Pathology of Biliary Disorders.


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Lecture session for Pathology of Biliary disorders.

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Pathology of Biliary Disorders.

  1. 1. Cognitoergo sum.…I think, therefore I am…!- -Rene Descartes
  2. 2. MB4-T2-Wk4-Biliary systemCPC 4.2.3 Professionalism & Ethics - of out of office consultations.. Abdominal problems…DD Counseling, SNAP & five A‟s… Upper abdominal discomfort with bloating & wind. after meal burps, stomach feels full & windy. ? worsening. Duration Symptoms for many months. Relation to food/fat Yes, makes it worse. Pain 3-4/10, ill defined, cramping. Nausea occasional, no vomiting. Wt loss, Anorexia, Dysphagia  No Bowel habit constipation, No pus, blood PR. Diet usually eats once a day, often fast foods. Little fruits &veggies. Lots of coffee*2CASE STUDY:Mrs. L.K is your eldest son’s high school teacher. You attend the parent-teacher interview todiscuss his school work and she asks for advice about her abdominal problems. You advise her tosee you at your rooms in the morning. She is 32 years old and married to a local police officer.
  3. 3. MB4-T2-Wk4-Biliary systemCPC 4.2.3 Alchohol 2-3 glasses of wines/night. 12-15 onweekends, more when friends. (Hepatitis, pancreatitis, gallstones) Family: Married to an accountant, no children but has 3lap dogs. (hydatid dis, echinococcosis.) MedicationShe is on COCP, (Budd-Chiari sy) PSH: Tonsillectomy & adenoidectomy at 5 years,appendicectomy at 14y. (Viral Hepatitis)3
  4. 4. MB4-T2-Wk4-Biliary systemInvestigations Upper abdominal USS – numerous gallstones in thick-walled gallbladder LFT – elevated GGT*, Alk Phos normal*…? Fasting glucose- 7.0 mmol/l Lipid profile - Total Chol 7.2, Trig. 2.8, HDL 2.0, LDL-5.1. Rectal examination – Hard stool in the rectum, nohemorrhoids or fissures.4
  5. 5. MB4-T2-Wk4-Biliary systemCPC 4.2.3: DD – commonest first. Gastritis Peptic ulcer Liver disease.. Fatty liver * Gallstones, Cholecystitis. Constipation * Irritable bowel syndrome Diverticulosis / Diverticulitis Pancreatitis - chronic Any thing else ??5Major Learning Issues:• Gall stones• Cholecystitis Acute/Chronic• Pancreatitis Acute/Chronic• Pancreatic cancer.Minor Learning Issues:• Cholangitis• Biliary Atresia• Secondary Biliary Cirrhosis• Carcinoma of Gallbladder• Cholangiocarcinoma(bile duct ca)• Hemochormatosis,• Wilson‟s• & α1AT deficiency
  6. 6. 6HBS:CommonClinical Presentations.Why!
  7. 7. MB4-T2-Wk4-Biliary systemPathological basis of signs and symptoms7Sign or symptom Pathological basisJaundice Haemolysis, liver disease or biliary obstructionDark urine Conjugated hyperbilirubinaemia (water-soluble)Pale faeces Biliary obstruction causing lack of bile pigmentsSpider naevi Gynaecomastia Secondary to hyperoestrogenismOedema Reduced plasma oncotic pressure - hypoalbuminaemiaXanthelasma Cutaneous lipid deposits  hypercholesterolaemia inchronic biliary obstruction.Steatorrhoea Malabsorption of fat - (e.g. biliary obstruction)Pruritus Biliary obstruction resulting in bile salt accumulationAscites Hypoalbuminaemia, portal hypertension and secondaryhyperaldosteronism.Bruising or bleeding Impaired hepatic synthesis of clotting factors – Vit K.Hepatomegaly hepatitis, infiltration (fat) or tumour (primary or secondary)Haematemesis Ruptured oesophageal varices due to portal hypertensionEncephalopathy Failure of liver to remove toxins mimicking or alteringbalance of neurotransmitters
  8. 8. MB4-T2-Wk4-Biliary systemSelf Assessment Questions: most common cause of acute Cholecystitis / cholelithiasis /pancreatitis? Common types & pathogenesis of cholelithiasis? Clinical features of acute cholecystitis / cholelithiasis? Morphology of acute & Chronic cholecystitis? (gross/micro) How obesity causes cholelithiasis? Pathogenesis of alcohol induced pancreatitis? What is cholestasis? common types? PBC, PSC, neonatal. Congenital: Hemochormatosis, Wilson‟s & α1AT deficiency? Common type & clinical features of of pancreatic cancer? What is primary sclerosing cholangitis? Common causes? Hepatocellular carcinoma ? Brief notes, diagnosis, AFP..
