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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 GallbladderThickened wall and pericholecystic fluid
Acalculous Biliary Disease
5-10% of patients with cholecystitisTypical 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 highMortality 40%
Acalculous Biliary Disease
Biliary dyskinesiaMore benign variantTypical gallbladder pain without stonesHIDA scan with stimulation shows abnormal
gallbladder emptyingSymptoms usually resolve with
cholecystecomy
Choledocholithiasis
Choledocholithiasis
Usually due to gallstones from gallbladderMay be primaryCholangitis (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 cancerBile 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
CausesAlcoholGallstonesERCPDrugsPancreas divisum Idiopathic
Ranson’s Prognostic Signs (Gallstone Pancreatitis) AdmissionInitial 48 hours
Age > 70 WBC > 18K Glucose > 220 mg/dl LDH > 40 IU/L AST > 250 U/dl
Hct < 10 BUN rise > 2 mg/dl CA2+ < 8 mg/dl Base deficit >5 mEq/L Fluid > 4L
Ranson’s Prognostic Signs (Alcoholic Pancreatitis)AdmissionInitial 48 hours
Age > 55 yrs WBC > 16 K Glu > 200 mg/dl LDH > 350 IU/L AST > 250 U/dl
Hct fall > 10 BUN rise > 5 mg/dl Ca2+ < 8 mg/dl PaO2 < 55 mg/dl
Base deficit >4 mEq/L Fluid > 6L
PancreatitisComplicationsPseudocyst
Hemorrage Rupture Infection
Pancreatic necrosis Infected pancreatic necrosisShock and respiratory failure
Large Pancreatic Pseudocyst
PancreatitisTreatment IV fluidsPancreatic rest
NPO NG suction if vomitting
? Antibiotics? OctreotideTPN
PancreatitisTreatment
SevereAntibiotics? Debridement? Peritoneal lavage
Pseudocyst Treatment
Treat only if symptomaticComplications rare in asymtomatic ptsPercutaneous drainage
Results variable Infection risk ?
Surgery Cyst-gastrostomy Cyst-jejunostomy Excision with pancreatectomy
PancreasNeoplasms
Benign LesionsSerous cystadenomaMucinous cystadenoma Intraductal papillary mucinous tumor (IPMT)
Serous Cystic Tumors
20-40% of cystic pancreatic neoplasmsMost benign with no malignant potentialGlycogen rich cells on FNAUsually occur in body or tail Indications for resection
? Diagnosis Symptoms
CT scan of serous cystadenoma
Mucinous Tumors
20 – 40% of cystic tumorsHave malignant potentialDon’t communicate with pancreatic ductTwo typesSurvival after resection
>50% 5 year survival without invasion Even with invasion, survival > ductal adenoCa
Mucinous Tumors
Types of Mucinous TumorsLess 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 NeoplasmsDuctal AdenocarcinomaApprox 30,500 new cases per year Incidence increasing4th leading cause of cancer deathMore frequent in men than womenMore frequent in blacks than whites80% occur between age 60 & 80 yrs70% arise in head or uncinate process
Malignant NeoplasmsDuctal 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 pancreatitisLess extensive resectionNo difference in cancer survivalFewer long-term GI side effectsNow 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 AdenocarcinomaUnresectable 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
InsulinomaGastrinomaVIPoma (Verner-Morrison Syndrome)GlucagonomaSomatostatinomaNonfunctional
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 benignHard to find
Arteriogram of insulinoma
CT of insulinoma
Portal venous sampling
Intraoperative US of insulinoma
Gallbladder and Pancreas
Gallbladder and Pancreas
Questions?