1
Q
Choledocholithiasis is
A
formation and migration of stones inside the biliary tree or common bile
duct
2
Q
pigment stones
A
– contain bilirubin and
calcium - radiopaque
3
Q
Risk factors for pigment gallstones:
A
1) hemolytic conditions (sickle cell anemia (beta chain issue),
hereditary spherocytosis, thalassemia (absence of 1 globulin))
2) liver cirrhosis
3) intraductal stasis (choledochole cyst, postsurgical billiary stricture)
4
Q
Risk factors for mixed gallstones:
A
1) Crohn’s disease
2) partial removal of ilium
3) decreased gallbladder motility:
- severe trauma (e.g. car accident)
- severe burns
- paralysis
5
Q
gallstones are asymptomatic in what percent of patients
A
70-80%
6
Q
gall stone attack
A
- sudden acute pain in the right upper quadrant,
lasts 30 minutes to several hours, until the
gallbladder relaxes - pain radiates to back, between blades, right
shoulder, behind sternum - change of posture, defecation do not relieve
pain
7
Q
_____ is positive in Cholelithiasis
only when it is complicated with Cholecystitis
A
Murphy’s sign
8
Q
Murphy’s sign is negative with
A
the stone
in the bile duct (Choledocholithiasis)
9
Q
Cholelithiasis signs and symptoms
A
- tachycardia
- nausea, vomiting (vomiting does not relieve pain)
- increased production of gas
- fat intolerance
10
Q
Signs and Symptoms in
Choledocholithiasis:
A
- the Charcot triad (indicates the ascending cholangitis)
= severe right upper quadrant pain
= jaundice
= fever - acute constant pain in the upper part of the
abdomen - obstructive jaundice
- Murphy’s sign is negative
11
Q
Cholelithiasis diagnosis
A
- Blood tests are informative in the cases of exacerbation:
- increased WBC (during migration only)
- increased common bilirubin content (left shift)
- increased alkaline phosphatase (enzyme present in liver and bile, synthesized by pregnant women)
- High ALP
- ultrasound
- CT
- MRI
- ERCP (endoscopic retrograde cholangiopancreatography)
- xray (porcelain gallbladder)
12
Q
ALP
A
-Alkaline phosphatase (ALP) is an enzyme presenting in all tissues of the body, but is particularly concentrated in: liver, bile duct, kidneys, bones, placenta
13
Q
-High ALP can show:
A
- liver disease
- bile duct obstruction
- presence of Paget’s disease with osteoblastic
activity - presence of pregnancy
- presence of Celiac disease
14
Q
gold standard for exam and diagnosis of gallbladder stones
A
ultrasound
15
Q
“porcelain
gallbladder”
A
characterized by calcification of gallbladder wall, developing usually in cholelithiasis complicated by chronic cholecystitis
16
Q
Radiologic exam can be used for differential diagnosis
between gallbladder and kidney stones.
On lateral lumbar X-ray film:
A
- the gallstones locate in front of lumbar spine - the kidney stones overlap L2 or locate posterior to it
17
Q
acute cholecystitis
A
when the cystic duct is obstructed
18
Q
chronic cholecystitis,
A
when long-term
presence of gallstones (“silent” stones)
leads to fibrosis of the gallbladder wall,
with further its calcification (“porcelain
gallbladder”)
19
Q
complications of cholelithiasis
A
- acute cholecystitis
- chronic cholecystitis
- gallbladder gangrene
- perforation of rupture
- cholangitis
- acute pancreatitis
20
Q
perforation or rupture of
the gallbladder
A
with
development of bile peritonitis
and high level of mortality
21
Q
cholangitis
A
when the common bile duct
is obstructed before joining
the pancreatic duct
22
Q
acute pancreatitis
A
when the hepatopancreatic duct or pancreatic duct is obstructed
23
Q
Cholecystitis
A
is defined as inflammation
of the gallbladder wall.
24
Q
the two forms of cholecystitis?
