Gi - Gallbladder, Pancreas Path

Front 1

What is the embryology of the Gallbladder?

Back 1

- derived from same foregut diverticulum that gives rise to liver

Front 2

Adult Gallbladder
- length?
- volume?
- functions?

Back 2

- 8 cm long
- 50 ml volume

Functions: store, concentrate, release bile

Front 3

Adult Gallbladder
- histo?

Back 3

- consists of mucous membrane, muscularis, adventitia
- mucosa lined by columnar epithelium
- mucosal diverticula lined by columnar epith -- dip into gallbladder wall (Rokitansky-Aschoff Sinuses)

Front 4

What are Rokitansky-Aschoff Sinuses?

Back 4

= mucosal diverticula lined by columnar epith that dip into gallbladder wall
- may be confused with adenocarcinoma

Front 5

What are the congenital abnormalities of the gallbladder?

Back 5

- agenesis
- atresia
- duplication

Front 6

What are the congenital abnormalities of the Bile Duct?

Back 6

- choledochal cyst (85%)
- choledochal diverticulum
- choledochocele

Front 7

Cholelithiasis
- what is?
- frequency?
- radiology?

Back 7

= presence of stones within lumen of gallbladder or within extrahepatic biliary tree

- 10-20% adult pop

- Easily visualized by US

Front 8

Cholelithiasis
- what are they made of?

Back 8

- 3/4 made primarily of cholesterol

Front 9

Cholelithiasis
- sx?

Back 9

- 80% asymptomatic
- fatty food intolerance
- biliary colic - severe episodic pain in upper abd secondary to intermittent obstruction of GB or common bile duct

Front 10

What are the types of Gall Stones?

Back 10

Cholesterol Stones
Pigment Stones (Black and Brown)

Front 11

Cholesterol Stones
- composed of?
- color?
- shape?

Back 11

= cholesterol, Ca salts, mucin
- yellow-tan
- round to faceted

Front 12

What are increased risks for Cholesterol Stones?

Back 12

- increased age
- women of reproductive age (contraceptives, mult pregs, etc)
- Estrogens - stim formation and increase secretion of bile by liver, decrease secretion of bile acids
- obesity
- ethnicity (Pima Indians)
- diet (cholesterol)
- metabolic abnormalities
- drugs (clofibrate)

Front 13

Black Pigment Stones
- shape?
- discrip?
- composition?

Back 13

- irregular in shape

- glassy black surface

= CaBilirubinate, bilirubin polymers, Ca salts, mucin

Front 14

Black Pigment Stones
- population?
- pathogenesis?
- increased risk?

Back 14

- old and undernourished patients

Path:
- increased conc of unconjugated bilirubin in bile

Increased risk:
- patients suffering from diseases with chronic hemolysis - sickle cell anemia, thalassemia
- cirrhosis

Front 15

Brown Stones
- descrip
- composition
- where found??

Back 15

- spongy, laminated
= CaBilirubinate, cholesterol, Ca soaps of FAs
- usually found in intrahepatic and extrahepatic bile ducts (not as much in GB)

Front 16

Brown Stones
- associated with what diseases?

Back 16

- bacterial cholangitis (e. coli)
- biliary helminth infection
- chronic mechanical obstruction (e.g., in sclerosing cholangitis)

Front 17

What are the contributing factors (pathway) to the formation of cholesterol stones?

Back 17

- supersaturation
- gallbladder hypomotility
- crystal nucleation
- accretion within the gallbladder mucous layer (adding layers around nucleus)

Front 18

What is the difference in the gall bladder that leads to the formation of black v. brown stones?

Back 18

Black - sterile gall bladder (chronic hemolysis)

Brown - infected intrahepatic/extrahepatic ducts

Front 19

What are the complications of gall stones?

Back 19

- cystic duct obstruction WITH inflammation
- cystic duct obstruction W/O inflammation (hydrops; mucocele)
- passage into biliary ducts (cholangitis, pancreatitis)
- passage into small intestines (gallstone ileus)

Front 20

Acute Cholecystitis
- types?
- cause?

Back 20

= diffuse inflammation of gallbladder SECONDARY to obstruction
- 90-95% assoc'd with gallstones
- Acalculus Cholecystitis - sepsis, severe trauma, Salmonella, PAN (polyarteriris nodosa)

Front 21

What is the name of cholecystitis WITHOUT gall stones?