  9. 9. MB4-T2-Wk4-Biliary systemCore Learning Issues (CLI): Major CLI:• Cholelithiasis• Cholecystitis – Acute, Chronic• Pancreatitis – Acute, Chronic• Pancreatic carcinoma Minor CLI:• Ca. gall bladder & biliary tract.• Other parasites, atresia, Autoimmune.• Congenital: Cystic fibrosis.• Hemochormatosis, Wilson‟s & α1AT deficiency• Pancreatic cysts, pseudocyst,• Other Tumours, carcinoid, MEN Types 1 & 2.9
  10. 10. Thought is Powerful & Free!--William ShakespeareHuman mind is the most powerful weapon in theworld.- e.g. Osama bin laden.Great monuments & Great wars have always started in a human mind…!
  11. 11. Pathology ofBiliary & Pancreatic DisordersDr. Shashidhar Venkatesh MurthyA/Prof. & Head of PathologySchool of Medicine.
  12. 12. Anatomy:
  13. 13. MB4-T2-Wk4-Biliary systemPhysiology: Bile is the main pathway for cholesterol excretion. Bile: cholesterol, bile salts & bile pigmint (bilirubin, biliverdin) Cholesterol made soluble by bile salts (soap) as micielles Excess cholesterol / low bile salt  Stone formation*.
  14. 14. MB4-T2-Wk4-Biliary systemBiliary Obstructions: Extrahepatic Obstruction:• Dislodged gallstones• Ca. CBD, Ca. Head of pancreas.• inflammatory stricture of CBD• accidental surgical ligation of CBD. Intrahepatic Obstruction:• Biliary atresia – Congenital.• Primary Biliary Cirrhosis• Primary Sclerosing Cholangitis.• Cystic fibrosis.Common Disorders:• Cholecystitis• Cholelithiasis• Choledocholithiasis.(Adeno Carcinoma)95% - Cholelithiasis (+cystitis)
  15. 15. MB4-T2-Wk4-Biliary systemCholelithiasis: Cholelithiasis/gall stones – 95% of GB dis. Incidence: West 20-40%, Asian 2-4%. 70-80% asymptomatic Mixed 80% - (cholesterol, ca+, bile, blood) Pure 20% - Pigment *, Cholesterol. Severe colicky Upper abdomen  Rt shoulder. Conjugated hyperbilirubinemia  Obstruction. Fat intolerance  clay stools - typical in chronic.
  16. 16. MB4-T2-Wk4-Biliary systemRisk Factors: CholelithiasisCholesterol Stones: Race/Demo: Western Age Middle/late. Excess Cholesterol• Female sex• Oral contraceptives• Pregnancy• Obesity• Rapid weight reduction• Gallbladder stasis• Disorders of bile acidmetabolism• Hyperlipidemia syndromesPigment Stones: Race – Asians Age: early Jaundice / Infections• Hemolysis syndromes• Biliary infections• Inflammatory boweldisorders.• Ileal resection or bypass.• Cystic fibrosis• Chronic Pancreatitis.80% Idiopathic.75% in American Pima race.
