18 - Non-tumor Diseases of pancreaticobiliary tract

Pathway of bile before reaching intestine

Left hepatic duct and right hepatic duct lead into common hepatic duct where it joins the cystic duct from the gallbladder and forms the common bile duct that leads into the gallbladder

Cholelithiasis

• Thai name + simple definition

นิ่วในถุงน้ำดี aka stones in the gallbladder

Cholelithiasis

• Two types, and which one is more common in Asia?

Cholesterol stone, pigmented stone

• Pigmented stones are more common in Asia

Cholesterol stone

• Main mechanism

• Color

• X-ray visibility

• Supersaturation of cholesterol

• Yellow

• Radiolucent mostly

Cholesterol stone

• Risk factors

• Forty, female, fatty, fertile

Pigmented stone

• Source

• Types

• Unconjugated bilirubin

• Black and brown

Black pigmented stone

• Cause

• Appearance

• Hemolysis

• Black, shiny, small, most radioopaque out of the 3, but not always

Brown pigmented stone

• Cause

• Appearance

• Infection

• Brown-ish green, large, relatively soft and greasy

Cholelithiasis

• Clinical features

• Treatment

• Usually asymptomatic, can present with RUQ abdominal pain that presents after a fatty meal and can radiate to back

• Elective cholecystectomy if the patient is symptomatic

Cholelithiasis

• Complications

• Cholecystitis due to backup of bile which causes irritation → empyema, perforation, fistula

• Obstruction of cystic duct, becoming a CBD stone

• Dysplasia and malignancy

• Gallstone ileus

• Mirizzi syndrome

Gallstone ileus vs Mirizzi syndrome

Both are complications of cholelithiasis

• Gallstone ileus: Blockage of the intestines due to a fistua formed by cholecystitis that allows for a gallstone to leave and block the intestines

• Mirizzi syndromoe: A gallstone that obstructs the cystic duct in a way that also compresses the common hepatic duct

Choledocholithiasis

• Location

Common bile duct

Choledocholithiasis

• Extra symptoms from a typicall gallstone

• Biliary colic, jaundice

• BUT can still be asymptomatic

Choledocholithiasis

• Investigation and treatment

• U/S, ERCP or MRCP(ฉีดสี) using a camera vs CT

• Surgery via open surgery, ERCP to get rid of the stone and maybe cholecystectomy entirely

What does it mean when choledocholithiasis is a secondary stone?

It means it formed in the gallbladder first

Cholecystitis

• Meaning

• Types

• Inflammation of the gallbladder

• Acute, chronic

Acute cholecystitis

• Clinical presentation

• Clinical sign to be tested

Patient presents with RUQ acute pain(can refer to back) and RUQ tenderness, fever and leukocytosis for more than 6 hours

• Patient often looks tired/sick unlike gallstones

Murphy’s sign

Acute cholecystitis

• Types

• Acute calculous cholecystitis

• Acute acalculous cholecystitis

Acute calculous vs acalculous cholecystitis

• Frequency

• Mechanism

• Calculous is much more common, 90% of the cases while acalculous is 10%

• Calculous is due to a stone such as the cystic duct or gallbladder neck, causing buildup of pressure which causes cells to release phospholipase A2 which reacts with lecithin in bile and turns it into lysolecithin → lysolecithin is a detergent that destroys GB’s protective mucus and leads to more damage. Acalculous has the same lysolecithin damage pathway but there is no stone needed. It’s often found in patient’s who have debilitating illnesses which might have ischemia and stasis which are driving factors

Acute cholecystitis

• Treatment

• Hydration and antibiotics NPO then surgery, while surgery right away in complications is also possible

Chronic cholecystitis

• What is it and what can it cause?

A finding on the removed gallbladder rather than a clinical diagnosis. Gallstones cause a hickened gallbladder wall, rokitansky-aschoff sinuses, and the damage is a dysplasia/malignancy risk

Acute cholangitis

• Definition

• Biliary obstruction that is infected by bacteria and that bacteria travels up

Acute cholangitis

• Clinical presentation

• Charcot’s triad: Fever, abdominal pain, jaundice

Reynolds Pentad

Charcot’s triad with shock + altered mental state, happens when tacute cholangitis isn’t treated and the bacteria causes septic shock

Acute pancreatitis

• Thai name + definition/mechanism

• ตับอ่อนอักเสบ + pancreatic enzymes attack the pancreas caused by activation of trypsinogen to trypsin

Acute pancreatitis

• Main causes

• Alcoholism, gallstones

Acute pancreatitis

• Clinical symptoms

• Severe, sudden epigastric pain that radiates to the back, n-v

  • In severe cases: Shock, peritoneal hemorrhage(Cullen and Grey-Turner signs)

Acute pancreatitis

• Diagnostic criteria

• 2/3 of:

  • Compatible abdominal pain(Severe, epigastric, radiates to back)

  • Amylase and/or lipase >3 upper normal limit

  • Corresponding imaging

Acute pancreatitis is an ___ but doesn’t require ___

Emergency condition but doesn’t require surgery

Chronic pancreatitis is a ___ condition

Irreversible

2 histo descriptions of chronic pancreatitis

1. Fibrosis

2. Duct dilatation

Liver Abscess

• Thai name + definition/mechanism

• หนองในตับ + a pus filled mass within the liver caused by bacteria, neutrophils and granulation tissue that wall them off

Liver Abscess

• Causative organisms

• Often polymicrobial, with key ones in Thailand being K. pneumoniae and melioidosis

How does bacteria usually get to the liver to form an abscess, and what’s some conditions that allow it?

Usually via ascending infection(ascending cholangitis)

• Age, diabetes, cirrhosis, immunocompromised

Liver Abscess

• Symptoms

• Fever, weight loss, systemic symptoms, RUQ tenderness, hepatomegaly

Liver Abscess

• Treatments

• Percutaneous, surgery, antibiotics

Which one of lipase and amylase

• Is detectable in urine?

• Amylase

Which one of lipase and amylase

• Lasts longer?

• Lipase

Clinical impact of lipase lasting longer than amylase

• Thai limitation

Amylase can appear normal despite AP if the patient presents after 2-3 days(Also along with 20% of alcohol induced AP and AP with severe hypertriglyceridemia, but like >1k mg/dL)

• Thai hospitals often only have amylase

There’s no point in ___ serum amylase and lipase ___ because ___

Tracking/following serum amylase and lipase after diagnosis of AP is pointless bc they don’t relate to severity/prognosis

Chronic pancreatitis

• Diagnosis

• Lipase/amylase levels

• Utility of pancreatic function testing

• Patient history, clinical presentation and imaging findings(CT/MRI) with no need for serum amylase/lipase

• Lipase/amylase is often normal because the damaged pancreas can’t makem ore

• Not used