Pathoma - Exocrine Pancreas, Gallbladder, Biliary Tract - Fundamentals Of Pathology

Front 1

What is an annular pancreas?

Back 1

Developmental malformation. Pancreas forms a ring around duodenum. Risk for obstruction.

Front 2

What is acute pancreatitis? Explain.

Back 2

Inflammation and hemorrhage of pancreas. Due to autodigestion of parenchyma by pancreatic enzymes. Premature activation of trypsin leads to activation of other enzymes.

Front 3

Two most common causes of acute pancreatitis is what?

Back 3

(1) Alcohol (is thought to close sphincter of oddi at the ampulla of vater)
(2) Gallstones

Front 4

Outside of the two most common causes of acute pancreatitis, what causes could cause acute pancreatitis?

Back 4

(1) Trauma (e.g., child in car accident with seatbelt such that it overlies abdomen instead of pelvis)
(2) Hypercalcemia (activates enzymes), hyperlipidemia
(3) Drugs
(4) Scorpion stings
(5) Mumps
(6) Rupture of posterior duodenal ulcer

Front 5

Classic features of acute pancreatitis?

Back 5

(1) Epigastric abdominal pain that radiates to the back.
(2) Nausea and vomiting
(3) Periumbilical and flank hemorrhage (necrosis can spread into periumbilical soft tissues)
(4) Elevation of serum lipase and amylase
(5) Hypocalcemia (saponification)

Front 6

Complications of acute pancreatitis?

Back 6

(1) Shock (hypovolemic from digesting vasculature)
(2) Pancreatic pseudocyst (fibrous tissue surrounding liquefactive necrosis)
- Would show formation of a mass and persistence of pancreatic enzymes in blood.
(3) Pancreatic abscess (usually due to e.coli)
- Persistently elevated amylase in the face of a recent bout of acute pancreatitis.
(4) DIC and ARDS (release of enzymes and TF that activate coagulation). Elastases can break down vessels in pulmonary circulation.

Front 7

Chronic pancreatitis is usually due to what?

Back 7

Recurrent bouts of acute pancreatitis.

Front 8

What is chronic pancreatitis? What is it most commonly due to?

Back 8

Fibrosis of pancreatic parenchyma.

Most commonly due to alcohol and cystic fibrosis; many cases are idiopathic.

Front 9

Clinical features of chronic pancreatitis?

Back 9

(1) Epigastric abdominal pain radiating to the back
(2) Pancreatic insufficiency
- Malabsorption with steatorrhea
- Malabsorption of ADEK vitamins
(3) Dystrophic calcification of pancreas
(4) Late secondary diabetes mellitus
(5) Increased risk for pancreatic carcinoma

Front 10

True or false: Amylase and lipase are useful markers for chronic pancreatitis.

Back 10

False. Most of the exocrine pancreas has been destroyed in chronic pancreatitis.

Front 11

What is pancreatic carcinoma?

Back 11

Adenocarcinoma that arises from pancreatic ducts.

Front 12

Pancreatic carcinoma is MC seen in what age group?

Back 12

Elderly (average age is 70)

Front 13

Major risk factors for pancreatic carcinoma?

Back 13

(1) Smoking
(2) Chronic pancreatitis

Front 14

Patients with pancreatic carcinoma generally present ________ (early/late).

Back 14

late in the course

Front 15

Clinical features of pancreatic carcinoma?

Back 15

(1) Epigastric abdominal pain and weight loss
(2) Obstructive jaundice with pale stools and palpable gallbladder (head of pancreas)
(3) Secondary diabetes mellitus (body or tail)
(4) Pancreatitis
(5) Migratory thrombophlebitis (swelling, tenderness in extremities; 10% of patients)

Front 16

Thin elderly smoking person that presents with diabetes. What should you think?

Back 16

Secondary diabetes to pancreatic carcinoma.

Front 17

Serum tumor marker for pancreatic carcinoma?

Back 17

CA 19-9

Front 18

Treatment of pancreatic carcinoma?

Back 18

(1) Whipple procedure
- Removing head and neck of pancreas, duodenum and gallbladder.

Front 19

Pancreatic carcinoma has a _________ (moderately good/poor) prognosis.

Back 19

poor (very poor, 1 year survival is less than 10%)

Front 20

What is biliary atresia? What does it lead to and how does it present?