A
- calculous
- acalcolous
25
calculous
when stones in the
| gallbladder are formed – 90%
26
acalcolous
- without formation of stones
- 10%
- most severe
27
Risk factors for calculous cholecystitis:
- female sex
- obesity
- rapid weight loss
- multiple pregnancies
- increasing age >35-40
- ethnic groups (Hispanic, Scandinavian)
- drugs (especially hormonal therapy
in women)
28
Etiology of acalculous cholecystitis
```
- critical illness (HIV, diabetes mellitus,
myocardial infarction)
- major surgery or severe trauma/burns
- sepsis
- long-term total parenteral nutrition
- prolonged fasting
- Salmonella infection
```
29
Pathogenesis of acute cholecystitis
```
etiological agents
↓
decrease the gallbladder motility
↓
delay of bile evacuation
↓
increase of pressure inside gallbladder, increase of bile concentration, activation of opportunistic bacteria (e.g. E.coli)
↓
inflammation of gallbladder wall
```
30
Pathogenesis of acute cholecystitis
```
inflammation of gallbladder wall
↓ ↑
edema of gallbladder wall
↓
compromising of blood flow and lymphatic drainage in
gallbladder wall and surrounding tissue
↓
ischemia and necrosis of gallbladder wall
and surrounding tissue
```
31
Pathogenesis of chronic cholecystitis:
Chronic cholecystitis occurs after repetitive mild
exacerbations of acute cholecystitis, and is
characterized by mucosal atrophy and fibrosis of
gallbladder wall
32
Signs and symptoms of acute cholecystitis
- acute pain in right upper abdomen that is severe
and constant, may last for days (!)
- this pain is increased with breathing
- pain radiates to right shoulder, or right scapula,
or right mid back (T8 –T9 levels)
- changing position and passing gas do not
relieve the pain
- large amount of meal or fat meal can trigger the
pain
- pain occurs several hours after eating and
awakens the patient during the night
- fever and chills
- nausea and vomiting
- vomiting does not relieve the pain (unlike to
peptic ulcer)
33
Signs and symptoms of chronic cholecystitis:
```
- the first symptoms are bitter taste and taste of
metal in the mouth in the mornings
- abdominal discomfort after meals
- complaints of gas accumulation
- nausea
- chronic diarrhea
- presence of skin xanthomas
```
34
skin xanthomas
Xanthomas represent focal accumulation of cholesterol, result from cholestasis or/and hyperlipidemia
35
diagnosis of cholecystitis
- ortner's sign
- georgievskiy-myussi's sign
- Murphy's sign
- Boas'sign
- blood test
- ultrasound sonography
- MRI
- CT-scan
- HBS- hepatobiliary scintigraphy
36
Differential diagnosis – for acute
| cholecystitis:
- acute peptic ulcer
- perforated peptic ulcer
- acute pancreatitis
- ureteral colic
37
Differential diagnosis – for chronic
| cholecystitis:
- peptic ulcer
- hiatal hernia
- colitis
- chronic pancreatitis
38
cholecystitis Complications:
- perforation or rupture of gallbladder
- ascending cholangitis
- local abscess
- peritonitis
39
Management of acute cholecystitis:
cholecystectomy
40
Management of chronic cholecystitis:
- diet modification
- antibiotics
- restriction of physical activity
41
Pancreatitis
when certain enzymes that normally do not
become active until they reach the small
intestine, become active in the pancreas
“digesting” this gland itself
-The enzyme Trypsin plays the most important role
in this process
42
Types of pancreatitis:
```
1) acute – is reversible disease, if does not turn
into chronic pancreatitis
2) chronic – is irreversible disease,
characterized by atrophy, fibrosis, and
calcification of pancreatic parenchyma
```
43
Etiology for acute pancreatitis
- alcohol use (even once)
- gallstones
- trauma of the abdomen
- viral infections (e.g. Mumps)
- pseudocysts
- medications (corticosteroids, estrogen, statins)
44
Etiology for chronic pancreatitis
- alcoholism
- cystic fibrosis
- pseudocysts
- idiopathic
45
Signs and Symptoms for acute pancreatitis
- sudden acute, severe pain in upper abdomen,
lasts from short time to days, and resolves
itself
- pain worsens after food eating
- pain may reach to across the back, level
T8–L1 – so called “band-like” pain
- pain could radiate to other areas:
= umbilical
= both flanks
= left shoulder
- pain worse when lying flat on the back
- pain decreases with sitting and flexion
forward (unlike to pain in cholelithiasis and acute cholecystitis)
- this pain is always accompanied by high blood pressure and tachycardia
- positive Cullen’s sign
- positive Grey-Turner’s sign
- nausea
- vomiting
- fever
46
where is the band-like pain located from acute pancreatitis
T8-L1 across the back
- pain could radiate to :
- umbilical
- both flanks
- left shoulder
47
when is pain worse in acute pancreatitis?
