Pancreaticobiliary

Treatment of Acute Pancreatitis

-Early aggressive IVF resuscitation - LACTATED RINGERS -NPO for bowel rest until N/V resolved -IV pain control -IV nausea -Antibiotics if septic. -At 72 hrs, oral refeeding if no severe disease or organ failure -Gallstones - cholecystectomy -Cholangitis +/- sepsis - emergent ERCP -ALcohol/Tobacco counseling -Hypertriglyceridemia - medical therapy/statins

Endoscopic ultrasound (EUS)

-Has a linear or radial US probe on the tip. -Use for staging cancer - invasion into the muscle layer of GI tract. Size of tumor. FNA, FNB or tumors, cysts. Measure and sample suspicious lymph node. Benign uses: Ruling out choledocolithiasis before moving to ERCP. Evaluate sphincer tone, external structures compressing GI tract such as aorta on esophagus.

Lipase

3 types of lipases are secreted by the pancreas and the work to digest triglycerides and fats in diet. Steatorrhea may be due to poor pancreas function.

Cystic Fibrosis

80-90% of patients with CF have pancreatic insufficiency requiring pancreatic enzyme tx.

Ranson's Criteria - Non-Gallstone

>3 is associated with 62% mortality rate. -Ranson's criteria isn't used much anymore since it takes 48 hrs to calculate. -Age >55 -WBC>16K -Blood glucose - >200 -AST >250 -LDH - 350 At 48 hrs: -Serum calcium <8mg/dL -Hematocrit drop >10% -Hypoxemia -BUN increased by at least 5 -Base excess >4 mEq/L -Sequestration of fluids >6L

Biliary Strictures

A narrowing of the CBD. Benighn strictures are due to chronic passage of stones down the CBD, acute pancreatitis. Malignant strictures occur from pancreas head cancers, cholangiocarcinoma, lymphomas. Signs: jaundice, elevated alk pho, transaminitis DIagnosis: US, CT, MRCP imaging shows dilated ducts or abrupt tapering of the CBD. Confirm with EUS/ERCP Treatment: ERCP with balloon dilation and or stent placement. Plastic stents are for benign strictures and must be removed in 3 months, metal stents 6-12 mos.

Ranson's Criteria - Gallstone Pancreatitis

Age>70 WBC >18k Blood glucose >220 AST >250 LDH >500 After 48 hrs Serum calcium <8 mg/dL Hematocrt drop >10% Hypoxemia BUN increased by at least 2 Base Excess >5 mEq/L Sequesteraton of fluids >4L

Primary Biliary Cholangtis (PBC)

An autoimmune cholestatic liver disease primarily affecting middle aged women. Associated with Sjorgens and RTA. Signs: 60% are asymptomatic with incidentally elevated Alk Phos. Sx: fatigue and pruritis. Diagnosis: Antimichondrial antibodies, RF, ASMA, ANA< antithyroid antibody, Alk phos >1.5x ULN, AST >5x ULN. Liver biopsy histology shows loss of canals of Hering. Tx: Urosodiol, steroids, obeticholic acid, OLT Prognosis - asymptomatic follows a benign course. Symptomatic has a rapid progression to ESLD.

Acute Cholecystitis

An impacted stone in the cystic duct with acute gallbladder inflammation and infection. Signs: RUQ pain > 6 hrs, radiating to the shoulder or back, nausea, emesis, fever, positive murphy's sign. Diagnosis: elevated liver enzymes, Alk phos, leukocytosis. Do ultrasound and see cholelithiasis. Can see gall bladder wall thickening. Treatment: Cholecystectomy. 50% will resolve without surgery though. Some have risk of gangrene and perforation. -Check for pancreatitis and rule out cholangitis.

Chronic Pancreatitis

Chronic irreversible pancreas damage thought to be the evolution from acute pancreatitis in certain patients. -Usually seen in men age>40, alcoholic, tobacco user, recurrent acute pancreatitis. Pathophys: not well understood. Acinar cells are damaged before islet cells, therefore you can develop diabetes as a late finding. Features: Fibrosis, changes to the PD Diagnose with imaging Treatment - remove inciting factor

Atlanta Classification

Classifies Acute Pancreatitis -Mild Acute Pancreatitis - no organ failure, no local or systemic complications. -Moderately severe acute pancreatitis - transient organ failure (<48 hrs) and or local or systemic complications without persistent organ failure. Severe pancreatitis - persistent organ failure (>48 hrs), single or multi-organ.

