Pancreaticobiliary System

Biliary System

refers to the organs and ducts that contribute to the production and transport of bile into the duodenum to aid in digestion

Biliary organs

GALLBLADDER, liver, pancreas

Ductal systems associated with the biliary system

hepatic ducts, cystic duct, common bile duct, pancreatic duct

Liver location

upper-right quadrant of the torso, immediately below the diaphragm, and is on top of the stomach, right kidney and intestines

Liver

largest organ in the body, weighs 3-4lbs

Glisson's capsule

tough fibrous tissue that completely covers the liver. contains blood vessels and lymphatics. also contains pain receptors

Portal vein

large vein that brings blood to the liver

Blood flow (Portal Circulation)

esophagus, stomach, spleen, intestines --> portal vein --> liver --> hepatic portal vein --> inferior vena cava --> right side of heart

Hepatic artery

oxygenated blood flows directly from the heart to the liver

At any given moment the liver holds about ___ of the body's total blood volume

1/3

The ___ lobe of the liver is ___ times larger than the ___

right; 6; left

Lobules

hexagonally-shaped functional units of the liver arranged in layers that radiate from the central vein; lobules are connected to small ducts that connect to larger ducts that ultimately form the hepatic duct

Portal triad

distinctive arrangement in the liver; a component of lobules; each segment has: a vein, an artery and cystic duct

Path of bile and wastes from liver

flow into a vast network of intrahepatic cuts that become larger in size and eventually form the right and left hepatic ducts which merge into the common hepatic duct

Common Bile Duct empties

bile into the duodenum

Liver's primary functions

bile formation, metabolism, vitamin storage, manufacturing anticoagulant and coagulant substances and detoxification

Liver can lose ___ of its cells before it stops functioning

3/4
only organ in the body that can regenerate itself

Common symptoms of liver disease:

jaundice, cholesthasis, hepatomegaly, portal hypertension, ascites, liver encephalopathy

jaundice

a yellow discoloration of the skin and eye whites due to abnormal high levels of bilirubin (brownish/yellow substance found in bile)

cholesthasis

reduced or stopped bile flow; can be caused by hepatitis, stone in bile duct, bile duct cancer, pancreatic cancer

hepatomegaly

liver englargement

portal hypertension

abnormal high pressure in the portal vein that may be due to increased resistance of blood flow through the liver

ascites

fluid build up in the abdominal cavity caused by fluid leaks from the intestine - often associated with portal hypertension

liver encephalopathy

deterioration of brain function due to accumulation of toxic substances that are normally removed by the liver

acute liver disease

occurs when the causation coincides with the symptoms; ex: Hepatitis A - caused by contaminated food and the patient feels violently ill almost immediately - one treated, 6 months until disease free

chronic liver disease

marked by the gradual destruction of the hepatocytes over a period of time; damaged tissue cannot carry out the normal liver functions, the production of proteins and substances is inhibited; also, the blood flow and purification process is altered; death

primary schlerosing cholangitis (PSC)

rare disease in which the bile ducts - both inside and outside the liver- become inflamed resulting in scarring and hardening (fibrosis) that narrows the bile ducts; in most cases PSC leads to cirrhosis, portal hypertension and liver failure; unknown caus

Cholaniocarcinoma may develop in __ - __% of PSC patients

7-15%

Cirrhosis

scarring of the liver; chronic liver disease; C: excessive alcohol consumption, hepatitis, use of certain drugs, chemical exposure, autoimmune disease, diabetes, malnutrition, wilson's disease (too much copper), hemochromatosis (too much iron)

Hepatitis

inflammation of the liver, usually caused by exposure to an infection agent; can be acute or chronic (chronic if disease lasts more than 6 months)

5 Types of Hepatitis Viruses

Hep A, Hep B, Hep C, Hep D, Hep E

Hepatitis A (HAV)

spread primarily through food or water contaminated by stool from an infected person; causes swelling of the liver, but it rarely causes lasting damage; S: feel as if have the flu or no symptoms at all; usually gets better on its own after several weeks

Hepatitis B (HBV)

spreads by contact w an infected person's blood, semen or other bodily fluid. (also woman to baby at birth); S: feel as if have the flu or no symptoms at all; Blood test confirms virus; usually gets better on its own- if not, called chronic HBV, which las

Chronic HBV

Lasts a lifetime; can lead to scarring of the liver, liver failure, or liver cancer

Hepatitis C (HCV)

spread through contact w infected blood; also through sex w infected person or mother to baby; most people do not have symptoms for years; infection can last a lifetime and may lead to liver cancer; medicines sometimes help; serious cases may need a liver

Health experts estimate ___ million people worldwide have chronic Hep C; ___ million in the US

180 million; 4 million in US

Hepatitis C Virus causes chronic infection in more than ___ percent of infected people