Back 21

Acalculus Cholecystitis

Front 22

Acute Cholecystitis
- gross?
- histo?

Back 22

Gross:
- external surface of GB is congested, layer of fibrinous exudate
- wall thick and edematous
- hemorrhagic mucosa
- often gallstones in lumen and/or within cystic duct

Histo:
- abundant acute/chronic inflamm
- edema
- hemorrhage of wall
- ulceration of mucosa
- widespread necrosis of mucosa (gangrenous cholecystitis)

Front 23

What is the dreaded complication of acute cholecystitis?

Back 23

PERFORATION!!
--> bile peritonitis

Front 24

What is Gangrenous Cholecystitis?

Back 24

Acute cholecystitis with widespread necrosis of GB mucosa

Front 25

Chronic Cholecystitis
- what is?
- cause?

Back 25

- most chronic disease of GB
- persistent inflamm of GB wall

Causes:
- repeat attacks of acute cholecystitis
- continued presence of gall stones

Front 26

What is the most common disease of the gallbladder?

Back 26

CHRONIC CHOLECYSTITIS

Front 27

Chronic Cholecystitis
- appearance on radiographs?
- gross?
- histo?

Back 27

CT/x-ray: wall/outline appears "layered"

Gross:
- wall thick and firm secondary to extensive fibrosis
- gallstones usually within GB
- mucosa may be ulcerated, atrophic, or intact

Histo:
- fibrotic wall
- Rokitansky-Aschoff Sinuses
- chronic inflamm infiltrate within wall

Front 28

What are Rokitansky-Aschoff Sinuses?

Back 28

diverticula/pockets in wall of GB - often due to increased pressure within GB due to gallstones

Front 29

Cholesterolosis
- what is?
- sx?
- gross?

Back 29

= accumulateion of cholesteorl-laden macrophages within submucosa of GB
- usually ayumptomatic

Gross: "strawberry gallb;sdder" - prominent, scattered, yellow flecks on mucosa surgact

Front 30

Tumors of GB
- benign
- malignant

Back 30

Benign: Papilloma (associated with gallstones)

Malig: Adenocarcinoma

Front 31

Adenocarcinoma of GB
- population?
- associated symptoms?
- location?
- gross?
- histo?
- survival rate?

Back 31

2% patietns udergoing GB surgery
- associated with cholethiasis and chronic and chronic cholecystitis
- most commonly occurs in fundus

Gross:
- papillary configuration (possibly)
- thickened, leathery wall (reactive desmoplasia)

Histo
- infiltrative
- usually well-differentiated neoplasm

5-year survival = <3%

Front 32

Porcelain Gallbladder
- what is?
- cause?

Back 32

= calcification due to excess gallstones
- almost always assocaited with adenocarcinoma

Front 33

Pancreas
- embryology?

Back 33

arises from 2 endodermal outpouchings on dorsal and ventral sides of duodenal tube
- majority = dorsal
- head = ventral

Front 34

Pancreatic drainage??

Back 34

Major Pancreatic Duct --> drains into Common Bile Duct immediately prox to ampulla of Vater

Front 35

Exocrine Pancreas v. Endocrine Pancreas
- % of pancreas?
- composition?
- function?

Back 35

Exocrine = 80-85% of pancreas
- composed of acinar cells
- synthesizes digestive enzymes: trypsin, chymotrypsin, amylase, carboxypeptidase, lipase, phospholipase, elastase

Endocrine Pancreas
- composed of Islets
- synthesizes hormones: insulin and glucagon --> secreted directly into blood

Front 36

What are the congenital abnormalities of the pancreas?

Back 36

- accessory pancreas
- annular pancreas
- pancreas divisum
- congenital cysts
- ectopic pancreas

Front 37

Ectopic Pancreas
- frequency?
- what is?
- descrip?

Back 37

Found in ~2% of autopsies

= ectopic tissue most commonly in walls of stomach, duod, jejunum (GI organs)

- nodular configuration
- found below mucosa, in muscularis, beneath serosa, or in small diverticula

Front 38

Acute Pancreatitis
- definition?
- presentation?

