Gallbladder and Pancreas
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Gallbladder
Anatomy and physiology
Calculous biliary disease
Benign acalculous biliary disease
Malignant biliary disease

Pancreas
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Anatomy, embryology and histology
Physiology
Pancreatitis
Neoplasms

Calculous Biliary Disease
 Incidence age and sex related
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More common in females
Incidence increases with age
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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
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Gram negatives
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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
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Anatomy, embryology and histology
Physiology
Pancreatitis
Neoplasms

Pancreatic Physiology

Acute Pancreatitis
 Alcohol
 Gallstones
 ERCP
 Drugs
 Pancreas divisum
 Idiopathic
Causes

Ranson’s Prognostic Signs (Gallstone Pancreatitis) Admission
Initial 48 hours
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Age > 70
WBC > 18K
Glucose > 220 mg/dl
LDH > 40 IU/L
AST > 250 U/dl
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Hct < 10
BUN rise > 2 mg/dl
CA 2+ < 8 mg/dl
Base deficit >5 mEq/L
Fluid > 4L

Ranson’s Prognostic Signs (Alcoholic Pancreatitis) Admission
Initial 48 hours
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Age > 55 yrs
WBC > 16 K
Glu > 200 mg/dl
LDH > 350 IU/L
AST > 250 U/dl
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Hct fall > 10
BUN rise > 5 mg/dl
Ca 2+ < 8 mg/dl
PaO
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< 55 mg/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
 4 th 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
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