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

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