Back 38

= inflammatory condition of exocrine pancreas
- results from injury to acinar cells

Variable Presentation:
- Mild: acute inflamm and edema
- Catastrophic: hemorrhagic pancreatitis with massive acinar cell necrosis

Front 39

What are the etiologies of Acute Pancreatitis?

Back 39

- gall stones (#1)
- alcohol abuse (#2)
- hypercalcemia
- drugs - thiazide diuretics
- Cocksackievirus
- trauma
- shock
- atheroembolism

Front 40

What is the pathology behind acute hemorrhagic pancreatitis?

Back 40

- middle-aged
- associated with alcoholism, chronic biliary disease

- due to acinar cell injury and duct obstruction --> extracellular leakage of activated digestive enzs --> autodigest pacnreatic and extrapancreatic tissue

- Trypsin (activated) --> activates other pancreatic proenzymes (phospholipase A2, proelastase)
--> PLA2 attacks membrane phospholipids (necrosis)
--> elastase digests walls of blood vessels (hemorrhage)
-----> leakage of lipase into interstitium (fat necrosis)

Front 41

Chronic Alcohol Abuse
- causes how much acute pancreatitis?
- how???

Back 41

- causes 1/3 cases of acute pancreatitis
-alcohol causes spasm or acute edema of Sphincter of Oddi
- alcohol stims secretion from small intestine --> triggers exocrine panc to release enzs

Front 42

Gall Stones
- causes how much acute pancreatitis?
- risk of acute pancreatitis?

Back 42

- cause 45% (majority) of pancreatitis

- risk of pancreatitis 25x higher than general pop

Front 43

Acute Pancreatitis
- gross?
- histo?

Back 43

Gross:
- edematous
- hyperemic
- may eventually become a retroperitoneal hematoma
- areas of fat necrosis (yellow white areas)

Histo:
- acinar cell necrosis
- fat necrosis
- intense acute inflamm

Front 44

What is one main possible complication of acute pancreatitis

Back 44

Pseudocyst - connective tissue encloses wide spaces of blood, necrotic tissue, enzymatic fluid

Front 45

Acute Pancreatitis
- clinical features?

Back 45

- severe epigastric pain
- nausea/vomiting
- may eventually lead to peripheral vascular collapse and SHOCK

Front 46

When is the typical onset of acute pancreatitis?

Back 46

After heavy meal, alcohol

Front 47

What is a serological sign of acute pancreatitis?

Back 47

Elevated amylase/lipase

Front 48

Chronic Pancreatitis
- what is?
- pathogenesis/cause?

Back 48

- progressive destruction of pancreas characterized by irregular fibrosis, calcification, and chronic inflammation

Path:
1. long-standing alcohol abuse
2. congenital anomalies/mechanical obstruction
3. repeated episodes of acute pancreatitis

Front 49

Chronic Pancreatitis
- mortality rate?

Back 49

3-4% per year

Front 50

Chronic Pancreatitis
- gross?
- histo?

Back 50

- gross?
- histo? Gross:
- firm pancreas
- cut surflace lacks normal lobulated appearance

Histo:
- irregular areas of fibrosis
- reduced number of size of exocrine/endocrine elements
- chronic inflammation cells: lymphocytes, plasma cells, macrophages

Front 51

What other clinical signs/problems are associated with Chronic Pancreatitis?

Back 51

- RECURRENT and progressive pancreatic insufficiency/destruction
- malabsorption
- diabetes

Front 52

What are the causes of Chronic Pancreatitis?

Back 52

1. Alcoholism (70%)
2. Idiopathic
3. Other - pancreatic duct obstruction (tumor, trauma, etc.), CF, hyperlipidemia, hereditary, tropical, hyperparathyroism

Front 53

Pancreatic Cystadenoma
- what is?
- patient pop?
- types?

Back 53

= large, multiloculated cystic tumors
- usually located to pancreatic body or tail

- usually women btwn 50-70 y.o.

- types: serous and mucinous

Front 54

Pancreatic Carcinoma
- most common type (%?)
- prognosis?

Back 54

- Ductal Adenocarcinoma = 90%

Prognosis: poor - often metastatic at time of dx...
- 5 yr survival = <1%

Front 55

Pancreatic Carcinoma
- signs and sx?

Back 55

- anorexia
- weight loss
- epigastric pain (radiating to back)
- Trousseau Syndrome (10%)
- Jaundice (50% - cancer of panc head)

Front 56

What is Trousseau Syndome?
- how often found and when?

