Diagnosis of the biliary tract and the pancreas 3 -...

THE DIAGNOSIS OF BILIARY

TRACT AND PANCREATIC

DISEASES

László Kalabay MD PhD

The entoero-

hepatic

circulation of

bilirubin

Blood(plasma)

hemoglobin (70%)other heme

proteins (30%)

Intestinal

lumenRES

verdoglobin

biliverdin

bilirubinbilirubin

mesobilirubin

urobilinogenstercobilinogen

LIVERbilirubin-glucuronide

0.5 mg%

Biliary tract

Portal vein

Hemorrhoidal veins

Kidney

Urine Stoolurobilinogenurobilin

approx. 4 mg/day

stercobilinurobilin

approx. 200 mg/day

The hepatobilary tree

Source: Images MD

Characteristics

of pain of

acute

abdomen

Source: Szabó Sz. et al. Családorvosi Fórum 2002/1_2-8. (2002)

CholelithiasisSymptoms

• Predisposing factors: 3F: female, fat, forty/fifty

• Occur following fatty meal

• Typically crampy pain n in the right upper quadrant, radiating to the

tip of the scapula

Laboratory findings

• Signs of inflammation, more expressed when cholecystitis is

present. elevated ESR, CRP, leukocytosis with the shift to the left

• Signs of obstruction only in choledocholithiasis

Treatment

• Cholecystectomy (laparoscopic preferred), in case of cholecystitis:

antibiotics (amoxicillin, metronidazole)

Complications

• Acute and chronic cholecystitis (gallbladder cc!)

• Choledocholithiasis, biliary tract obstruction

• Hydrops, empyema

• Perforation of the cholecyst

• Gallstone ileus

Acute cholecystitis

Symptoms

• as above + fever, chills

Laboratory findings

• Elevated ESR, CRP, leukocytosis with the

shift to the left

Treatment

• Cholecystectomy (emergency or elective)

• Antibiotics (amoxicillin, metronidazole)

Choledocholithiasis

Symptoms

• Typical pain + jaundice, dark urine, clay-like stool

Laboratory findings

• Direct hyperbilirubinemia, elevated serum alkaline phosphatase,

(less elevated serum transaminases)

• Usually signs of inflammation (ESR, CRP, leukocytosis)

Differential diagnosis

• Other causes of biliary tract obstruction: cholanciocarcinoma, Vater

papilla sclerosis or carcinoma, primary sclerotizing cholangitis

• Courvoisier’s sign: jaundice with painless palpable gallbladder

Therapy

• Surgical: choledochotomy, cholecystectomy

• ERCP

Diagnostic evaluation of the gallbladder 1

Diagnostic advantages Diagnostic limitations Comment

Plain abdominal X-ray

Low cost

Readily available

Relatively low yield

?Contraindicated in

pregnancy

Pathognomic findings:

calcified gallstones,

limey bile, porcelain

gallbladder,

emphysematous

cholecystitis, gallstone

ileus

Gallbladder ultrasound (USG)

Rapid; Accurate

identification of gallstones

(>95%); Simultaneous

scanning of gallbladder,

liver, bile ducts, pancreas;

„Real-time” scanning allows

assessment of gallbladder

volume, contractility; May

detect very small stones

Bowel gas, massive

obesity, ascites,

recent barium study

Not limited by

jaundice, pregnancy

Procedure of choice to

detect stones

Source: Harrison's Principles of Internal Medicine 18th Ed. McGraw-Hill 2012

Diagnosis of stone disease by ultrasound

Source: Images MD

Diagnostic evaluation of the gallbladder 2

Diagnostic

advantages

Diagnostic limitations Comment

Radioisotope scans (HIDA, DIDA, etc.)

Accurate

identification of

cystic duct

obstruction

Simultaneous

assessment of bile

ducts

?Contraindicated in

pregnancy

Se Bi >103-205 uM/L

Cholecystogram low

resolution

Indicated for

confirmation of

suspected acute

cholecystitis

Less sensitive and less

specific in chronic

cholecystitis

Useful in diagnosis of

acalculous

cholecystopathy, esp. if

given with CCK to

assess gallbladder

emptying


Healthy subject compared with patient with

cholelithiasis

Source: Images MD

Diagnostic evaluation of the bile ducts 1

Diagnostic

advantages

Diagnostic

limitations

Contra-

indications

Compli-

cations

Comment

Hepatobiliary ultrasound (USG)

