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159 Cards in this Set
- Front
- Back
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PANCREAS, GALLBLADDER, AND BILIARY TRACT - LEE - FRIDAY FEB 16
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ACUTE PANCREATITIS
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what is acute pancreatitis, and what can it range from in severity?
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a group of reversible lesions characterized by inflammation of the pancreas, ranging in severity from edema and fat necrosis to parenchymal necrosis with severe hemorrhage
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how commin is acute pancreatitis?
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relatively common
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what is the most common cause, and what % of cases are due to this?
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biliary tract disease and alcoholism (80%)
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what % are idiopathic?
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10-20%
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what infections can cause acute pancreatitis (3)?
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1) mumps; 2) coxsackieviruses; 3) Mycoplasma pneumoniae
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what metabolic disorders can cause acute pancreatitis (2)?
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1) hypertriglyceridemia; 2) hyperparathyroidism
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inherited alterations in what types of genes can cause acute pancreatitis (2)?
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1) pancreatic enzymes (cationic trypsinogen, PRSS1); 2) pancreatic enzyme inhibitors (trypsin inhibitor, SPINK1)
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what can cause obstruction leading to acute pancreatitis (4)?
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1) tumors; 2) pancreatic divisum (developmental anomaly); 3) parasites; 4) biliary sludge
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what else can cause acute pancreatitis (3)?
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1) trauma (surgery, blunt); 2) acute ischemia (thrombosis, embolism, vasculitis, shock); 3) medications
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what is the pathogenesis of acute pancreatitis?
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autodigestion of the pancreatic substance by inappropriately activated pancreatic enzymes
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what is the last step before releasing activated enzymes into the pancreas?
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acinar cell injury
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what types of necrosis occur in acute pancreatitis?
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1) fat necrosis; 2) parenchymal necrosis; 3) necrosis of blood vessels (with subsequent hemorrhage)
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what else is seen in the pathology (2)?
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1) edema; 2) acute inflammatory reaction
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what are seen in severe cases (3)?
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1) acute necrotizing pancreatitis; 2) hemorrhagic pancreatitis; 3) extensive extrapancreatic fat necrosis (omentum, mesentery)
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what is the most predominant clinical feature?
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abdominal pain
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what type of pain is it, and where is it often felt?
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constant and intense - often referred to the upper back
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what is another clinical feature of acute pancreatitis?
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peripheral vascular collapse and shock
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what are three laboratory findings that may be abnormal?
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1) serum amylase; 2) serum lipase; 3) hypocalcemia
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what is the time progression of serum amylase changes (onset, peak, and return to normal)?
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elevate 2-12 hours following onset, peak at 24-30 hours, return to normal in 3-4 days
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what test has greater specificity than serum amylase, but is not frequently performed?
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P-type (pancreatic) isoenzymes
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what is time course and specificity of elevated serum lipase like, compared to serum amylase?
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more specific, and time course is similar to amylase, but remains elevated for longer
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what may hypocalcemia result from, and what significance does it have?
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precipitation of calcium soaps in the fat necrosis - if it is persistent, it is a poor prognostic sign
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how is acute pancreatitis managed?
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"resting" the pancreas by total restriction of food and fluids, and by supportive treatment
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what % of patients die early in the illness, and why?
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5%, from shock
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what other systemic problems/organ failures can occur (4)?
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1) shock; 2) ARDS; 3) acute renal failure; 4) DIC
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what other complications can occur (3)?
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1) pancreatic abscess; 2) pseudocyst; 3) duodenal obstruction
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PSEUDOCYSTS
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what are pseudocysts?
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localized collections of non-hemorrhagic material rich in pancreatic enzymes
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what is lacking from pseudocysts?
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epithelial lining
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what processes are present in variable amounts (2)?
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1) inflammation; 2) fibrosis
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what are pseudocysts associated with (3)?
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1) acute pancreatitis; 2) chronic pancreatisis; 3) trauma
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what are complications of pseudocysts (4)?
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1) abscess; 2) perforation; 3) peritonitis; 4) mass
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CHRONIC PANCREATITIS
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what is chronic pancreatitis?
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irreversible destruction of exocrine pancreatic parenchyma by inflammation and fibrosis
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what is destroyed in the late stages?
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endocrine parenchyma
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what is the most common cause?
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long term alcohol abuse
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what % are idiopathic?
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40%
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what are other causes (3)?
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1) long term duct obstruction; 2) hereditary (PRSS1 or SPINK1 germline mutation); 3) tropical (possibly related to malnutrition)
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what abnormality is idiopathic chronic pancreatitis associated with?
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CFTR gene mutation (but no other clinical features of cystic fibrosis and normal sweat chloride test)
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what are five main pathologic features of chronic pancreatitis?