85%

Hepatitis D

usually occurs in conjunction w Hep B infection

Hepatitis E

similar to A, prevalent in developing countries

Primary liver cancer symptoms

Pain or discomfort in the right upper abdomen, jaundice, weight loss, distention of the abdomen; MIGHT BE NO symptoms at all in the early stage

Most common type of primary liver cancer

Hepatocellular carcinoma (HCC)

Hepatocellular carcinoma (HCC)

most common type of primary liver cancer; accounts for 80-90% of liver cancers; occurs more in men than women, usually in people 50-60 years old; C: usually cirrhosis

How is diagnosis of primary liver cancer usually made?

blood test, ultrasound, CAT scan, MRI scan;
may also include a biopsy of the tumor itself

Only ___-___% of HCC can be removed completely using surgery

10-20%; chemotherapy and radiation are usually not effective but may be used to shrink large tumors so that surgery has a greater chance of success

If the HCC cannot be completely removed, the disease is usually deadly in ___ to ___ months

3-6 months

Cancer affecting the liver is more commonly ____

metastatic cancer from the colon, lung, breast

Cholaniocarcinomas

account for 1 or 2 out of every 10 cases of liver cancer; these cancers start in the bile ducts

Of those diagnosed with colorectal cancer ___% will have metastatic lesions to the liver, however only ___% will be candidates for synchronous resection

25%, 10%

Ocular Melanoma

rare cancer of melanocytes (cells that produce the pigment melanin) found in the eye; most common site of metastasis is the liver

Pancreas location

lies behind the stomach and is approximately 15-20cm long and 5 cm wide

Ampulla of Vater

formed at the union of the pancreatic duct and the common bile duct; specifically is located at the duodenal pill of Vater/sphincter of Oddi

Sphincter of Oddi

a complex set of muscles that regulate the flow of bile and pancreatic juices into the duodenum, prevent bile from entering the pancreatic duct and prevent intestinal contents from entering the biliary system; if gallbladder is removed the sphincter of Od

Major functions of the pancreas

produce digestive enzymes to aid in digestion of fats and proteins, control the amount of sugar in the blood by producing insulin and other hormones; Endocrine and exocrine glands

Exocrine glands

make up the majority of the pancreas, produce digestive enzymes to aid in digestion of fats and proteins; these enzymes (500-1000ml/day) flow through the pancreatic duct to join the common bile duct to drain through the ampulla into the duodenum

In ___% of people the pancreatic duct joins the common bile duct to drain through the ampulla

93%

Pancreatic divisum

In 7% of the population the common bile duct and the pancreatic duct do not join together and instead enter the ampulla separately

Endocrine glands

Found in the pancreas; control the amount of sugar in the blood by producing insulin and other hormones; these products are released directly into the circulation

Pancreatitis

inflammation of the pancreas (acute and chronic)

Acute Pancreatitis

occurs suddenly/lasts for a short period of time ~3-4 days; usually caused by gallstones or by drinking too much alcohol over time; S: pain in the abdomen, nausea, vomiting, fever, rapid pulse

Approximately ________ cases of acute pancreatitis occur in the US each year and about ___% of the cases lead to severe damage of the pancreas

80,000 ; 20%

Complications that may result from acute pancreatitis:

pancreatic necrosis (parts of the pancreas become dead), pancreatic abscess, pseudocysts (accumulations of fluid and tissue debris around the pancreas), pancreatic fistula, enzymes and toxins enter the bloodstream injuring the heart, lungs and kidneys

Chronic pancreatitis

occurs when digestive enzymes attack and destroy the pancreas and nearby tissues, causing scarring and pain; does not resolve fully and results in slow destruction of the pancreas; C: usually many years of alcohol abuse, but may be triggered by only one a

Complications that may result from chronic pancreatitis

diabetes mellitus, poor absorption of nutrients from the digestive tract (especially fats), cancer of the pancreas, blockage of bile ducts, pseudocyst

Gallstone pancreatitis

an inflammation of the pancreas caused by the obstruction of the ampulla of Vater or a biliary stone

Pancreatic cancer/ Adenocarcinoma of the pancreas

4th leading cause of cancer deaths in men/women in the US; C: unknown, S: loss of appetite, weight loss, abdominal discomfort, nausea and jaundice; Surgical resection is usually the best chance for cure; studies indicate that stents may be an effective pa

Risk factors for developing pancreatic cancer

Obesity, smoking, hereditary history, increase in age, diabetes and chemical exposure

Only ___ to ___% of pancreatic cancer patients are considered surgical candidates

15-20%

Intraductal papillary-mucinous tumors (IPMT)/ Intraductal pancreatic-mucinous tumors (IPMT)

develops in the cell lining of the main pancreatic duct; these tumors secrete a large amount of mucous and cause the pancreatic duct to dilate and obstruct the flow of pancreatic juices to the duodenum. IPMT may give the appearance of cysts; S: abdominal