  17. 17. MB4-T2-Wk4-Biliary systemCholelithiasis:Crystallization of bile within biliary system. Risk factors:• female gender, obesity, diabetes mellitus (FFFF…!) Pathogenesis: Cholesterol is made soluble by bile salts and lecithins. More cholesterol or less bile salts  chol. Monohydratecrystals  stone. Etiologic factors.• Supersaturation – excess Cholesterol – crystals.• Calcium Microprecipitation - Nucleation.• Stasis - Mucous  trap crystals – aggregation• Stone growth environment: infection, stasis, etc.
  18. 18. MB4-T2-Wk4-Biliary systemCholelithiasis: Morphology & Types:• Mixed Chol (Ca+Bile salt)* Multiple,faceted, yellow-grey.• Rarely Pure cholesterol: Round spiky.• Bile Pigment stones (black/brown).Infection / Jaundice. % Calcium = radioopaque.
  19. 19. MB4-T2-Wk4-Biliary systemGallstones + Chronic Cholecystitis
  20. 20. MB4-T2-Wk4-Biliary systemCholesterol (Pure) Gallstones, bleeding.20Round, yellow, spiky, bleeding. Note thickened inflammed gall bladder.
  21. 21. MB4-T2-Wk4-Biliary systemCholecystitis + gall stones  Abscess.21Pigment stones in Infection: Inflammed, thickened gallbladder filled with pus & black gall stones.Small stone is seen obstructing neck  acute pain.Adherent OmentumPus & Stones (black)Stone in the neckUNSW MuseumPigment stones inHemolysis - Bilirubin
  22. 22. MB4-T2-Wk4-Biliary systemGall stones in CBDStones in CBDStonees in GB20% of mixed chol. stones and >50% of pigment stones are radio-opaque
  23. 23. MB4-T2-Wk4-Biliary systemComplications of Cholelithiasis: Obstruction Sec biliary cirrhosis* Cholecystitis Cholangitis Biliary colic Jaundice Empyema Liver abscess Mucocele Pancreatitis. Peritonitis Carcinoma Fistula formation Gall stone ileus.Gallstone ileus
  24. 24. It is not enough to have a good mind;the main thing is to use it well…!- -Rene Descartes
  25. 25. MB4-T2-Wk4-Biliary systemAcute Cholecystitis: 90% Cholelithiasis. 10% non-calculous Females common. Outflow obstruction by a small gallstone. Infection – E.coli.  Empyema. Risk of perforation, peritonitis, fistula Gall stone ileus when stone enters GIT. Serum amylase normal (high with pancreatitis). Mild jaundice in 20% - obstructive. Acute inflammation, hemorrhage, edema, neutrophils. Gangrenous cholecystitis: when obstruction is severecompromising blood supply. Green-black necrotic.
  26. 26. MB4-T2-Wk4-Biliary systemChronic Cholecystitis: Females. Recurrent / Chronic. Thick fibrotic wall. Thick bile – biliary gravel. Aschoff-Rokitansky sinuses –diverticula - Due to increasedluminal pressure (obstruction) Diffuse infiltration by chronicinflammatory cells.
  27. 27. What we think,we become!--Buddha
  28. 28. MB4-T2-Wk4-Biliary systemNeoplastic Disorders: (rare) Benign tumours:• Bile duct adenoma, cystadenoma Malignant tumours:• Adenocarcinoma Ducts lined by cuboidal tocolumnar mucin secreting cells separated bydesmoplastic (fibrotic) stroma.• Cholangiocarcinoma (Bile duct carcinoma)• Presents with Jaundice.• Early spread with very poor prognosis.
  29. 29. MB4-T2-Wk4-Biliary systemCarcinoma Gallbladder: Females , Hispanics. Mexico & Chile 5th-7th decade Common – Lithiasis * abdominal pain, anorexia, High ALP. Commonly Adenocarcinoma Late diagnosis Poor prognosis. 5% 5 year survival.
