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Gallbladder and Pancreas Gallbladder Anatomy and physiology Calculous biliary disease Benign acalculous biliary disease Malignant biliary disease Pancreas Anatomy, embryology and histology Physiology Pancreatitis Neoplasms Calculous Biliary Disease Incidence age and sex related More common in females Incidence increases with age May remain silent Complications include 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 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 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 ? 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 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 Questions?