2. MB4-T2-Wk4-Biliary system
CPC 4.2.3
Professionalism & Ethics - of out of office consultations..
Abdominal problems…DD
Counseling, SNAP & five A‟s…
Upper abdominal discomfort with bloating & wind.
after meal burps, stomach feels full & windy. ? worsening.
Duration Symptoms for many months.
Relation to food/fat Yes, makes it worse.
Pain 3-4/10, ill defined, cramping.
Nausea occasional, no vomiting.
Wt loss, Anorexia, Dysphagia No
Bowel habit constipation, No pus, blood PR.
Diet usually eats once a day, often fast foods. Little fruits &
veggies. Lots of coffee*
2
CASE STUDY:
Mrs. L.K is your eldest son’s high school teacher. You attend the parent-teacher interview to
discuss his school work and she asks for advice about her abdominal problems. You advise her to
see you at your rooms in the morning. She is 32 years old and married to a local police officer.
3. MB4-T2-Wk4-Biliary system
CPC 4.2.3
Alchohol 2-3 glasses of wines/night. 12-15 on
weekends, more when friends. (Hepatitis, pancreatitis, gall
stones)
Family: Married to an accountant, no children but has 3
lap dogs. (hydatid dis, echinococcosis.)
MedicationShe is on COCP, (Budd-Chiari sy)
PSH: Tonsillectomy & adenoidectomy at 5 years,
appendicectomy at 14y. (Viral Hepatitis)
3
4. MB4-T2-Wk4-Biliary system
Investigations
Upper abdominal USS – numerous gallstones in thick-
walled gallbladder
LFT – elevated GGT*, Alk Phos normal*…?
Fasting glucose- 7.0 mmol/l
Lipid profile - Total Chol 7.2, Trig. 2.8, HDL 2.0, LDL-
5.1.
Rectal examination – Hard stool in the rectum, no
hemorrhoids or fissures.
4
7. MB4-T2-Wk4-Biliary system
Pathological basis of signs and symptoms
7
Sign or symptom Pathological basis
Jaundice Haemolysis, liver disease or biliary obstruction
Dark urine Conjugated hyperbilirubinaemia (water-soluble)
Pale faeces Biliary obstruction causing lack of bile pigments
Spider naevi Gynaecomastia Secondary to hyperoestrogenism
Oedema Reduced plasma oncotic pressure - hypoalbuminaemia
Xanthelasma Cutaneous lipid deposits hypercholesterolaemia in
chronic biliary obstruction.
Steatorrhoea Malabsorption of fat - (e.g. biliary obstruction)
Pruritus Biliary obstruction resulting in bile salt accumulation
Ascites Hypoalbuminaemia, portal hypertension and secondary
hyperaldosteronism.
Bruising or bleeding Impaired hepatic synthesis of clotting factors – Vit K.
Hepatomegaly hepatitis, infiltration (fat) or tumour (primary or secondary)
Haematemesis Ruptured oesophageal varices due to portal hypertension
Encephalopathy Failure of liver to remove toxins mimicking or altering
balance of neurotransmitters
8. MB4-T2-Wk4-Biliary system
Self Assessment Questions:
most common cause of acute Cholecystitis / cholelithiasis /
pancreatitis?
Common types & pathogenesis of cholelithiasis?
Clinical features of acute cholecystitis / cholelithiasis?
Morphology of acute & Chronic cholecystitis? (gross/micro)
How obesity causes cholelithiasis?
Pathogenesis of alcohol induced pancreatitis?
What is cholestasis? common types? PBC, PSC, neonatal.
Congenital: Hemochormatosis, Wilson‟s & α1AT deficiency?
Common type & clinical features of of pancreatic cancer?
What is primary sclerosing cholangitis? Common causes?
Hepatocellular carcinoma ? Brief notes, diagnosis, AFP..
9. MB4-T2-Wk4-Biliary system
Core Learning Issues (CLI):
Major CLI:
• Cholelithiasis
• Cholecystitis – Acute, Chronic
• Pancreatitis – Acute, Chronic
• Pancreatic carcinoma
Minor CLI:
• Ca. gall bladder & biliary tract.