  30. 30. MB4-T2-Wk4-Biliary systemCa Bile duct: Cholangiocarcinoma: Adeno Carcinoma ofcholangiocytes. Thoratrast exposure? Increased incidence inulcerative colitis. Presents with obstructivejaundice – early diagnosis. Intrahepatic or extrahepatic. Increasing incidence. ? toxin
  31. 31. 31Living becomes a glorious experienceonly when there is tolerance and love.Willingness to compromise with otherpeople’s ways of living andcooperation. These make happy andsuccessful societies.-- Baba.
  32. 32. MB4-T2-Wk4-Biliary system32CPC 4.2.4 – HBS – Part 22 weeks later she present again to your GP practice.-Worsening abdominal pain - „The worst I ever had-It’sterrible, please do something’ Central, severe 9/10 constant, radiates to back. > 12hours. Associated with vomiting x 3 this morning. Nohaematemesis. Bowels opened yesterday no blood mucus. Hasn‟tpassed urine in 8 hours. Doesn‟t feel like drinking oreating. „I just want to lie here- Don’t make me move’ No Pale stools / dark urine. Hasn‟t passed urine sincethis morning.
  33. 33. MB4-T2-Wk4-Biliary systemHistory & Examination: Abdomen distended, tender. Guarding ++epigastrium. Investigations.• FBP –WCC↑, Plt 100 10x9• urea 7.4 mmol/l [2.5-6.6mmol/l]• decreased eGFR 70 [>90]• Crea 140umol/l [60-120umol/l]• LFT glucose 7.8, Ca+ Decreased, ALT & GGT ↑↑↑• Amylase lipase - ↑↑33DD: Acute Abdomen, Pancreatitis, perforated pepticulcer, appendicitis, diverticulitis,
  34. 34. “Outer world is the reflection ofour inner world (thoughts)”--Baba
  35. 35. Pathology ofPancreatic DisordersShashidhar Venkatesh MurthyAssoc. Prof & Head of Pathology
  36. 36. MB4-T2-Wk4-Biliary systemIntroduction: Pancreas Exocrine & Endocrine gland.• Develops from two embryonic buds (dorsal & ventral)• Head, neck & body, Portal circulation*• Susceptible to Obstruction, ischemia, trauma, toxins.• Highly destructive “lytic” enzymes Disorders:• Congenital: annular, divisum, ectopic, cysts.• Acute & Chronic pancreatitis.• Cysts & Tumors: Adenocarcinoma. Diagnosis:• Serum amylase, lipase & ERCP/MRCP*• Biopsy is hazardous. – don’t mess with pancreas...!
  37. 37. MB4-T2-Wk4-Biliary systemAnatomyHistology
  38. 38. MB4-T2-Wk4-Biliary systemCongenital Disorders: Pancreatic Divisum:• Most common 3-10%• Failure of fetal duct union.• Congenital chronicpancreatitis. Cystic Fibrosis:• CFTR gene mutation– thick secretions. Annular Pancreas• 2nd part duodenumobstruction. Ectopic Pancreas• stomach and duodenum.
  39. 39. MB4-T2-Wk4-Biliary systemAcute Pancreatitis Acute Inflammation of pancreas leading to enzymaticautodigestion & Hemorrhage, fat necrosis of surroundingtissue with systemic effects & multiorgan failure. Release & activation of pancreatic enzymes. Defectiveinactivation of trypsin. Common Etiology Alcohol & Gall stones (& Idiopathic). Trauma, Viral infection, Hyperlipidemia, hypercalcemia,shock, trauma, drugs, infections, snake bite – rare causes. Autoimmune disorders  immune pancreatitis. Blacks 10 times common than other races * Outcome: Heal, complications or chronic.
  40. 40. MB4-T2-Wk4-Biliary system
  41. 41. MB4-T2-Wk4-Biliary systemAcute Pancreatitis:Pathogenesis of clinical features:SUMMARY:Trypsin  Kallikrein  Thrombosis - NecrosisProtease  Blood Vessel injury – Bleeding.Lipase  Fat necrosis  Inflammation.