- when laying flat on the back
| - after eating food
48
when is pain decreased in acute pancreatitis?
-with sitting and flexion forward
49
Cullen’s sign
– is superficial edema
and bruising in the subcutaneous fatty tissue
around the umbilicus
50
Grey-Turner’s sign
ecchymosis of flanks
-bruising of the flank, which may be indicative of
pancreatic necrosis with retroperitoneal or
intraabdominal bleeding
51
what sign can predict acute pancreatitis
both Cullen’s and Grey-Turner’s signs can
| predict acute pancreatitis
52
Signs and Symptoms for chronic pancreatitis
- acute pain is not resolved itself
- pain increases after eating and drinking
- change of position does not relieve the pain
- band-like pain
- nausea
- severe vomiting
- fatty stool
- signs of diabetes mellitus II only: thirst, polyuria
- weight loss
53
Diagnosis:
```
- blood amylase and lipase are 4-6 times higher
than normal variations
Lipase is better indicator!
- urine amylase is significantly increased
- blood glucose level increased
- ultrasound
- CT-scan
- MRI
```
54
Complications for acute pancreatitis
```
- pancreatic
abscess
- pancreonecrosis
- acute gastritis and duodenitis because they
are adjacent organs
- internal bleeding with development of
hypovolemic shock
- lung problems (enzymes may affect the lung
tissue causing its inflammation)
```
55
Complications for chronic pancreatitis
- diabetes mellitus
- pancreatic cancer
- calcification of pancreas
- multiple cysts
56
Pancreatic Cancer
-is a malignant neoplasm
originating from transformed cells of the pancreas
-The most common type is Adenocarcinoma (95%), arising from the exocrine component, from the cells that line the ducts of the pancreas
57
Predisposing Factors for pancreatic cancer
- chronic pancreatitis
- smoking
- family history
- age over 60 years old - diet with high amount of red meat, soft drinks
- obesity
- partial gastrectomy as treatment of obesity
- Helicobacter pylori infection
58
pancreatic cancer Signs and Symptoms
-early is asymptomatic aka the "silent" disease
- unexplained weight loss
- anorexia
- nausea, vomiting
- steatorrhea (pooping fat)
-clinical depression
- painless jaundice, may be associated with
itching
- jaundice develops when the cancer locates
in the head of pancreas
-pain in upper abdomen, radiates to back if tumor is in body or tail
-trousseau sign
-pulmonary embolism
59
what is the most common location for pancreatic cancer?
head -75%
body -15%
tail -10%
60
Trousseau sign
unexplained thrombophlebitis of superficial veins anywhere in the body,
portal vein or deep veins of the extremities
61
pulmonary embolism is a symptom of pancreatic cancer
because the pancreatic cancer produces the blood clotting chemicals
62
Pancreatic cancer diagnosis
-blood CA-19-9 – this is a tumor marker that
is frequently elevated in pancreatic or liver cancer
- CT-scan
- endoscopic ultrasound (EUS)
- endoscopic ultrasound with endoscopic needle
biopsy
63
pancreatic cancer Metastases steps
```
#1 – to regional lymphatic nodes
#2 – liver-portal vein
#3 – lungs and pleura
```
64
Endocrine Pancreatic Tumors
- Insulinoma
| - Zollinger-Ellison syndrome
65
Insulinoma
-located in tail
-endocrine pancreatic tumor
- beta-cell tumor, generally
benign, is characterized by overproduction of
Insulin, which can result in hypoglycemia
66
Zollinger-Ellison syndrome Gastrinoma
-arises in the duodenum, pancreas and
peripancreatic soft tissue
- It is characterized by overproduction of Gastrin
which stimulates extreme hydrochloric acid
secretion
- it causes multiple peptic ulceration not only in
the stomach and duodenum, but also in
jejunum
- it can metastasize to the liver leading to
significantly short life
67
Zollinger- Ellison syndrome Diagnosis:
- blood testing to detect increased gastrin levels
- upper gastrointestinal (GI) endoscopy
- imaging tests to look for gastrinoma
- measurement of stomach acid
(gastric pH less than 2.0; large gastric volume >140 mL)
is highly suggestive of ZES
GE
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