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1) atrophy of acini; 2) fibrosis; 3) chronic inflammation; 4) calcification/pancreatic calculi; 5) pseudocyst formation
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CARCINOMA OF THE PANCREAS
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what type of cancer is this, and where does it originate?
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adenocarcinoma of the exocrine pancreas
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how does it rank as far as leading causes of cancer death in the US?
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4th
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what is prognosis and 5 year survival rate?
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extremely poor prognosis (less than 5% 5 year survival rate)
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who does it occur in (race and age)?
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elderly (80% of cases between ages of 60 and 80) and more common in blacks
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what is the most important risk factor?
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smoking
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what diet increases risk?
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high fat
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what diseases increase risk?
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1) chronic pancreatitis; 2) diabetes mellitus
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what other substance increases risk?
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alcohol
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what familial syndromes increase risk (list)?
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hereditary pancreatitis, Peutz-Jeghers syndrome, hereditary breast and ovarian cancer, HNPCC (Lynch II variant)
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what is the most frequently altered oncogene in pancreatic cancer?
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K-RAS
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what is the most frequently inactivated tumor suppressor gene in pancreatic cancer?
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P16 gene
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what is the most common location in the pancreas for pancreatic carcinoma, and what % of cases arise there?
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head: 60% (15% body, 5% tail, 20% diffuse)
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what does pancreatic carcinoma look like grossly?
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hard, gray-white, stellate, poorly defined masses
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what does it look like microscopically, and what feature is seen?
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adenocarcinoma, with dense stromal fibrosis ("desmoplastic reaction")
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what are typical cinical features (list)?
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weight loss, abdominal pain, back pain, anorexia, N/V, malaise, weakness
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what other signs were mentioned as clinical features (2)?
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1) progressive jaundice (90%); 2) Trousseau sign
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what is Trousseau sign, and what % of cases does it occur in?
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migratory thrombophlebitis - occurs in 10% of cases
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what is it caused by?
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elaboration of platelet-aggregating factors and procoagulants from tumor or its necrotic products
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what is a serum marker for diagnosis and follow up?
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CA 19-9
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what other tools are used for diagnosis (2)?
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1) CT or ultrasound-guided needle aspirate; 2) ERCP with brushings or biopsy
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what % are resectable at the time of diagnosis?
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<20%
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what operation is performed, and what else is it known as?
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pancreatoduodenectomy ("Whipple operation")
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OTHER NEOPLASMS OF THE PANCREAS
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what % of pancreatic neoplasms are cystic neoplasms?
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5%
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what types of cystic neoplasms must we know (2)?
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1) serious cystadenoma; 2) mucinous cystic neoplasm
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what other cystic tumors can occur in the pancreas (2)?
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1) intraductal papillary mucinous neoplasm; 2) solid pseudopapillary tumor (solid-cystic tumor)
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what is a serous cystadenoma, and what surrounds the cysts?
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benign cystic neoplasm composed of glycogen-rich cuboidal cells surrounding small cysts
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what are other names for a mucinous cystic neoplasm (2)?
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1) mucinous cystadenoma; 2) cystadenocarcinoma
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who do mucnous cystic neoplasms almost always arise in?
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women
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where in the pancreas do they arise?
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tail
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how malignant are they?
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low grade (benign, borderline malignant)
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what are they usually associated with?
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dense stroma (similar to ovarian stroma)
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what is the treatment?
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distal pancreatectomy with splenectomy
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what other neoplasm of the tumor occurs, and with what frequency?
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pancreatic endocrine neoplasms (islet cell tumors): about 2%
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CHOLELITHIASIS (GALLSTONES)
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what % of adult populations in developed countries have gallstones?
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10-20%
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what does prevalence increase with?
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age
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what are the two main types of gall stones, and how prevalent (%) is each type?
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1) cholesterol stone (80%); 2) pigment stone (primarily bilirubin - 20%)
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what races are most likely to get cholesterol stones (3)?
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1) Native American; 2) Mexican; 3) Northern European
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what are the three biggest risk factors for cholesterol stones?
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1) age; 2) female sex hormones (female gender, oral contraceptives, pregnancy); 3) obesity
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what are associated conditions (4)?
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1) rapid weight reduction; 2) gallbladder stasis; 3) inborn disorders of bile acid metabolism; 4) hyperlipidemia syndromes
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what race is most likely to get pigment stones?
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Asian
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what may cause pigment stones (2)?
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1) biliary nfections; 2) chronic hemolytic syndromes
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what biliary infections may be responsible (2)?
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1) liver fluke; 2) E. coli
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what are the four contributing factors to cholesterol stone pathogenesis?