Presentation of Acute Pancreatitits

Chief complaint is epgastric abdominal pain, RUQ or LUX -On exam - vitals will have fever, tachycardia, dyspnea if moderate to severe. -General - can be well or ill appearing -Abdomen will be tender rarely with rebound. -Can have Cullen's sign or Turner's side with bruising.

Choledochal Cysts

Congenital anomalies of the biliary tract. Type I: caused by weakness of the bile duct wall. Signs and sx: can be asymptomatic, jaundice, FTT Diagnosed by ultrasound or ERCP Tx: surgical excision is recommended because it can cause cancer in 10-15% of cases. Surgical excision called Roux-en-Y with choledoco-jejunostomy)

Acute Cholangitis

Impacted stone in the CBD causing bile stasis and bacterial superinfection with Gram negative rods or enteric pathogens. Signs: Charcot's triad: pain 90%, Jaundice - 80% Fever - 95% Reynold's Pentad: addition of hypotension and AMS Diagnosis - ERCP or PTC Tx: ERCP or PTC, abs to cover GNRs. This is an emergency!

Choledocholithiasis

Impacted stone in the common bile duct. Sigsn include painful jaundice. Diagnosis - US shows dilated CBD, CT or MRCP may show actual stones in the CBD, elevated LFTs. T billi - >4 benign choledocholithiasis T billi >10 - malignancy Treatment: EUS +/- ERCP with stone removal is the gold standard. IR PHTC with internal external biliary drain can be performed in unstable patients or those with altered anatomy. Eventually you will do a cholecystectomy to prevent recurrence.

Upper endoscopy

Indicated for dyspagia, upper GI bleed, GERD, Barret's esophagus, dyspepsia, biopsies for celiac, EOE, esophagitis.

Enteroscopy

Indicated for negative colonoscopy and negative upper endoscopy but patient still bleeding from somewhere. Positive tagged RBC scan for small bowel bleed. Single balloon - double balloon.

Colonoscopy

Indications: screening and surveillance of colorectal cancer. Lower GI bleeds, suspected colitis, IBD, microscopic colitis, infection, ischemia, polpectomy.

Sphincter of Oddi Dysfunction

The sphincter of oddi limits the flow of bile through the ampulla. SOD can cause post-cholecystectomy pain, recurrent pancreatitis, or pain in pts with GB but no cholelithiasis. Type I - pain + dilated CBD 10 mm + elevated liver enzymes Type II - pain + 1 other criteria Type III - pain only Diagnosis - check LFTS, US, MRCP, ERCP, biliary scintigraphy Treatment - ERCP sphincterotomy

Post Hepatic Jaundice

Obstructive - bilirubin is conjugated but not able to be excreted due to a blockage. Examples: malignancy, stricture, gallstones, Mirizzi's syndrome, biliary atresia, cholestasis, increased conjugated bilirubin.

Acute Peri-Pancreatic Fluid Collection

Occurs in 30-50% of acute pancreatitis, most resolve spontaneous.

The ble duct

They are suppled by portal blood and lymph nodes allowing for selective exchange and filtering. Bile secretion begins at the level of the tiniest ducts, travels through the portal triads, through the intrahepatics and to the extrahepatics.

Chronic Cholecystitis

Gall bladder is damaged by repeated attacks of acute cholecystitis due to gallstones. -Can present like acute cholecystitis but with chornic inflammation found on surgical pathology. Rarely cause fistula, gangrene or perforation. Diagnosis - same as acute cholecystitis Treatment: Cholecystectomy

Pregnancy and Gallbladder

Gall stones are more common in pregnancy due to decreased gallbladder motility. Increased cholesterol saturation of bile. Estrogen increases secretion of cholesterol. Progesterone reduces bile acid secretion, slows GB emptying. -Acute cholecystitis - second most common surgery in preganancy.