  42. 42. MB4-T2-Wk4-Biliary systemGrey Turner Sign - Cullen‟s SignSevereMild
  43. 43. MB4-T2-Wk4-Biliary systemAcute Pancreatitis:a: The pancreas edematousand hemorrhagic (H). Pancreatictissue becomes necrotic andmay become semi-liquid.b: fat necrosis seen as whitespots (F) in mesenteric andretroperitoneal fat.Histologically these foci arecomposed of necrotic adiposetissue, with adjacent reactiveinflammation.
  44. 44. MB4-T2-Wk4-Biliary systemAcutePancreatitis:K KHemorrhage in thehead of Pancreas withedema.CT Scan appearance
  45. 45. AcutePancreatitis:L K KHemorrhage in thehead of Pancreas withedema.CT Scan appearanceA-StomachB-SpleenC-PeritoneumD-Pancreas
  46. 46. MB4-T2-Wk4-Biliary systemAcute Hemorrhagic Pancreatitis:Head
  47. 47. MB4-T2-Wk4-Biliary systemAcute Hemorrhagic Pancreatitis:Fat NecrosisAcini NecrosisHemorrhageNormal Acini
  48. 48. MB4-T2-Wk4-Biliary systemAcute Hemorrhagic Pancreatitis:Fat NecrosisAcini NecrosisHemorrhageNormal Acini
  49. 49. MB4-T2-Wk4-Biliary systemAcute Pancreatitis: ComplicationsPancreatic cancer
  50. 50. At the center of your being youhave the answer; you knowwho you are and you knowwhat you want!Lao Tzu
  51. 51. MB4-T2-Wk4-Biliary systemCPC 2.7- Mr J.M. 51y, depression. Mr J.M. 51 year old High School principal inTownsville. Several months - stress, anxiety and depression. Treatment for this with anti depressants andcognitive behavior therapy has been reasonablysuccessful although he remains stressed. makes an earlier appointment. „His trousers are hanging off him. No appetite. myankles have been a bit swollen recently. Could not walk…. Too tired…! Epigastric intermittent pain. „Bit dark urine … recently‟
  52. 52. MB4-T2-Wk4-Biliary systemChronic Pancreatitis: Clinical:• Painful, relapsing, inflammation, fibrosis & exocrine atrophy.Cystic/atrophic ducts.• Irreversible loss of pancreatic function *• Malabsorption, albumin, wt. loss – Exocrine• Type I DM – Endocrine loss.• Recurrent obstructive Jaundice – obstruction. Causes:• Toxic metabolic- 70%: Alcohol, Hyperlipidaemia, toxins, drugs,hypercalcaemia.• Idiopathic-20%: Early/Late.• Others: Genetic, autoimmune, Post necrotic. Complications:• Pseudocyst, Calcification, lithiasis & Carcinoma.
  53. 53. MB4-T2-Wk4-Biliary systemChronic Pancreatitis:
  54. 54. MB4-T2-Wk4-Biliary systemChronic fibrosing Pancreatitis:DuodenumFibrosispancreas (P) is atrophic and replaced by rubbery, fibrous tissue, in which dilatedducts (D) are seen (Clinically by ERCP). In many cases calculi are present in thedilated ducts. In this example the duodenum is attached (A).
  55. 55. MB4-T2-Wk4-Biliary systemChronic PancreatitisAtrophy, Fibrosis, CalcificationThe pancreas is shrunken and fibrotic. The main ductis dilated and filled with calcified secretions (arrows).