Back 56

= migratory thrombophelebitis
- occurs in 10% patients with pancreatic adenocarcinoma
- may be initial clinical evidence of the cancer

Front 57

To where does pancreatic carcinoma metastasize?

To what other areas might it directly extend?

Back 57

Metast: regional lymph nodes and liver

Directly Extend: stomach and duodenum

Front 58

Pancreatic Carcinoma
- risk factors??

Back 58

- smoking
- polycyclic hydrocarbons
- diet
- diabetes
- chronic pancreatitis

Front 59

Pancreatic Carcinoma
- gross?
- histo?

Back 59

Gross:
- firm, gray, poorly demarcated multinodular mass embedded in dense connective tissue stroma
-satellite tumor nodules in mesenteric locations

Histo:
- >75% are well-differentiated adenocarcinomas
- prominant desmoplastic reaction often observed
- Perineural invasion may be seen

Front 60

What is a desmoplastic reaction?

Back 60

Growth of fibrous or connective tissue around a tumor

Front 61

What are the different cells of the Pancreatic Islets?
- functions??
- locations?

Back 61

Alpha Cells: secrete GLUCAGON --> increases blood glucose
- located in outer rim of islets

Beta Cells: secrete INSULIN (within secretory vesicles)
- located throughout islet (60-70% of all islet cells)

Delta Cells---
D Cells: secrete SOMATOSTATIN --> inhibitory hormone --> reduces alpha/beta/delta/acinar cell secretions
D1 Cells: secrete VASOACTIVE INTESTINAL PEPTIDE (VIP) --> induces glycogenolysis and hyperglycemia AND regulates tone, motility, ion/water secretion by epith cells of GI tract
- located in periphery of islet

Front 62

Islet Cell Tumors
- frequency? (%?)
- effects?
- most common type? (%?)

Back 62

- Rare! <10% of all pancreatic neoplasms

- Many are nonfunctioning
- Functional tumors may or may not be part of MEN Syndrome --> can produce clinical symptomatology thru hormone release

- Beta Cell Tumors = 75% (most common)

Front 63

Beta Cell Tumors
- aka?
- % of islet cell neoplasms?
- malignancy?
- location?
- size?
- solitary or multiple?
- dx?
- tx?

Back 63

aka: INSULINOMA

= most common islet cell tumor (75%)
- most benign (small percentage malignant)
- most in body or tail of pancreas
- < 3 cm diam
- 90% are solitary -> excised easily
- dx: lab testing (high blood insulin and tumor cells)
- tx: surgical incision

Front 64

Beta Cell Tumors
- histo??

Back 64

- the neoplastic cells resemble normal beta cells
- BUT distributed in trabecular or solid patterns

- amyloid may be found in stroma of the tumors

Front 65

Beta Cell Tumors
- result?
- clinical symptoms?

Back 65

- produce severe hypoglycemia thru autonomous secretion of insulin (even when low blood sugar)

SX:
- sweating
- nervousness
- hunger
- lethargy
- eventual coma
**Most cases have only mild hypoglycemia or NO sx

Front 66

Islet Cell Tumors - secretion of ectopic hormones......
- what hormones?
- result?

Back 66

- Can secrete ACTH, PTH, Calcitonin, Vasopressin

- Cause 10% of paraneoplastic Cushing Syndrome (second only to SCC of lung)

Front 67

MEN I
- what is?
- often associated with??

Back 67

Pituitary Adenoma +
Parathyroid Adenoma +
Endocrine Pancreas Adenoma

- frequently associated with Z-E Syndrome

Front 68

Zollinger-Ellison Syndrome
- characterized by??

Back 68

1. Intractable gastric hypersecretion
2. Peptic ulceration
3. Elevated blood gastrin levels

Front 69

Gastrinomas
- malignant?
- metastasis?
- histo?

Back 69

- majority are malignant (70-90%)
- metast to regional lymph nodes and liver
- histo: similar to intestinal carcinoid tumors

Front 70

Pancreatic Gastrinoma
- aka?
- what are?
- how formed?

Back 70

aka: Zollinger-Ellison Syndrome
- G cell tumors --> secrete Gastrin
- Arise from multipotent primitive endocrine cells that inappropriately differentiate into G cells (G cells not usually found in normal islets)