Biliary Colic

Gallstones. More common in women, increasing age, the western diet, pregnancy, TPN, medications (like estrogens or lipid meds) -Symptomatic pain due to the presence of gallstones with intermittent obstruction of the cystic duct. Signs: post-prandial pain RUQ, nausea, emesis, NO FEVER. Diagnosed through normal labs and RUQ US showing stones in the gallbladder. Treatment: Cholecystectomy if symptomatic. No surgery if not bothersome to patient.

Prehepatic jaundice

Hemolytic - caused by hemolysis of RBC before they reach the liver. Ex: malaria, sickle cell anemia, thalassemia, G6PD, Increased unconjugated bilirubin.

Intra-hepatic jaundice

Hepatocellular - the liver itself is unable to metabolize and excrete bilirubin. Ex: hepatitis, PBC, cirrhosis, alcoholic liver disease, toxins. Increased unconjugated bilirubin.

AST/ALT

Hepatocellular enzymes that reflect liver injury. When AST:ALT is 2:1 - alchol related injury.

GGT

High sensitivity for biliary disease, evaluate for source of elevated alc phos.

Causes of Acute Pancreatitis

#1 - Gallstones #2 - Alcohol #3 - Tumors #4 - Hypertriglycerdema #5 - Drug induced

Labs and Imaging for Acute Pancreatitits

-Lipase and/or Amylase >3 times the upper limit of normal -CBC - Leukocytosis -KUB/CXR - may have left sided pleural effusion -Ultrasound - eval for gallstones, dilated common bile duct, rarely finds tumors/masses/cysts -CT/MCRP - Gold standard.

Pancreas Cysts

-Pseudocyst -Serous cystadenoma -Mucinous cystic neoplasm -Intraductal papillary mucinous neoplasm

Endoscopic Retrograde Choliangopancreatography (ERCP)

-Upper endoscope with a side viewing capability which assists the endoscopist in finding the ampulla to the CBD. Various tools can be used in conjunction such as wires, stents, cautery, biopsy, brushing. Benign uses: choledocolithasis, gallstone pancreatitis, benign strictures, PD leaks. Malignant uses: Stent malignant strictures, choliangiocarcinoma, pancreatic cancer.

Clinical Definition of Acute Pancreatitis

1.) Epigastric pain 2.) Serum lipase 3x the ULN 3.) Imaging shows pancreatitis on CT or MRI

Acinar cells

Cells in the pancreas that make, store and secrete digestive enzymes.

Gallbladder

A storage reservoir for concentrated bile acids to be delivered to the duodenum so that fats can be digested in a controlled fashion. It holds 30-50 mL of fluids. Following a meal, CCK stimulates the release of bile from the gallbladder and pancreas juices from the pancreas to help aid in digestion.

Billiary Dyskinesia

Abnormal peristalsis of the GB to push bile through the CBD. Signs and symptoms include abdominal pain. Diagnosis - NM HIDA scan with CCK, pain with admin of CCK, low GB EF% Treatment: Cholecystectomy, though some patients still have pain despite surgery and must be warned of this

Gallbladder Polyps

Adenomyomatosis refers to acquired hyperplastic GB lesions found on 1% of all cholecystectomy specimens. Adenomas are found on 0.15% of all specimens. Signs: Asymptomatic DIagnosis - US Treatment: Size >10 mm, requires surgery given risk of progression to malignancy. Recommend surveillance for anything 6-9 mm.

Islet cells

Cells of the pancreas that secrete insulin to regulate blood sugar.

Autoimmune Pancreatitis

Autoimmune inflammatory fibrosing disease of the pancreas. There are two types: -Type I AIP - Pancreas become infiltrated with plasma cells that stain positive for IgG4. Serum concentrations of IgG4 can also be elevated. 50% relapse. Type II AIP - rare, not associated with IgG4, may be related to IBD, seen in younger patients. Very few relapses. Treatment - Glucocorticoid Therapy

Total Billirubin

Breakdown products of heme. Unconjugated vs. conjugated. Unconjugated is filtered through the liver to become conjugated.

What is the gold standard for diagnosis of Pancreatitis?