  56. 56. MB4-T2-Wk4-Biliary systemChronic Pancreatitis:Dilated DuctsIslets (endocrine)FibrosisNote: Fibrosis replacing exocrine glands. 0nly ducts & Islets remain in late stage.Inflam
  57. 57. MB4-T2-Wk4-Biliary systemChronic Pancreatitis: Complications
  58. 58. MB4-T2-Wk4-Biliary systemChronic Pancreatitis- Pseuocyst
  59. 59. Control your senses and you arebeyond trouble.Let them loose and you arebeyond help…!- - Lao Tzu
  60. 60. MB4-T2-Wk4-Biliary systemPancreatic tumours: Cysts:• True cysts• Polycystic diseases, MEN syndromes:• Von-hippel-lindau disease. Adenoma:• Cystadenoma• Endocrine - Insulinoma, gastrinoma etc. Carcinoma:• Adenocarcinoma – common.60
  61. 61. MB4-T2-Wk4-Biliary systemPancreatic Cancer Increasing in incidence. 4th common (next to Colon Ca). 10-15 per 100 000, more with age >70y. Men are affected twice as often as women. Unknown etiology, Several Risk factors Smoking, Diabetes & Diet.• High calorie, fat, meat, salt, fried, soy beans & nitrosamines. Also increased incidence in Hereditary pancreatitis,MEN, hereditary non-polyposis colon cancer-HNPCC.
  62. 62. MB4-T2-Wk4-Biliary systemPancreatic Cancer Adenocarcinoma fibrosis stricture, Obstructivejaundice & weight loss. Advanced disease at presentation. Poorprognosis. 85% only palliative care. Palpable gallbladder + jaundice  Ca Pan(Courvoisiers sign). diabetes (due to ß cell destruction) Depression*, Migratory thrombophlebitis - Trousseaus
  63. 63. MB4-T2-Wk4-Biliary systemCa. Pancreas : Pathogenesis
  64. 64. MB4-T2-Wk4-Biliary systemPancreatic CancerTumorHeadBody Tail
  65. 65. MB4-T2-Wk4-Biliary systemPancreatic Ca with fibrosis (Chronic pancreatitis)Note: dysplastic glands infiltrating into fibro (spindle cells) myxoid (pale blue) stroma.Malignant gl.Ca. InfiltrationIslet (normal)Fibrous stroma
  66. 66. Ca PancreasClinical FeaturesTumour marker:CEA & CA19–9 antigenTrousseau syndrome
  67. 67. MB4-T2-Wk4-Biliary systemCa Pancreas & Depression Cancer pancreas has a reputation of being a deadly andoften painful disease, with very poor prognosis. Depression and anxiety occur more frequently Depression and anxiety may even precede symptoms orknowledge of the diagnosis. The etiology of depression in patients with cancer of thepancreas may be traced to more than the diseasessymptoms.Steve Jobs
  68. 68. A scholar who cherishes thelove of comfort is not fit to bedeemed a scholar.Lao Tzu
  69. 69. Give someone a fish and youfeed him for a day.Teach someone to fish and youfeed him for a lifetime!Lao Tzu
  70. 70. MB4-T2-Wk4-Biliary systemAcute Pancreatitis: Summary Gross: Inflammation,Hemorrhages (red arrows)and chalky white areas of fatnecrosis (white arrows). Microscopy: Hemorrhage,Acute inflam, fat necrosis. Complications:Mechanisms: Obstruction, Acinar damage, Enzyme anomaly.Pathogenesis: Activation of enzymes in the acini/ducts autodigestion  Fat necrosis  Ca+ soap + inflammation.
  71. 71. MB4-T2-Wk4-Biliary systemCholesterolosis of gallbladder mucosaCholesterol filled Foamymacrophages in mucosalfolds
  72. 72. To attain knowledge, addthings every day.To attain wisdom, removethings every day.Lao Tzu
  73. 73. MB4-T2-Wk4-Biliary systemChronic Pancreatitis- Pseuocyst
  74. 74. MB4-T2-Wk4-Biliary system5 A‟s & SNAP74• Ask: 1. patients with diabetes, hypertension,hyperlidaemia, obesity or existing vascular disease• Assess: 2.Number of cigarettes or equivalent/day,Dependance 3.readiness to change/motivation• Advise: 4.provide written information, 5.motivationalinterviewing• Assist: 6.NRT ? Bupropion(Zyban) 7.Support• Arrange: 8.referral to QUIT 9.follow up with the GPSNAP Counseling: Smoking, Nutrition, Alcohol &Physical Activity.
