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Gall bladder and Pancreas Flashcards

1
Q

What is cholelithiasis

A

Gallstones, which are hard stone-like or gravel-like material found within the biliary system, most often in the gall bladder.

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2
Q

What is cholecystectomy

A

Surgical removal of the gallbladder

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3
Q

Constituents of normal bile

A

Cholesterol, phospholipids, bile salts and bilirubin

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4
Q

Structure of bile

A

Hydrophobic cholesterol aggregate in the middle with hydrophilic bile salts on the periphery and bilirubin scattered throughout.

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5
Q

Pathogenesis of cholesterol gallstones

A

Gallstones form where there is an imbalance between the ratio of cholesterol to bile salts. Micelle formation is disrupted causing free crystallization of cholesterol on micelle surface

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6
Q

Pathogenesis of bilirubin gallstones

A

Excess bilirubin can’t be solubilised in bile salts causing it to aggregate. This excess bilirubin is due to excess haemolysis

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7
Q

Treatment for pigment gallstones

A

Surgery

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8
Q

Are gallstones purely cholesterol or bilirubin based

A

No, they often occur in mixtures

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9
Q

Aetiology of gallstones

A

Gallbladder pH, mucosal glycoproteins

Infection and inflammation biliary lining

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10
Q

What is cholecystitis

A

Inflammation of the gallbladder

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11
Q

Acute cholecystitis common cause

A

Gallstone obstruct flow of bile - Initial sterile - Becomes infected - May cause empyema, rupture or peritonitis - Intense adhesions within 2-3 days

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12
Q

Development of chronic cholecystitis

A

Associated with gallstones, usually develops after bouts of acute cholecystitis. The gallbladder is thickened due to fibrosis but not distended

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13
Q

Chronic cholecystitis can cause inflammation leading to pockets in the wall of gallbladder known as

A

Rokitansky-Aschoff sinuses. They are outpouchings of gallbladder mucosa into the gallbladder muscle layer and subserosal tissue as a result of hyperplasia and herniation of epithelial cells through the fibromuscular layer.

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14
Q

What causes Rokitansky-Aschoff sinuses

A

Increase pressure and recurrent damage to the wall of gallbladder

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15
Q

Carcinoma of gallbladder is what type

A

Adenocarcinoma

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16
Q

What is cholangiocarcinoma

A

Cancer of the bile ducts, presents with obstructive jaundice

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17
Q

What type of cancer is cholangiocarcinoma

A

Adenocarcinoma

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18
Q

Cholangiocarcinoma is associated with what other diseases

A

Ulcerative colitis and Primary sclerosing cholangitis

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19
Q

Why does pancreas present with back pain

A

Pancreas is very posterior and has a dermatome at the upper half of the back

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20
Q

What is pancreatitis

A

Inflammation of the pancreas

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21
Q

What is elevated in acute pancreatitis

A

Serum amylase, patient’s in severe abdominal pain

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22
Q

Pathogenesis of acute pancreatitis

A

Blockage of bile duct via gallstones damages the Sphincter of Oddi causing pancreatic duct epithelial injury.
Autodigestion of pancreatic acinar cells due to loss of protective barrier
The release of lytic enzymes from pancreas causes -
Lipase: Intra and peripancreatic fat necrosis
Protease: Tissue destruction and haemorrhage

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23
Q

What is a pancreatic pseudocyst

A

A circumscribed collection of fluid rich in pancreatic enzymes, blood and necrotic tissue. It is a complication of pancreatitis and is prone to infection, haemorrhage, rupture and obstruction

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24
Q

What is chronic pancreatitis

A

Repeat bouts of acute pancreatitis may lead to chronic pancreatitis which is very fatal. Pancreatic tissue is replaced by chronic inflammation and scar tissue. This destroys exocrine acinar cells and endocrine Islets of Langerhaan

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25
Q

Why is resection of pancreatic tumours hard

A

The pancreas is closely associated with the duodenum and hence this has to be resected together. It is an endocrine organ that affects the body functions along with endocrine roles in digestion

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26
Q

Pancreatic carcinoma is of what type

A

Adenocarcinoma

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27
Q

Pancreatic adenocarcinoma normally spreads to

A

Duodenum, stomach and spleen. Haematogenous spread to the liver and lymph nodes

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28
Q

Risk factors for gallstones

A 
Female
Fair
Fertile - Had previous children
Fat - High BMI > 30, hyperlipidaemia
Forty - Age > 40 or Familial
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29
Q

What is biliary colic

A

Gallstone/bladder attack, when a gallstone temporarily blocks the bile duct.