• Other parasites, atresia, Autoimmune.
• Congenital: Cystic fibrosis.
• Hemochormatosis, Wilson‟s & α1AT deficiency
• Pancreatic cysts, pseudocyst,
• Other Tumours, carcinoid, MEN Types 1 & 2.
9
10. Thought is Powerful & Free!
--William Shakespeare
Human mind is the most powerful weapon in the
world.- e.g. Osama bin laden.
Great monuments & Great wars have always started in a human mind…!
11. Pathology of
Biliary & Pancreatic Disorders
Dr. Shashidhar Venkatesh Murthy
A/Prof. & Head of Pathology
School of Medicine.
13. MB4-T2-Wk4-Biliary system
Physiology:
Bile is the main pathway for cholesterol excretion.
Bile: cholesterol, bile salts & bile pigmint (bilirubin, biliverdin)
Cholesterol made soluble by bile salts (soap) as micielles
Excess cholesterol / low bile salt Stone formation*.
14. MB4-T2-Wk4-Biliary system
Biliary Obstructions:
Extrahepatic Obstruction:
• Dislodged gallstones
• Ca. CBD, Ca. Head of pancreas.
• inflammatory stricture of CBD
• accidental surgical ligation of CBD.
Intrahepatic Obstruction:
• Biliary atresia – Congenital.
• Primary Biliary Cirrhosis
• Primary Sclerosing Cholangitis.
• Cystic fibrosis.
Common Disorders:
• Cholecystitis
• Cholelithiasis
• Choledocholithiasis.
(Adeno Carcinoma)
95% - Cholelithiasis (+cystitis)
15. MB4-T2-Wk4-Biliary system
Cholelithiasis:
Cholelithiasis/gall stones – 95% of GB dis.
Incidence: West 20-40%, Asian 2-4%.
70-80% asymptomatic
Mixed 80% - (cholesterol, ca+, bile, blood)
Pure 20% - Pigment *, Cholesterol.
Severe colicky Upper abdomen Rt shoulder.
Conjugated hyperbilirubinemia Obstruction.
Fat intolerance clay stools - typical in chronic.
16. MB4-T2-Wk4-Biliary system
Risk Factors: Cholelithiasis
Cholesterol Stones:
Race/Demo: Western
Age Middle/late.
Excess Cholesterol
• Female sex
• Oral contraceptives
• Pregnancy
• Obesity
• Rapid weight reduction
• Gallbladder stasis
• Disorders of bile acid
metabolism
• Hyperlipidemia syndromes
Pigment Stones:
Race – Asians
Age: early
Jaundice / Infections
• Hemolysis syndromes
• Biliary infections
• Inflammatory bowel
disorders.
• Ileal resection or bypass.
• Cystic fibrosis
• Chronic Pancreatitis.
80% Idiopathic.
75% in American Pima race.
17. MB4-T2-Wk4-Biliary system
Cholelithiasis:
Crystallization of bile within biliary system.
Risk factors:
• female gender, obesity, diabetes mellitus (FFFF…!)
Pathogenesis:
Cholesterol is made soluble by bile salts and lecithins.
More cholesterol or less bile salts chol. Monohydrate
crystals stone.
Etiologic factors.
• Supersaturation – excess Cholesterol – crystals.
• Calcium Microprecipitation - Nucleation.
• Stasis - Mucous trap crystals – aggregation
• Stone growth environment: infection, stasis, etc.
18. MB4-T2-Wk4-Biliary system
Cholelithiasis:
Morphology & Types:
• Mixed Chol (Ca+Bile salt)* Multiple,
faceted, yellow-grey.
• Rarely Pure cholesterol: Round spiky.
• Bile Pigment stones (black/brown).
Infection / Jaundice. % Calcium = radio
opaque.
21. MB4-T2-Wk4-Biliary system
Cholecystitis + gall stones Abscess.