  75. 75. MB4-T2-Wk4-Biliary systemAcute Pancreatitis: Clinical Features Mild (edema) & Severe (Hemorrhagic) forms. Constant severe epigastric pain radiating to the back Fever, Nausea and/or vomiting Respiratory & circulatory failure DIC, Shock, Fat necrosis, hemorrhage. Abdominal tenderness, distension, guarding, and rigidity,Mild jaundice, Diminished or absent bowel sounds. Hypocalcemia, High Amylase-P (early) High Lipase >24h – (only lipase ↑ in chronic) CT Scan – diagnostic. ? Grey Turner‟s sign ? Cullen‟s sign
  76. 76. MB4-T2-Wk4-Biliary system“acute abdomen” Differential Diagnosis: Acute Pancreatitis: medical emergency ofthe first magnitude. Multiorgan failure – fatal. Differential diagnosis:• Perforated acute appendicitis.• Perforated Acute diverticulitis.• Perforated peptic ulcer.• Acute cholecystitis & Rupture.• Infarction of the bowel.• Intestinal Obstruction.
  77. 77. MB4-T2-Wk4-Biliary systemAcute Pancreatitis: Principles of Lab Diagnosis: Full blood count: neutrophil leukocytosis. Serum amylase: greatly elevated. Serum Lipase: Elevated after 24h. (72-96h) Serum albumin: falls (severe inflam. Exud) Serum calcium: falls - Complex with necrotic Fat. Blood sugar: hyperglycemia if severe – loss ofendocrine part. Alkaline phosphatase: mild elevation obstruction oflower end of bile duct (gall stone) Bilirubin: mild direct Bil, oedema & obstruction of lowerend of bile duct.
  78. 78. MB4-T2-Wk4-Biliary systemCPC 4.2.7- May, 35y woman. May, 35y, indigenous woman, lives in a remoteAboriginal community. After hour visit… “I’ve got terrible gut pains”, since 2h. Students must specifically ask about…? Alcohol, DM.. (PUD, IHD, Gall bl, Drugs) Tenderness & guarding in epigastrium. Absent bowel sounds. Social & family History of alcohol abuse. Diabetes not well controlled.
  79. 79. MB4-T2-Wk4-Biliary systemCPC 4.2.7- May, 35y woman. Differential diagnosis Perforated ulcer, Acute Gastro-enteritis,/infarction, pancreatitis, gall bladderdisease, peptic ulcer.• Heart – MI• Lung – pleurisy, PE, FBC (Hb 132, WCC 21.9), RFT (Na 136,urea 6.1, creatinine 0.07, Ca 1.8) AXR, USG, CXR, ECG, Lipase- 2400 U/L Amylase* lipase *
  80. 80. MB4-T2-Wk4-Biliary systemPancreatic CancerPleomorphic glands (A) in a denselyfibrotic (desmoplastic) stroma (B)Section of head of pancreas showingan ill-defined mass in the pancreaticsubstance (arrowheads) and the greendiscoloration of the CBD due toobstruction of bile flowAB
  81. 81. MB4-T2-Wk4-Biliary systemSilence…81To the question "Who am I?" the only relevant answer is silence. Youneed to discard all answers in words, including "I am Nothing" or "Iam the Cosmic Self" or "I am the Self" - and just stick to the question"Who am I?". All other answers are just thoughts. Thoughts cannever be complete. Only Silence is complete.Thoughts are not the goal in themselves. Their goal is Silence. Whenyou ask the question "Who am I?" you get no answer, there issilence. That is the real answer. For your soul is solidified silence.This solidified silence is wisdom, is knowledge.The easy way to silence the thoughts is to arouse the feelings. For,through feelings only peace, joy and love dawn. And they are allyour very nature.- Sri Sri Ravishankar