Back 20

Failure to form or early destruction of extrahepatic tree. Leads to biliary obstruction within first 3 months of life. Presents with jaundice (CB) and progresses to cirrhosis.

Front 21

Cholelithiasis is due to precipitation of what?

Back 21

Cholesterol or bilirubin in bile

(1) Supersaturation can precipitate it
(2) Decreased phospholipids (e.g., lecithin) or bile (e.g. Crohn's or Cholestyramine) can precipitate it
(3) Stasis (can cause growth of bacteria, deconjugates bilirubin which can form stones)

Front 22

Explain how a patient with Crohn's can get gallstones.

Back 22

Enterohepatic circulation of bile occurs in the ileum. This pervents reabsorption, preventing recirculation and causing bile juice to have lower concentration of bile. This can precipitate gallstones.

Front 23

MC type of gallstone?

Back 23

Cholesterol is the most common type of stone in the west.

Front 24

Cholesterol stones are usually ____________ (radiopaque/radiolucent).

Back 24

radiolucent

Front 25

Risk factors for gallstones?

Back 25

(1) Age (avg. age around 40)
(2) Estrogen (HMG CoA Reductase)
(3) Clofibrate (lipid lowering agent; same as estrogen)
(4) Native American ethnicity
(5) Crohns disease
(6) Cirrhosis (decreased bile salts)

Front 26

Bilirubin stones are usually ____________ (radiopaque/radiolucent).

Back 26

radiopaque (they look black in color)

Front 27

Risk factors for bilirubin gall stones.

Back 27

(1) Extravascular hemolysis
(2) Biliary tract infection (e.g., E.coli, Ascaris lumbricoides, Clonorchis sinensis)

Front 28

Gallstones are usually _____________ (symptomatic/asymptomatic).

Back 28

asymptomatic

Front 29

A mnemonic for complications of gallstones. List and tell a few words about each complication.

Back 29

BAAGG

B - Biliary colic (waxing and waning RUQ pain, gallbladder contracts against stone in cystic duct)
A - Acute pancreatitis
A - Acute cholecystitis (cystic duct stone --> pressure buildup --> squeezed blood vessels of the wall --> ischemia --> bacterial overgrowth --> inflammation)
G - Gallstone ileus
G - Gallbladder cancer

Front 30

Acute cholecystitis presents how?

Back 30

(1) RUQ pain, radiating to right scapula.
(2) Fever with elevated WBCs
(3) Nausea and vomiting
(4) Increased serum alkaline phosphatase
(5) Risk of rupture if left untreated

Front 31

What is chronic cholecystitis due to?

Back 31

Due to chemical irritation from longstanding cholelithiasis.

Front 32

What is this and what is it a hallmark of?

Back 32

Chronic cholecystitis. The image shows Rokitansky-Aschoff sinus formation.

Front 33

Clinical presentation of chronic cholecystitis?

Back 33

(1) Vague RUQ pain, especially after eating
(2) Porcelain gallbladder is late complication (dystrophic calcification)

Front 34

Treatment of chronic cholecystitis?

Back 34

Cholecystectomy, especially if porcelain gallbladder is present.

Front 35

Ascending cholangitis can arise due to __________.

Back 35

gallstones

Front 36

Ascending cholangitis is usually due to what?

Back 36

Ascending infection with enteric gram-negative bacteria.

Front 37

How does ascending cholangitis present?

Back 37

(1) Sepsis
(2) Jaundice
(3) Abdominal pain

Increased incidence with choledocholithiasis

Front 38

What is gallstone ileus? How does it occur?

Back 38

When a gallstone enters and obstructs small bowel. Due to cholecystitis with fistula formation between gallbladder and small bowel.

Front 39

What is a gallbladder carcinoma?

Back 39

Adenocarcinoma arising from glandular epithelium that lines the gallbladder wall.

Front 40

Major risk factor for gallbladder carcinoma?

Back 40

Gallstones, especially with porcelain gallbladder.

Front 41

Gallbladder CA classically presents in [...]

Back 41

Classically presents as cholecystitis in elderly woman. Cholecystitis is basically a disease of 40 year olds or 50 year olds. Consider gallbladder carcinoma in an elderly woman with new onset cholecystitis.

Particularly poor prognosis.