Pathoma - Exocrine Pancreas, Gb, & Liver

Front 1

Developmental malformation in which the ventral pancreatic bud abnormally encircles 2nd part of duodenum, forming a ring around the duodenum that may cause duodenal narrowing; Risk of duodenal obstruction.

Back 1

Annular Pancreas (Cause, What, Risk) - FA131, P115

Front 2

Inflammation and hemmorhage of the pancreas due to autodigestion of pancreatic parenchyma by pancreatic enzymes resulting in liquefactive necrosis (of pancreas itself) and fat necrosis. Premature activation of Trypsin leads to activation of other pancreatic enzymes.
GET SMASHED + Rupture of a posterior duodenal ulcer
Gallstones, Ethanol (Most common causes), Trauma, Steroids, Mumps, Autoimmune dz, Scorpion sting, Hypercalcemia/Hypertriglyceridemia, ERCP, Drugs (e.g. sulfa drugs).
Clinical presentation: epigastric abdominal pain radiating to back, anorexia, nausea and vomiting, periumbilical and flank hemorrhage (necrosis spreads into the periumbilical soft tissue and retroperitoneum).
Labs: elevated amylase, lipase (higher specificity).
Can lead to DIC, ARDS, diffuse fat necrosis, hypocalcemia (Ca is consumed during saponification in fat necrosis), pseudocyst formation (formed by fibrous tissue surrounding liquefactive necrosis and pancreatic enzymes, presents as an abdominal mass w/ elevated serum amylase, rupture is associated w/ release of enzymes into the abdominal cavity and hemorrhage), hemorrhage, shock, pancreatic abscess (Often due to E coli; presents w/ abdominal pain, high fever and persistently elevated amylase) infection, and multi organ failure.

Back 2

Acute Pancreatitis - FA131, P115

Front 3

Fibrosis of pancreatic parenchyma, most often secondary to recurrent acute pancreatitis. Most commonly due to alcohol (Adults) and cystic fibrosis (Children); However many cases are idiopathic.
Clinical features: Epigastric pain that radiates to the back, pancreatic
insufficiency -> malabsorption and steatorrhea and fat-soluble vitamin
deficiency, dystrophic calcification of pancreatic parenchyma on imaging; contrast studies reveal a 'chain of lakes' pattern due to dilation of pancreatic ducts. diabetes mellitus (Late complication due to destruction of islets.
Chronic calcifying pancreatitis is strongly associated with alcoholism and smoking.
Increased risk of pancreatic CA.

Back 3

Chronic Pancreatitis - FA131, P115

Front 4

Adenocarcinoma arising from the pancreatic ducts most commonly seen in the elderly (Average age is 70). Major risk factors are smoking and chronic pancreatitis.
Clinical features: Epigastric abdominal pain radiating to back, weight loss (Due to malabsorption and anorexia), obstructive jaundice w/ palpable GB (Courvoisier's sign) and pale stools (Associated w/ tumors in the head of the pancreas), Secondary DM, migratory thrombophlebitis (Trousseau sign) - presents as swelling, erythema (redness) and tenderness to palpation of extremities (Seen in 10% of patients).
Serum tumor marker: CA 19-9
Surgical resection involves en bloc removal of the head and neck of pancreas, proximal duodenum, and GB (Whipple procedure).
Prognosis average 6 months or less (1 year survival is <10%); very aggressive; usually already metastasized at presentation; tumor more common in pancreatic head.
Increased risk in Jewish and AA males.

Back 4

Pancreatic CA - FA132, P116

Front 5

Failure to form or early destruction of extrahepatic biliary tree that leads to biliary obstruction w/in the first 3 months of life.
Presents w/ jaundice and progresses to cirrhosis (Back pressure into liver -> Damage to liver cells).

Back 5

Biliary Atresia - FA131, P115

Front 6

Solid, round stones in the gallbladder due to preceipitation of XOL or BR in bile.
1) Supersaturation of XOL or BR
2) Decreased PLs or Bile acids
3) Stasis
Usually asymptomatic
Complications: Biliary colic, acute and chronic cholecystitis, ascending cholangitis, gallstone ileus, and GB cancer.
Diagnose w/ US and tx w/ cholecystectomy.

Back 6

Cholelithiasis (Gallstones) - FA335, P116

Front 7

Yellow stones are the most common type (80%), especially in the West. Radiolucent w/ 10-20% opaque due to calcification.
Associated with obesity, Crohn's disease (Terminal ileum dmg -> Decreased bile acid reuptake), cystic fibrosis, advanced age, clofibrate, estrogens (Increased activity of HMG CoA reductase -> Increased XOL syn. and Increased lipoprotein Rs on liver -> Increased XOL uptake), multiparity, rapid weight loss, cirrhosis, and Native American origin.
Risk factors (4 F's):
1) Female
2) Fat
3) Fertile
4) Forty

Back 7

XOL Cholelithiasis (Gallstones) - FA335, P116

Front 8

Cholestyramine

Back 8

Lipid lowering agent. Binds bile acids in the GI tract preventing their reabsorption. A decrease in biles acids can lead to cholelithiasis. - P116

Front 9

Pigmented stones that are usually radiopaque.
Risk factors include: Extravascular hemolysis (Increased BR in bile), alcoholic cirrhosis, advanced age, and biliary tract infection (e.g. E coli, Ascaris lumbricoides, and Clonorchis sinensis).
Ascaris lumbricoides - Common roundworm that infects 25% of the world's population, especially in areas w/ poor sanitation (fecal oral transmission).
Clonorchis sinensis (Chinese liver fluke) - Endemic in China, Korea, and Vietnam. Also increases risk for cholangitis and cholangioCA.

Back 9

BR Cholelithiasis (Gallstones) - FA335, P116

Front 10

Waxing and waning RUQ pain due to gallbladder contracting against a stone lodged in the cystic duct or common bile duct.
Symptoms are relieved if stone passes.

Back 10

Biliary Colic - FA335, P117

Front 11

Common bile duct obstruction can result in ... (2)

Back 11

Acute pancreatitis or Obstructive jaundice - P117

Front 12

Acute inflammation of the gallbladder wall. Impacted stone in the cystic duct results in dilation w/ pressure ischemia, bacterial overgrowth (E coli), and inflammation.
Presents w/ RUQ pain, of radiating to the RIGHT SCAPULA, fever w/ elevated WBC count, N/V, and elevated serum alkaline phosphatase (from duct dmg)
Risk of rupture if left untreated.

Back 12

Acute Cholecyctitis - P117

Front 13

Chronic inflammation of the gallbladder due to chemical irritation from longstanding cholelithiasis, w/ or w/o superimposed bouts of acute cholecystitis.
Histology: Characterized by herniation of GB mucosa into the muscular wall (ROKITANSKY-ASCHOFF SINUS).
Presents w/ vague RUQ pain, especially after eating. Porcelain GB is a late complication (1) Shrunken, hard GZB due to chronic inflammation, fibrosis, and dystrophic calcification 2) Increased risk for CA)
Tx is cholecystectomy, especially if porcelain GB is present.

Back 13

Chronic Cholecystitis - P117