Gallbladder

non-essential organ; approximately 7-10cm in length and 2.5-3.5 in width; capable of holding up to 50 ml of bile

Bile

a greenish-yellowish fluid comprised of mainly water (97%), bile salts and fatty acids when originally produced by the liver

The bile stored in the gallbladder is concentrated to about ___ of its original volume

1/5

As the bile is secreted from the gallbladder, it flows through the ___

cystic duct

The cystic duct joins with the _____ to form the ____

common hepatic duct, common bile duct

Common bile duct

begins at the bifurcation (division into two branches) of the cystic duct and the common hepatic duct; extends downward until it joins with the main pancreatic duct to form the ampulla of Vater

From the common hepatic duct bile can flow (2 places)

1. to the common bile duct which empties into the duodenum
2. to the cystic duct where it then flows upward in a retrograde path into the gallbladder

Primary function of the gallbladder

store and regulate the amount of bile released into the duodenum

Primary functions of bile

aid in the digestion of fats, help neutralize gastric acids in the duodenum

How much bile is produced by the liver daily

1/2 to one full liter

Cholelithiasis

presence or formation of gallstones in the gallbladder; accounts for 90% of biliary system disease; ~1 million new cases each year and half of those undergo biliary surgery; has been linked to gallbladder cancer

2 types of gallstones

cholesterol stones and pigment stones

cholesterol stones

make up over 50% of all gallstones; form when bile secreted by the liver is supersaturated with cholesterol

risk factors for the formation of gallstones

increase in age, ethnic and hereditary factors, obesity, diabetes, liver cirrhosis, long-term IV nutrition and spinal cord injury

Biliary colic

right upper abdominal pain that feels like cramping

Symptoms of cholelithiasis (typically present after a stone larger than 8mm moves through or becomes lodged in the biliary ducts causing obstruction)

biliary colic, acute cholecystitis

Potential complications of cholelithiasis

cholangitis, perforation of the gallbladder, gangrene and hepatic damage

Choledocholithiasis

presence or formation of stones in the common bile or hepatic ducts

Stones that form in the common bile duct are always ___ stones

Pigment

Cholangitis

inflammation of the bile duct due to bacterial infection; usually caused when the duct is obstructed by a gallstone, stricture or tumor; treatment includes antibiotic therapy and ERCP to drain the obstructed bile ducts; placement of a biliary stent within

Potential complications of choledocholithiasis

biliary colic, obstructive jaundice and acute gallstone pancreatitis

cholecystitis

an acute or chronic inflammation of the gallbladder, usually caused by an obstruction of the biliary ducts by gallstones; occurs more often in women than men and incidence increases after the age of 40; S: abdominal pain in upper right side, nausea, vomit

chronic cholecystitis

caused by repeated mild attacks of acute cholecystitis; may eventually lead to the thickening of the walls of the gallbladder=gallbladder shrinks and eventually loses its ability to properly function

Extrahepatic bile duct cancer

rare adenocarcinoma found in the extra hepatic bile duct. Associated with long-standing ulcerative colitis, Crohn's disease and primary sclerosing cholangitis; S: painless obstructive jaundice; 30% have gallstones

Cholangiocarcinoma

adenocarcinoma of the bile ducts; can occur anywhere within bile ducts, however most common in the hepatic ducts or the ampulla; S: loss of appetite, weight loss, abdominal discomfort, nausea and jaundice; surgical resection is best chance for cure

How is cholangiocarcinoma most often diagnosed

during a laparotomy for another biliary system disease or during a diagnostic procedure to determine the level and cause of a biliary obstruction; at time of diagnosis most tumors have locally spread or metastasized

Risk factors of cholangiocarcinoma

hereditary, age and pre-existing congenital abnormalities of the bile duct

Klatskin's tumor

a cholangiocarcinoma of the common hepatic duct bifurcation (split into two branches); tumor may involve one or both right/left hepatic ducts; generally small tumors, sharply localized and seldom metastasizing; S: jaundice and/or abnormal liver tests

Gallbladder cancer

adenocarcinoma found in the gallbladder; relatively rare and occurs in women more than men; S: very delayed and once appear resemble those of other gallbladder diseases, liver cancer or pancreatic cancer; ~80% of patients with gallbladder cancer have gall

Risk factors for Gallbladder cancer

primary sclerosing cholangitis, ulcerative colitis and cirrhosis, previously having gallstones or polyps in the gallbladder

5 year survival rate for gallbladder cancer

5% (typically by time of diagnosis patients have less than a year)

Ampullary cancer

adenocarcinoma that develops in the ampulla; obstructs flow of bile and causes jaundice => earlier detection than pancreatic cancers