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30
Q

Symptoms of biliary colic

A

Gradual build-up of pain in RUQ. Radiates to back/shoulder. May last 2-6 hours and associated with indigestion and/or nausea

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31
Q

What is the hartmann’s pouch

A

A spheroid or conical pouch at the junction of neck of gallbladder and cystic uct. Gallstones can often be found here.

32
Q

FIrst line investigation for gallstones

A

Ultrasound, it’s cost effective, no radiation and diagnostic

33
Q

CT scans and cholelithiasis

A

CT scan’s aren’t very useful if looking for gall stones, but can be used to deal with it’s complications such as finding a tumour or a perforation

34
Q

Treatment for acute cholecystitis

A

IV antibiotics and fluids, analgesics
Abdominal US, FBC, CRP, Serum Amylase
Monitor - BP, urine, pulse
Surgical assessment for cholecystectomy

35
Q

Complications of gallstones

A 
Gallstone may travel to common bile duct causing -
Jaundice
Cholangitis
Acute pancreatitis
Gallstone ileus
36
Q

What is gallstone ileus

A

Presence of a large gallstone (> 2.5cm in diameter) predisposes to cholecysto-enteric fistula formation by gradual erosion through the gallbladder fundus. This gallstone can travel into the bowel and get lodged along the GI tract

37
Q

Follow up on ultrasound showing bile duct dilation with gallstones present

A

ERCP - Endoscopic retrograde cholangiopancreatography to clear duct or establish drainage

38
Q

Follow up on US showing no bile duct dilation but gallstones suspected

A

MRCP - Magnetic resonance cholangiopanreatography to provide further diagnostic information on position or absence of gallstone.

39
Q

Cause of acute pancreatitis

A

Alcohol, gallstones

40
Q

Treatment for acute pancreatitis

A

Laparoscopic cholecystectomy or ERCP if frail

41
Q

Treatment for gallstone ileus

A

Urgent laparotomy to remove stones

Interval cholecystectomy within 3 months

42
Q

Cholangiocarcinoma treatment

A

Resection of liver and gallbladder due to high nodal metastases

43
Q

Palliation of cholangiocarcinoma

A

Biliary stent, survivial 1 - 6 months

44
Q

What arteries supply the pancreas

A

Ant. and post. sup. pancreaticoduodenal artery from coeliac trunk
Ant. and post. inf. pancreaticoduodenal artery from SMA
Dorsal pancreatic artery
Transverse pancreatic artery

45
Q

Venous drain of pancreas

A

Via splenic vein to the portal vein

46
Q

Endocrine and exocrine cells of pancreas

A

Exocrine - Acinar cells

Endocrine - Islents of Langerhans

47
Q

Pancreatic fluid secretion is regulated by

A

Vagus nerve and gastrin levels

48
Q

What do acinar cells secrete

A

Protease, pancreatic lipase/amylase and other enzymes such as ribonuclease, deoxyribonuclease, gelatinase and elastase

49
Q

Management of most cases of acute pancreatitis

A

80% by analgesics and IV fluids

50
Q

Aetiology of acute pancreatitis

A 
I GET SMASHED
Idiopathic - 20% of cases
Gallstones - 65% of cases
Ethanol - >80mg ETOH/day
Trauma
Steroids
Mumps and other infections coxsackie B and viral hep
Autoimmune - IgG4 related disease
Scorpion bite
Hypercalcaemia, hyperparathyroidism, hyperlipidaemia
ERCP - 30% of cases
Drugs - Azathioprine
51
Q

Pathophysiology of acute pancreatitis

A

Bile reflux theory -
Obstruction of common bile duct leads to reflux of bile into pancreas
Hyperstimulation of pancreatic acinar cells with CCK