21
Pigment stones in Infection: Inflammed, thickened gall
bladder filled with pus & black gall stones.
Small stone is seen obstructing neck acute pain.
Adherent Omentum
Pus & Stones (black)
Stone in the neck
UNSW Museum
Pigment stones in
Hemolysis - Bilirubin
24. It is not enough to have a good mind;
the main thing is to use it well…!
- -Rene Descartes
25. MB4-T2-Wk4-Biliary system
Acute Cholecystitis:
90% Cholelithiasis. 10% non-calculous
Females common.
Outflow obstruction by a small gallstone.
Infection – E.coli. Empyema.
Risk of perforation, peritonitis, fistula
Gall stone ileus when stone enters GIT.
Serum amylase normal (high with pancreatitis).
Mild jaundice in 20% - obstructive.
Acute inflammation, hemorrhage, edema, neutrophils.
Gangrenous cholecystitis: when obstruction is severe
compromising blood supply. Green-black necrotic.
26. MB4-T2-Wk4-Biliary system
Chronic Cholecystitis:
Females.
Recurrent / Chronic.
Thick fibrotic wall.
Thick bile – biliary gravel.
Aschoff-Rokitansky sinuses –
diverticula - Due to increased
luminal pressure (obstruction)
Diffuse infiltration by chronic
inflammatory cells.
28. MB4-T2-Wk4-Biliary system
Neoplastic Disorders: (rare)
Benign tumours:
• Bile duct adenoma, cystadenoma
Malignant tumours:
• Adenocarcinoma Ducts lined by cuboidal to
columnar mucin secreting cells separated by
desmoplastic (fibrotic) stroma.
• Cholangiocarcinoma (Bile duct carcinoma)
• Presents with Jaundice.
• Early spread with very poor prognosis.
29. MB4-T2-Wk4-Biliary system
Carcinoma Gallbladder:
Females , Hispanics.
Mexico & Chile
5th-7th decade
Common – Lithiasis *
abdominal pain, anorexia, High ALP.
Commonly Adenocarcinoma
Late diagnosis
Poor prognosis.
5% 5 year survival.
30. MB4-T2-Wk4-Biliary system
Ca Bile duct: Cholangiocarcinoma:
Adeno Carcinoma of
cholangiocytes.
Thoratrast exposure?
Increased incidence in
ulcerative colitis.
Presents with obstructive
jaundice – early diagnosis.
Intrahepatic or extrahepatic.
Increasing incidence. ? toxin
31. 31
Living becomes a glorious experience
only when there is tolerance and love.
Willingness to compromise with other
people’s ways of living and
cooperation. These make happy and
successful societies.
-- Baba.
32. MB4-T2-Wk4-Biliary system
32
CPC 4.2.4 – HBS – Part 2
2 weeks later she present again to your GP practice.
-Worsening abdominal pain - „The worst I ever had-It’s
terrible, please do something’
Central, severe 9/10 constant, radiates to back. > 12
hours.
Associated with vomiting x 3 this morning. No
haematemesis.
Bowels opened yesterday no blood mucus. Hasn‟t
passed urine in 8 hours. Doesn‟t feel like drinking or
eating.
„I just want to lie here- Don’t make me move’
No Pale stools / dark urine. Hasn‟t passed urine since
this morning.
43. MB4-T2-Wk4-Biliary system
Acute Pancreatitis:
a: The pancreas edematous
and hemorrhagic (H). Pancreatic
tissue becomes necrotic and
may become semi-liquid.
b: fat necrosis seen as white
spots (F) in mesenteric and
retroperitoneal fat.
Histologically these foci are
composed of necrotic adipose
tissue, with adjacent reactive
inflammation.
50. At the center of your being you
have the answer; you know
who you are and you know
what you want!
Lao Tzu
51. MB4-T2-Wk4-Biliary system
CPC 2.7- Mr J.M. 51y, depression.
Mr J.M. 51 year old High School principal in
Townsville.
