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21 Cards in this Set
- Front
- Back
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Cholelithiasis: definition
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Cholelithiasis is the presence of stones in the gallbladder—chole- means "bile", lithia means "stone", and -sis means "process
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Symptomatic cholelithiasis
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“Biliary colic”
The pain occurs due to a stone obstructing the cystic duct, causing wall tension; pain resolves when stone passes Pain usually lasts 1-5 hrs, rarely > 24hrs Ultrasound reveals gallstones Exam, WBC, and LFT normal in this case Treatment: Laparoscopic cholecystectomy |
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Acute calculous cholecystitis
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Persistent cystic duct obstruction leads to GB distension, wall inflammation & edema
Can lead to: empyema, gangrene, rupture Pain usually persists >24hrs. Fever, nausea, vomiting Tenderness to palpation U/S: stones, thickening of wall, perichlecystic fluid Nuclear HIDA scan shows nonfilling of GB -If U/S non-diagnostic, obtain HIDA Treatment: NPO, IVF, Antibiotics, surgery within 48 hours |
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Choledocholithiasis
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Can present similarly to cholelithiasis, except with the addition of jaundice
DDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with pain Trans-abdominal ultrasounds not as effective at finding. Need to use endoscopic ultrasound. Treatment: Endoscopic retrograde cholangiopancreatography (ERCP) -Stone extraction and sphincterotomy Interval cholecystectomy after recovery from ERCP |
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Best modalities for picking up stones in bile duct
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Endoscopic ultrasound
MRCP Both equally good Transabdominal ultrasound not as effective |
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Charcot's triad and Reynold's pentad
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Fever, RUQ pain, jaundice (Charcot’s triad)
If also altered mental status and signs of shock = Reynold’s pentad Seen in ascending cholangitis (cholangitis) |
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Gallstone pancreatitis
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Symptoms
-Epigastric pain radiating to back Major cause of acute pancreatitis Pathophysiology Reflux of bile into pancreatic duct and/or obstruction of ampulla by stone Elevation of amylase and lipase ALT > 150 (3-fold elevation) has 95% PPV for diagnosing gallstone pancreatitis Treatment: ABC, resuscitate, NPO/IVF, pain meds Once pancreatitis resolving, ERCP with stone extraction/sphincterotomy Cholecystectomy before hospital discharge |
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Gallbladder carcinoma: risk factors
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Female sex
Age > 50 years Gallstones > 40 years (mostly cholesterol). High risk population such as Native Indians, Chile Chronic cholecystitis Calcified GB (porcelain GB) |
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Gallbladder carcinoma: treatment and prognosis
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Treatment
Surgery: -Only chance for cure Palliation: -ERCP for jaundice / pruritus Prognosis -Poor, less than 6 months -Invasion usually local (contiguous spread) -If detected incidentally at time of cholecystectomy, then may survive long-term |
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Cholangiocarcinoma: risk factors and pathology
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Primary sclerosing cholangitis (PSC)-seen in inflammatory bowel disease
Congenital hepatic fibrosis; choledochal cysts Pathology -Klatskin tumor (location: hilum) -AdenoCa (90%), |
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Cholangiocarcinoma: presentation
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Cholestasis, jaundice, pruritus, weight loss
Hepatomegaly; ascites, RUQ mass (late) Cholangitis rare |
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Cholangiocarcinoma: diagnosis
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Labs:
-Cholestatic obstructive LFTs -Elevated serum CA19-9 (>100 U/ml) in 55-65% US: dilated intrahepatic or extrahepatic duct; no mass detected CT: dilated intra or extrahepatic ducts; usually difficult to identify mass lesion ERCP: -Detect level of stricture -Brush cytology -Stenting for palliation or bridge to surgery |
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Pancreatic carcinoma: risk factors, pathology, presentation
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Risk Factors
-Smoking -(Recent onset of diabetes) Pathology -AdenoCa (>90%); islet cell (5%); cystadenocarcinomas -Head (76%); body (20%); tail (10%) Presentation -Pain. Nausea/vomiting. Anorexia, weight loss, jaundice -Mass; Palpable distended GB (Courvoisier’s sign) |
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Pancreatic carcinoma: imaging and treatment
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Imaging
-Abdominal Ultrasound -Abdominal CT scan --Best study if suspicion is high -Abdominal MRI -ERCP --Best study to palliate with stenting -Endoscopic Ultrasound --Best study to find small lesions and to stage disease Treatment -Surgical (Whipple Procedure): < ¼ are resectable; 1/10 are potentially curable -Chemo +/- radiotherapy -Palliation: stenting |
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Pancreatic adenocarcinoma: prognosis
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5-year survival rate is 2-5%
Advanced disease at presentation, jaundice if in the head (70%-80%). Back pain (25%), recent onset of diabetes, anorexia. Trousseau’s (migratory thrombophlebitis), recent pancreatitis CT scan detects tumors >3 cms. EUS is effective and most sensitive for small lesions< 2-3 cms Allows EUS-guided FNA for tissue dx |
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Ampullary carcinoma: risk factors, presentation
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Pancreatic cancer involving only ampulla
Risk Factors -Familial Polyposis -Ampullary adenoma Presentation -Cholestatic jaundice -Pruritus -Intermittent bleeding -Cholangitis -Pancreatitis -Obstructive LFTs |
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Ampullary carcinoma: diagnosis, therapy, course
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Diagnosis
-CT or US: Dilated intra- & extra- hepatic ducts and no mass lesion or ?duodenal mass -ERCP: Usually diagnostic --Biopsies --Brushings for cytology -EUS: Staging Therapy -Distinguish from pancreatic cancer or cholangiocarcinoma -Surgical resection possible in 75% --Pancreatoduodenectomy (Whipple’s) Course -Better prognosis than pancreatic cancer -Otherwise palliation: --Stenting --Ampullectomy |
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Pancreatic neuroendocrine tumors (islet cell)
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Solid tumors
Need to distinguish as: -Functional vs Non-functional All endocrine tumors appear similar histologically. Immunohistochemistry and biochemical data used to distinguish subtype Inuslinoma, VIPoma,gastrinoma, glucagonoma, somatistatinoma |
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Serous cystadenoma
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Elderly women (>60); asymptomatic
Large lesions; multiloculated , multicystic(honeycomb) Malignant transformation is rare |
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Intraductal papillary mucinous neoplasm
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Premalignant, seen in elderly men, pancreatic duct obstruction
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Mucinous cystadenoma/carcinoma
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40-60 years of age
Unilobular or multilobular cyst containing mucin Should be resected Excellent prognosis if resected prior to carcinoma |
