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Gallbladder and Pancreas
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Gallbladder
Anatomy and physiology
Calculous biliary disease
Benign acalculous biliary disease
Malignant biliary disease
Pancreas
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Anatomy, embryology and histology
Physiology
Pancreatitis
Neoplasms
Calculous Biliary Disease
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Incidence age and sex related
More common in females
Incidence increases with age
May remain silent
Complications include
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Acute cholecystitis
Choledocholithiasis
Cholangitis
Gallstone pancreatitis
Gallstone ileus
Gallbladder adenocarcinoma
Gallstone Incidence
Gallbladder with Stones
CT of Gallbladder
Thickened wall and pericholecystic fluid
Acalculous Biliary Disease
 5-10% of patients with cholecystitis
 Typical patient
 Critically
ill
 Burns
 Long-term
TPN
 Major non-biliary operations (AAA, Cardiac
bypass)
Acalculous Biliary Disease
 Etiology
 Unclear
 Stasis
and ischemia ?
 Symptoms and Signs
 Similar
to calculous presentation
 May be masked by other critical illness
Acalculous Biliary Disease
 Treatment usually open cholecystectomy
 Incidence of gangrene, perforation, and
empyema high
 Mortality 40%
Acalculous Biliary Disease
 Biliary dyskinesia
 More benign variant
 Typical gallbladder pain without stones
 HIDA scan with stimulation shows abnormal
gallbladder emptying
 Symptoms usually resolve with
cholecystecomy
Choledocholithiasis
Choledocholithiasis
 Usually due to gallstones from gallbladder
 May be primary
 Cholangitis (Charcot’s triad)
 Fever
and chills
 RUQ pain
 Jaundice
Choledocholithiasis
 Treatment of cholangitis
 IV
fluids
 Antibiotics
Gram negatives
 Enterococcus
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 ERCP
 Open
common duct exploration
Malignant Biliary Disease
 Gall bladder cancer
 Bile duct cancer
CT of Gallbladder Cancer
Survival Following Resection of T2 Gallbladder Cancer
Bile Duct Carcinoma
Bile Duct Carcinoma
ERCP showing hilar tumor
Pancreas
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Anatomy, embryology and histology
Physiology
Pancreatitis
Neoplasms
Pancreatic Physiology
Acute Pancreatitis
Causes
 Alcohol
 Gallstones
 ERCP
 Drugs
 Pancreas divisum
 Idiopathic
Ranson’s Prognostic Signs (Gallstone Pancreatitis) Admission
Initial 48 hours
 Age > 70
 Hct < 10
 WBC > 18K
 BUN rise > 2 mg/dl
 Glucose > 220 mg/dl
 CA2+ < 8 mg/dl
 LDH > 40 IU/L
 Base deficit >5 mEq/L
 AST > 250 U/dl
 Fluid > 4L
Ranson’s Prognostic Signs (Alcoholic Pancreatitis) Admission
Initial 48 hours
 Age > 55 yrs
 Hct fall > 10
 WBC > 16 K
 BUN rise > 5 mg/dl
 Glu > 200 mg/dl
 Ca2+ < 8 mg/dl
 LDH > 350 IU/L
 PaO2 < 55 mg/dl
 AST > 250 U/dl
 Base deficit >4 mEq/L
 Fluid > 6L
Pancreatitis
Complications
 Pseudocyst
 Hemorrage
 Rupture
 Infection
 Pancreatic necrosis
 Infected pancreatic necrosis
 Shock and respiratory failure
Large Pancreatic Pseudocyst
Pancreatitis
Treatment
 IV fluids
 Pancreatic rest
 NPO
 NG
suction if vomitting
 ? Antibiotics
 ? Octreotide
 TPN
Pancreatitis
Treatment
Severe
 Antibiotics
 ? Debridement
 ? Peritoneal lavage
Pseudocyst Treatment
 Treat only if symptomatic
 Complications rare in asymtomatic pts
 Percutaneous drainage
 Results
variable
 Infection risk ?
 Surgery
 Cyst-gastrostomy
 Cyst-jejunostomy
 Excision
with pancreatectomy
Pancreas
Neoplasms
Benign Lesions
 Serous cystadenoma
 Mucinous cystadenoma
 Intraductal papillary mucinous tumor (IPMT)
Serous Cystic Tumors
 20-40% of cystic pancreatic neoplasms
 Most benign with no malignant potential
 Glycogen rich cells on FNA
 Usually occur in body or tail
 Indications for resection
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Diagnosis
 Symptoms
CT scan of serous cystadenoma
Mucinous Tumors
 20 – 40% of cystic tumors
 Have malignant potential
 Don’t communicate with pancreatic duct
 Two types
 Survival after resection
 >50%
5 year survival without invasion
 Even with invasion, survival > ductal adenoCa
Mucinous Tumors
Types of Mucinous Tumors
 Less common type
 Nealy
always in women
 Almost always in pancreatic tail
 Contains areas of ovarian-like stroma
 More common type
 Occurs
in both sexes
 Lacks ovarian-like stroma
 Found anywhere in pancreas
CT scan of mucinous cystadenoma
Malignant Neoplasms
Ductal Adenocarcinoma
 Approx 30,500 new cases per year
 Incidence increasing
 4th leading cause of cancer death
 More frequent in men than women
 More frequent in blacks than whites
 80% occur between age 60 & 80 yrs
 70% arise in head or uncinate process
Malignant Neoplasms
Ductal Adenocarcinoma
 Risk factors
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Age > 60 yrs
Cigarette smoking
History of hereditary pancreatitis
Occupational exposure to carcinogens
? Diabetes
? Chronic pancreatitis
Progression Model for Pancreatic Cancer
ERCP showing double duct sign
Ca Uncinate Process
Surgical Therapy – Whipple’s Operation
Trimble’s Procedure
Trimble’s Procedure
Pyloric Preservation
Pyloric Preservation
 Initially recommended for pancreatitis
 Less extensive resection
 No difference in cancer survival
 Fewer long-term GI side effects
 Now standard operation for cancer
Pancreatic adenocarcinoma
Adjuvant therapy
 Chemotherapy in all patients
 Agents
evolving
 Gemcitibine becoming standard
 Immunotherapy with interferon?
 Radiation therapy in margin positive patients
Results of Treatment for Pancreatic
Ductal Adenocarcinoma
 Unresectable patients
 Mean survival 7-9 months
 Palliative chemo extends survival by weeks
 Resection
 Survival depends on stage
 Node negative, margin negative
40-45% 3 year survival
 Node
positive or margin positive
25-35% 3 year survival
Endocrine Neoplasms
 Insulinoma
 Gastrinoma
 VIPoma (Verner-Morrison Syndrome)
 Glucagonoma
 Somatostatinoma
 Nonfunctional
Insulinoma
 Most common of endocrine tumors
 Whipple triad
 Presentation
 Fatigue
 Weakness
 Hunger
 Tremor
 Diagnosis
 Monitored fasting
 Measurements of insulin and glucose with symptoms
Localization
 Small (usually < 1.5 cm)
 Usually benign
 Hard to find
Arteriogram of insulinoma
CT of insulinoma
Portal venous sampling
Intraoperative US of insulinoma
Gallbladder and Pancreas
Gallbladder and Pancreas
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