></ul><ul><ul><li>Peptic ulcer disease </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Ampulla carcinoma </li></ul></ul><ul><ul><li>Metastatic disease to the pancreas </li></ul></ul>
  59. 72. Pancreatic Carcinoma <ul><li>Treatment: </li></ul><ul><ul><li>Prognosis is poor, with no survivors to 5 yrs </li></ul></ul><ul><ul><li>10-15% are resectable </li></ul></ul><ul><ul><li>If resectable 30% survive less than 2 yrs </li></ul></ul><ul><ul><li>Chemotherapy gives poor response </li></ul></ul><ul><ul><li>A whipple procedure for temporary relief </li></ul></ul><ul><ul><ul><li>Includes removal of small portion of duodenum, distal stomach, GB, CBD, regional nodes, some jejunum & pancreas </li></ul></ul></ul>
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