Several months - stress, anxiety and depression.
Treatment for this with anti depressants and
cognitive behavior therapy has been reasonably
successful although he remains stressed.
makes an earlier appointment.
„His trousers are hanging off him. No appetite. my
ankles have been a bit swollen recently.
Could not walk…. Too tired…!
Epigastric intermittent pain.
„Bit dark urine … recently‟
52. MB4-T2-Wk4-Biliary system
Chronic Pancreatitis:
Clinical:
• Painful, relapsing, inflammation, fibrosis & exocrine atrophy.
Cystic/atrophic ducts.
• Irreversible loss of pancreatic function *
• Malabsorption, albumin, wt. loss – Exocrine
• Type I DM – Endocrine loss.
• Recurrent obstructive Jaundice – obstruction.
Causes:
• Toxic metabolic- 70%: Alcohol, Hyperlipidaemia, toxins, drugs,
hypercalcaemia.
• Idiopathic-20%: Early/Late.
• Others: Genetic, autoimmune, Post necrotic.
Complications:
• Pseudocyst, Calcification, lithiasis & Carcinoma.
54. MB4-T2-Wk4-Biliary system
Chronic fibrosing Pancreatitis:
Duodenum
Fibrosis
pancreas (P) is atrophic and replaced by rubbery, fibrous tissue, in which dilated
ducts (D) are seen (Clinically by ERCP). In many cases calculi are present in the
dilated ducts. In this example the duodenum is attached (A).
61. MB4-T2-Wk4-Biliary system
Pancreatic Cancer
Increasing in incidence.
4th common (next to Colon Ca).
10-15 per 100 000, more with age >70y.
Men are affected twice as often as women.
Unknown etiology,
Several Risk factors Smoking, Diabetes & Diet.
• High calorie, fat, meat, salt, fried, soy beans & nitrosamines.
Also increased incidence in Hereditary pancreatitis,
MEN, hereditary non-polyposis colon cancer-HNPCC.
62. MB4-T2-Wk4-Biliary system
Pancreatic Cancer
Adenocarcinoma fibrosis stricture, Obstructive
jaundice & weight loss.
Advanced disease at presentation. Poor
prognosis. 85% only palliative care.
Palpable gallbladder + jaundice Ca Pan
(Courvoisier's sign).
diabetes (due to ß cell destruction)
Depression*,
Migratory thrombophlebitis - Trousseau's
67. MB4-T2-Wk4-Biliary system
Ca Pancreas & Depression
Cancer pancreas has a reputation of being a deadly and
often painful disease, with very poor prognosis.
Depression and anxiety occur more frequently
Depression and anxiety may even precede symptoms or
knowledge of the diagnosis.
The etiology of depression in patients with cancer of the
pancreas may be traced to more than the disease's
symptoms.
Steve Jobs
68. A scholar who cherishes the
love of comfort is not fit to be
deemed a scholar.
Lao Tzu
69. Give someone a fish and you
feed him for a day.
Teach someone to fish and you
feed him for a lifetime!
Lao Tzu
70. MB4-T2-Wk4-Biliary system
Acute Pancreatitis: Summary
Gross: Inflammation,
Hemorrhages (red arrows)
and chalky white areas of fat
necrosis (white arrows).
Microscopy: Hemorrhage,
Acute inflam, fat necrosis.
Complications:
Mechanisms: Obstruction, Acinar damage, Enzyme anomaly.
Pathogenesis: Activation of enzymes in the acini/ducts
autodigestion Fat necrosis Ca+ soap + inflammation.
74. MB4-T2-Wk4-Biliary system
5 A‟s & SNAP
74
• Ask: 1. patients with diabetes, hypertension,
hyperlidaemia, obesity or existing vascular disease
• Assess: 2.Number of cigarettes or equivalent/day,
Dependance 3.readiness to change/motivation
• Advise: 4.provide written information, 5.motivational
interviewing
• Assist: 6.NRT ? Bupropion(Zyban) 7.Support
• Arrange: 8.referral to QUIT 9.follow up with the GP
SNAP Counseling: Smoking, Nutrition, Alcohol &
Physical Activity.
