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Biliary Tract and Pancreas

Biliary Tract and Pancreas

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Published by: sarguss14 on Dec 05, 2008
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General PathologyBiliary Tract and Pancreas1 December 07
 
Biliary TractBile
Two major functions
o
Elimination of bilirubin, excess cholesterol, andxenobiotics that are insufficiently water soluble to beexcreted in urine
o
Emulsification of dietary fat in the gut by bile acids(cholic acid, chenodeoxycholic acid)Unconjugated → ConjugatedReabsorbed in terminal ileum (enterohepatic circulation)
Cholestasis
Systemic retention of not only bilirubin but also other soluteseliminated in bile, particularly bile salts and cholesterol
Due to hepatocellular dysfunction or biliary obstructionAccumulation of bile pigment within the hepatic parenchyma – Kupffer cellsBile ductular proliferationBile lakesPortal tract fibrosis
Secondary Biliary Cirrhosis
Most common cause is extrahepatic cholelithiasisBiliary atresia, malignancies of the biliary tree and head of the pancreas, and stricturesCholestasisBile duct proliferation with surrounding neutrophilsPeriportal fibrosis
Primary Biliary Cirrhosis
Middle-aged womenM:F = 1:10Possibly autoimmune
o
Autoantibodies to mitochondrial pyruvatedehydrogenase 90%Insidious onset, usually presenting with pruritusHyperbilirubinemia, jaundice, cirrhosis late↑ alkaline phosphatase, cholesterol
Figure 1-Nonsuppurative, granulomatous destruction of medium-sized intrahepatic bile ducts = florid duct lesion
 Primary Sclerosing Cholangitis
Inflammation, obliterative onion-skin fibrosis, and segmentaldilatation of the obstructed intrahepatic and extrahepatic bileductsString of beads on ERCP70% associated with inflammatory bowel disease,particularly ulcerative colitisM:F = 2:1, third through fifth decadesProgressive fatigue, pruritus, jaundiceChronic courseIncreased risk for cholangiocarcinoma
Cholelithiasis
Very commonCholesterol stones
o
Bile is supersaturated with cholesterol
o
Gallbladder stasis
o
F>M
o
Obesity
o
Advancing agePigment stones – calcium bilirubinate salts
o
Asian more than Western
o
Chronic hemolytic syndromes
Clinical Features
 
o
Asymptomatic
o
Biliary colic
o
Cholecystitis
o
Gallstone ileus
 
General Pathology –
Biliary Tract and Pancreas
by 
VGY 
Page
2
of 10
Cholecystitis
Acute calculous
o
Obstruction of GB neck or cystic duct
o
RUQ pain radiating to right shoulder 
o
Fever, nausea, leukocytosis
o
Potential surgical emergencyAcute acalculous – seriously ill ptsChronic
o
Recurrent attacks of pain
o
Nausea and vomiting
o
Associated with fatty meals 
Choledocholithiasis
Stones within the biliary treeWest from gallbladdeAsia – primary ductal and intrahepatic stone formationSymptoms due to:
o
Biliary obstruction
o
Pancreatitis
o
Cholangitis
o
Hepatic abscess
Cholangitis
Acute inflammation of bile ductsDue to biliary obstruction, usually choledocholithiasisBacterial infection from gut, i.e., gram negative aerobes
o
Fever, chills, abdominal pain, jaundiceLatin America and Near East: Fasciola hepatica,schistosomiasisFar East: Clonorchis sinensis, Opisthorchis viverriniAIDS: cryptosporidiosis
Biliary Atresia
1/3 of cases of neonatal cholestasis1 in 10,000 live birthsComplete obstruction of bile flow caused by destruction or absence of all or part of the extrahepatic bile ductsAcquired inflammatory disorder Normal stools to acholic stoolsBile ductular proliferation on liver bxCirrhosis by 3 to 6 months of age.Require liver transplantation
Gallbladder Carcinoma
Seventh decadeF>MDiscovered at late stage, usually incidentalExophytic and infiltrating typesAdenocarcinomaLocal extension into liver, cystic duct, portahepatic LNsMean 5 yr survival 1% 
Cholangiocarcinoma
Older ptsM>FPainless jaundice, N/V, weight lossOpisthorchis sinensis (liver fluke),inflammatory boweldiseaseTumors usually small at dx yet not resectableKlatskin tumor – arises at bifurcationAdenocarcinomaMean survival 6 to 18 months
 
General Pathology –
Biliary Tract and Pancreas
by 
VGY 
Page
3
of 10
 PancreasBrief History
Herophilus, Greek surgeon first described pancreas.Wirsung discovered the pancreatic duct in 1642.Pancreas as a secretory gland was investigated by Graaf in1671.R. Fitz established pancreatitis as a disease in 1889.Whipple performed the first pancreatico-duodenectomy in1935 and refined it in 1940.
Pancreas
Gland with both exocrine and endocrine functions6-10 inch in length60-100 gram in weight
Location: retro-peritoneum*, 2
nd
lumbar vertebral levelExtends in an oblique, transverse positionParts of pancreas: head, neck, body and tail
Embryology
Endodermal originDevelops from ventral and dorsal pancreatic budsVentral bud becomes the uncinate process and inferior headof pancreasDorsal bud becomes superior head, neck, body and tailVentral bud duct fuses with dorsal bud duct to become mailpancreatic duct (Wirsung)
Head of Pancreas
Includes uncinate process
Flattened structure, 2 – 3 cm thick
Attached to the 2
nd
and 3
rd
portions of duodenum on theright
Emerges into neck on the left
Border b/w head & neck is determined by GDA insertion
SPDA and IPDA anastamose b/w the duodenum and the rt.lateral border 
Neck of Pancreas
2.5 cm in length
Straddles SMV and PV
Antero-superior surface supports the pylorus
Superior mesenteric vessels emerge from the inferior border 
Posteriorly, SMV and splenic vein confluence to form portalvein
Posteriorly, mostly no branches to pancreas
Body of Pancreas
Elongated, long structure
Anterior surface, separated from stomach by lesser sac
Posterior surface, related to aorta, lt. adrenal gland, lt. renalvessels and upper 1/3
rd
of lt. kidney
Splenic vein runs embedded in the post. Surface
Inferior surface is covered by tran. mesocolon
Tail of Pancreas
Narrow, short segment
Lies at the level of the 12
th
thoracic vertebra
Ends within the splenic hilum
Lies in the splenophrenic ligament

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