52
Q

Presentation of acute pancreatitis

A 
Acute onset epigastric pain
Radiating to the back
Very severe
Nausea + Vomiting
Jaundice
Might have trigger such as ERCP/gallstone
53
Q

Examination of acute pancreatitis

A 
Diffuse upper abdominal tenderness
Soft
Normal bowel sound
Fullness in epigastrium - Pseudocyst
Severe -Widespread gauarding and absent BS, presents like peritonitis
54
Q

Classical signs visible in acute pancreatitis

A

Erythema abigne
Cullen’s sign
Grey-Turner’s sign

55
Q

Investigations for acute pancreatitis

A

IV access
Bloods - FCB, coagulation, U&E, LFT, CRP, lactate
ABG
Chest x-ray: Pleural effusion
Abdominal x-ray: Sentinel loop, dilated terminal ileum close to the pancreas

56
Q

CRP limit that points to acute pancreatitis

A

CRP > 150 requires urgent CT scan within 24 hours as it points to acute pancreatitis

57
Q

First line diagnostic investigation for acute pancreatitis

A

Ultrasound scan -

58
Q

US sign for gallstones

A

Absence of echoes posterior to calculi “shadowing”

59
Q

CT scan in acute pancreatitis

A

Assess severity day 5 form onset of symptoms
As follow up
Potential intervention
Look for complications

60
Q

Complications of acute pancreatitis

A 
Fluid collection
Pancreatic/peripancreatic necrosis
Ascites
Bleeding
Abscess
61
Q

Is ERCp diagnostic in acute pancreatitis

A

No, used for treatment of CBD obstruction with gallstones

62
Q

Prognostic tool for acute pancreatitis

A 
Glasgow criteria
PaO2 < 8kPa (60mmHg)
Age > 55
Neutrophilic WBC > 15 * 10-9/l
Calcium < 2 mmol//L
Renal function (Urea > 16mmol/L)
Enzymes (AST/ALT > 200or LDH > 600)
Albumin < 32 g/L
Sugar (Glucose > 10mmol/L)
Score of 3 or more is severe pancreatitis
63
Q

Management of acute pancreatitis

A 
Conservative at first
Electrolyte correction
Fluid resusitation
Oxygen
Antibiotics and nutrition if needed
Index admission laparoscopic cholecystectomy
64
Q

Treatment of pancreatic pseudocyst

A

Nothing, endoscopic drainage if symptomatic

Can perform cystogastrotomy

65
Q

Now can pancreatic necrosis be assessed

A

Via CT scan

Fine needle aspiration for microbiology sample

66
Q

Presentation of chronic pancreatitis

A

Very similiar to acute pancreatitis
Alcohol history, smoker, medication
Masses/ascites/jaundice on examination

67
Q

Investigating chronic pancreatitis

A

US, CT scan, CXR/AXR, MRI, ERCP

68
Q

Aetiology of chronic pancreatitis

A 
Alcohol
Idiopathic
PD obstruction
Autoimmune
Tropical countries due to deficiency in methionine, Zinc and Selenium
Hereditary - CFand alpha-1-antitrypsin
69
Q

Management of chronic pancreatitis

A 
Manage acute episodes 
Creon as enzyme replacement
Surgery -
Pustow procedure
Frey procedure
70
Q

Complication of chronic pancreatitis

A 
Splenic vein thrombosis
Pseudoaneurysm of splenic vein
Pleural effusion
Ascites
Pancreatic cancer
Pseudocysts
Biliary or duodenal obstruction
71
Q

Types of pancreatic endocrine cancers

A

Gastrinoma, insulinoma and glucagonoma

72
Q

Symptoms of pancreatic tumour

A

Weight loss
Back pain
Jaundice (painless loose pale stools, steatorrhoea)
Dark urine

73
Q

Investigating pancreatic tumours

A

US
CT scan
MRI and MRCP

74
Q

Management of inoperable cases of pancreatic tumour

A

ERCP or PTC and stent insertion

Decompression of obstructed bile ducts

75
Q

Management of operable cases of pancreatic tumour

A

Laparoscopy and staging
ERCP stent
Resection or palliative bypass

GI (32 decks)

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