75. MB4-T2-Wk4-Biliary system
Acute Pancreatitis: Clinical Features
Mild (edema) & Severe (Hemorrhagic) forms.
Constant severe epigastric pain radiating to the back
Fever, Nausea and/or vomiting
Respiratory & circulatory failure
DIC, Shock, Fat necrosis, hemorrhage.
Abdominal tenderness, distension, guarding, and rigidity,
Mild jaundice,
Diminished or absent bowel sounds.
Hypocalcemia, High Amylase-P (early)
High Lipase >24h – (only lipase ↑ in chronic)
CT Scan – diagnostic.
? Grey Turner‟s sign ? Cullen‟s sign
76. MB4-T2-Wk4-Biliary system
“acute abdomen” Differential Diagnosis:
Acute Pancreatitis: medical emergency of
the first magnitude.
Multiorgan failure – fatal.
Differential diagnosis:
• Perforated acute appendicitis.
• Perforated Acute diverticulitis.
• Perforated peptic ulcer.
• Acute cholecystitis & Rupture.
• Infarction of the bowel.
• Intestinal Obstruction.
77. MB4-T2-Wk4-Biliary system
Acute Pancreatitis: Principles of Lab Diagnosis:
Full blood count: neutrophil leukocytosis.
Serum amylase: greatly elevated.
Serum Lipase: Elevated after 24h. (72-96h)
Serum albumin: falls (severe inflam. Exud)
Serum calcium: falls - Complex with necrotic Fat.
Blood sugar: hyperglycemia if severe – loss of
endocrine part.
Alkaline phosphatase: mild elevation obstruction of
lower end of bile duct (gall stone)
Bilirubin: mild direct Bil, oedema & obstruction of lower
end of bile duct.
78. MB4-T2-Wk4-Biliary system
CPC 4.2.7- May, 35y woman.
May, 35y, indigenous woman, lives in a remote
Aboriginal community. After hour visit…
“I’ve got terrible gut pains”, since 2h.
Students must specifically ask about…?
Alcohol, DM.. (PUD, IHD, Gall bl, Drugs)
Tenderness & guarding in epigastrium.
Absent bowel sounds.
Social & family History of alcohol abuse.
Diabetes not well controlled.
79. MB4-T2-Wk4-Biliary system
CPC 4.2.7- May, 35y woman.
Differential diagnosis
Perforated ulcer, Acute Gastro-enteritis,
/infarction, pancreatitis, gall bladder
disease, peptic ulcer.
• Heart – MI
• Lung – pleurisy, PE,
FBC (Hb 132, WCC 21.9), RFT (Na 136,
urea 6.1, creatinine 0.07, Ca 1.8)
AXR, USG, CXR, ECG, Lipase- 2400 U/L
Amylase* lipase *
80. MB4-T2-Wk4-Biliary system
Pancreatic Cancer
Pleomorphic glands (A) in a densely
fibrotic (desmoplastic) stroma (B)
Section of head of pancreas showing
an ill-defined mass in the pancreatic
substance (arrowheads) and the green
discoloration of the CBD due to
obstruction of bile flow
A
B
81. MB4-T2-Wk4-Biliary system
Silence…
81
To the question "Who am I?" the only relevant answer is silence. You
need to discard all answers in words, including "I am Nothing" or "I
am the Cosmic Self" or "I am the Self" - and just stick to the question
"Who am I?". All other answers are just thoughts. Thoughts can
never be complete. Only Silence is complete.
Thoughts are not the goal in themselves. Their goal is Silence. When
you ask the question "Who am I?" you get no answer, there is
silence. That is the real answer. For your soul is solidified silence.
This solidified silence is wisdom, is knowledge.
The easy way to silence the thoughts is to arouse the feelings. For,
through feelings only peace, joy and love dawn. And they are all
your very nature.
- Sri Sri Ravishankar