CT with IV contrast

Biliary Atresia

Congenital destruction or absence of all extra-hepatic bile ducts causing complete obstruction of flow. This leads to liver fibrosis and eventually cirrhosis. Possibly caused by a virus. -You get neonatal jaundice that persists beyond physiologic jaundice or >14 days. -T Billi - 6-12 mg/dL with >50% conjugated -Acholic, pale, white stools Diagnosed by exam with a firm, enlarged liver. Liver biopsy shows edema, fibrosis, bile stasis. Tx: Kasai Procedure then liver transplant Prognosis - death within two years if untreated.

Pancreas Insufficiency

Decreased exocrine function of the pancreas, symptoms include weight loss, steatorrhea, abd pain with meals, Testing: feces pancreas elastase Tx: Pancreatic enzyme supplements.

Proteases

Digest proteins into amino acids.

Pseudocyst

Encapsulated cyst occuring 4-6 weeks after an episode of acute pancreatitis, may be asymptomatic if less than 5 cm in size or require drainage. (endoscopic preferred)

Alkaline Phosphatase

Excreted from the liver, bone, placenta, kidneys and small intestines.

Ectopic Pancreas Tissue or Pancreatic Rests

Extra pancreas tissue located elsewhere such as the stomach, benign with no consequences.

Indtraductal Paillary Mucinous Neoplasm

Female = males, ages 60s-70s, alarm features that require surg consult due to risk of progression to mucinous adenocarcinoma. -Dilated PD with abrupt tapering of the PD -Solid or enhancing area, mural nodule -Size >3 cm

Stone Locations

Majority of stones are asymptomatic and located in the GB (75%). Next most common, they are located in the cystic duct causing intermittent biliary pain.

Annular Pancreas

Pediatric congenital anomaly where the pancreas wraps around the duodenum causing a bowel obstruction. Treatment is a duodenduodenostomy.

Local Complications of acute pancreatitis

Peri-pancreatic fluid collections, necrosis (sterile or infected), pseudocyst, walled off necrosis.

Video Capsule Endoscopy

Pill camera, swallowed pill camera to identify small bowel lesions.

Endocrine Function of Pancrease

The pancreas is also composed of islet cells which secrete insulin to regulate blood sugar.

Mucinous Cystic Neoplasm

Rare adenoma of the pancreas, more common in females, ages in the 50s.

Primary Sclerosing Cholangitis

Rare, chronic progressive scarring dsease of the biliary tract with increased risk for cholangiocarcinoma when a dominant stricture is present. Asscoiated wth IBD, primarily UC and can appear before or after the IBD diagnosis. -Jaundice and elevated Alk Phos -MRCP vs. ERCP shows pruning of the intrahepatics with a possible dominant stricture. Brushngs sent for FISH. Tx: Liver transplant, monitor cholangiocarcinoma. Prognosis - cirrhosis, cholangiocarcinoma.

Amylase

Secreted by the pancreas and salivary glands, digests starches and glycogen in the diet.

Exocrine Function of Pancreas

The pancreas is composed of acinar cells whch make, store and secrete digestive enzymes.

Pancreas Divsum

The dorsal and ventral pancreatic ducts do not fuse during embyogenesis, occurs 5-10% of the population, usually asymptomatic but can cause acute pancreatitis.

Endoscopic Mucosal Resection (EMR)

Use for large polyps. For adenomas usually large that >2cm. Inject methylene blue and saline mixture into the submucosa layer which lifts the polyps and clearly demarcates the borders then resect. -Repeat scope in 3-6 mos to confirm clean polyp bed.

Radiofrequency Ablation and Argon Plasma Coagulation

Used to treat Barrett's esophagus or radiation proctitis.

Serous Cystadenoma

Usually benign, female > male, age 70s, transformation to cystadenoacarcinoma is very rare.

Necrotizing Pancreatitis

Walled off necrosis - infected, necrotic fluid collection containing liquefied debris (often requires surgical debridement)

Jaundice

Yellow discoloration of the skin due to the high levels of bilirubin in the blood. It also causes scleral icterus, pruritus, dark coca cola urine and light colored stool.