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1) cholesterol supersaturation; 2) gallbladder hypomotility; 3) crystal nucleation; 4) acccretion
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what types of cholesterol stones are there (2)?
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1) pure; 2) mixed
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what types of pigment stones are there (2)?
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1) black; 2) brown
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which type(s) of stone usually is solitary (one stone)?
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pure cholesterol stone
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which type(s) of stone is the largest?
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pure cholesterol stone (often 2-4 cm)
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which type(s) of stones are the smallest?
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black and brown pigment stones (both 0.2-0.5 cm), mixed cholesterol stones are 0.2-3cm
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what color are pure and mixed cholesterol stones?
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pure are white-yellow, mixed are variable
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what type(s) of stones are irregularly shaped?
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black and brown pigment stones
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what shape are pure cholesterol stones?
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round-oval
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what shape are mixed cholesterol stones?
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faceted-round
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what are the cut surfaces of pure cholesterol stones and mixed cholesterol stones like?
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crystalline (both)
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what are the cut surfaces ofblack pigment stones and brown pigment stones like?
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black: crystalline/amorphous; brown: laminated
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what % of cholelhitiasis cases are asymptomatic/silent?
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80%
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what type of pain do gall stones cause?
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colicky pain - excruciating and constant
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what is the risk of producing complications requiring surgery (within five years)?
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30%
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what are common complications of gall stones (must know - 4)?
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1) cholecystitis (acute and chronic); 2) choledocholithiasis; 3) ascending cholangitis; 4) acute pancreatitis
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what are uncommon complications (4)?
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1) gallstone ileus; 2) biliary enteric fistula; 3) "porcelain gallbladder"; 4) hydrops of gallbladder
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what is the most common treatment for gall stones?
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laprascopic cholecystectomy (also can have open cholecystectomy, oral bile salt therapy, and percutaneous radiologic extraction)
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ACUTE CHOLECYSTITIS
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what types of acute cholecystitis are there (2)?
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1) calculous; 2) acalculous
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what causes acute calculous cholecystitis?
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obstruction of neck or cystic duct
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what % of cholecystitis are acalculous?
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<5%
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what can cause acute acalculous cholecystitis (list)?
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postoperative state after major, nonbiliary surgery, trauma, burns, multisystem organ failure, sepsis, prolonged intravenous hyperalimentation, postpartum state, vasculitis
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what is gallbladder like, and what is seen on the surface?
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enlarged, edematous gallbladder, with fibrinous exudate on the surface
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what other pathological features are seen (3)?
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1) gangrenous cholecystitis; 2) empyema; 3) porcelain gallbladder
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what is porcelain gallbladder?
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deposition of calcium within the gallbladder wall
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CHRONIC CHOLECYSTITIS
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what may chronic cholecystitis be a sequel to?
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repeated bouts of mini-acute cholecystitis
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what % of the cases have gall stones?
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more than 90%
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what is the pathologic course like?
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extremely variable, sometimes miniimal
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what two features will be seen?
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1) fibrosis; 2) chronic inflammation (variable degree)
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what structure is characteristic of chronic cholecystitis (name and what they are)?
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Rokitansky-Aschoff sinuses (mucosal diverticuli)
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CHOLESTROLOSIS
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what is another name for cholestrolosis?
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"strawberry gallbladder"
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what happens in cholestrolosis, and where?
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focal accumulation of triglyceride and cholesterol-laden macrophages within the tips of mucosal folds
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what is the clinical significance?
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none
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CARCINOMA OF THE GALLBLADDER
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what sex and age does carcinoma of the gallbladder most commonly occur in?
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slightly more common in women, in the 7th decade of life
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what is the 5 year survival rate?
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1% (rarely discovered at a resectable stage)
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what % of cases have gallstones?
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60-90%
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what type of carcinoma is seen, and what feature does it have?
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adenocarcinoma, with marked desmoplastic reaction
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what % of cases have preoperative diagnosis of carcinoma?
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<20%
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CARCINOMA OF THE EXTRAHEPATIC BILE DUCTS
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what is the presenting feature of carcinoma of the extrahepatic bile ducts?
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painless, progressive jaundice
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what age and sex is it most common in?
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old men
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what % of cases have gallstones?
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33%
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what diseases increase the risk of carcinoma of the extrahepatic bile ducts (3)?
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1) primary sclerosing cholangitis; 2) ulcerative colitis; 3) choledochal cyst
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what increases the risk in Asia?
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biliary tree fluke infection (Clonorchis sinensis)
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what type of carcinoma is seen, and what feature does it have?
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adenocarcinoma, with marked desmoplastic reaction
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what is the mean survival range for this disease?
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6 to 18 months (usually not resectable
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