Rapid;

simultaneous

scanning of

gallbladder,

liver, bile

ducts,

pancreas

Bowel gas,

massive

obesity,

ascites,

barium, portal

bile duct

obstruction

Poor

visualization of

distal common

bile duct

None None Initial

procedure of

choice in

investigating

possible

biliary tract

obstruction


Ultrasonography of duct stones is not as reliable

as of those in the bile duct

Source: Images MD


Diagnostic

advantages

Diagnostic

limitations

Contra-

indications

Compli-

cations

Comment

Computer tomography (CT)

Simultaneous

scanning of

gallbladder, liver,

bile ducts,

pancreas

Accurate

identification of

dilated bile ducts,

masses

Not limited by

jaundice, gas,

obesity, ascites

High-resolution

image

Guidance for

fine-needle

biopsy

Extreme

cachexia

Movement

artifact

Ileus

Partial bile tract

obstruction

High cost

May not be

readily available

Pregnancy Reaction to

iodinated

contrast, if

used

Indicated for

evaluation

of hepatic or

pancreatic

masses

Procedure

of choice in

investigating

possible

biliary

obstruction

if diagnostic

limitations

prevent

USG


CT of the biliary tract: choledocholithiasis (left) and

gallbladder carcinoma with local invasion and a

separate metastasis near a percutaneous

transhepatic biliary stent (right)

Source: Images MD


Diagnostic advantages Diagnostic

limitations

Contra-

indications

Compli-

cations

Comment

Magnetic resonance cholagiopancreatography (MR)

Useful modality for

visualizing pancreatic and

biliary ducts

Can identify pancreatic

duct dilatation or stricture,

pancreatic duct stenosis,

and pancreas divisum

Has excellent sensitivity

for bile duct dilatation,

biliary stricture, and

intraductal abnormalities

Cannot

offer

therapeutic

intervention

Some metal

alloy

implants


MR of the biliary tract: choledocholithiasis (left),

cholangiocarcinoma surrounding the middle

hepatic vein and a second lesion posteriorly and

medially near the spine (right)

Source: Images MD


Diagnostic

advantages

Diagnostic

limitations

Contra-

indications

Compli-

cations

Comment

Endoscopic retrograde cholangiopancreatogram (ERCP)

Simultaneous

pancreatography

Visualization/biopsy

of ampulla and

duodenum

Best visualization of

distal biliary tract

Bile or pancreatic

cytology

Endoscopic

sphincterotomy and

stone removal

Biliary manometry

Not limited by

ascites,

coagulopathy,

abscess

Gastroduodenal

obstruction

?Roux en Y

biliary-enteric

anastomosis

Pregnancy

Acute

pancreatitis

?Severe

cardiopulmonar

y disease

Pancreatitis

Cholangitis,

sepsis

Infected

pancreatic

pseudocyst

Perforation

(rare)

Hypoxemia,

aspiration

Cholangiogram

of choice in:

Absence of

dilated ducts

?Pancreatic,

ampullary or

gastroduodenal

disease

Prior biliary

surgery

PTC

contraindicated

or failed

Endoscopic

sphincterotomy

a treatment

possibility


ERCP: choledocholithasis

(top left), patent

pancreatic and occluded

common bile duct (bottom

left) and long stricture of

the common hepatic duct

(bottom right)

Source: Images MD

Sphincterotomy and stone extraction of common bile duct

stones

Source: Images MD


Diagnostic

advantages

Diagnostic

limitations

Contra-

indications

Compli-

cations

Comment

Percutaneous transhepatic cholangiogram (PTC)

Extremely

successful when

dilated ducts are

dilated

Best visualization

of proximal biliary

tract

Possible separate

visualization of

obstructed left

ductal system

Bile

cytology/culture

Percutaneous

transhepatic

drainage

Nondilated or

sclerosed

ducts

Pregnancy

Uncorrectable

coagulopathy

Massive

ascites

Hepatic

abscess

Bleeding

Hemobilia

Bile peritonitis

Bacteremia,

sepsis

Largely

replaced by

CT and

MRI

Usually

initial

cholangio-

gram of

choice

when bile

ducts are

dilated


Percutaneous

transhepatic

cholangiography

(PTC): extensive

perihilar

cholangiocarcinoma

with extension into

secondary

intrahepatic

branches

Source: Images MD

The diagnosis of pancreatic diseases -

general considerations

• Relative inaccessibility to direct examination and nonspecific nature of abdominal pain

• >90 % of the pancreas must be damaged before maldigestion of fat and protein is manifested.

• Pancreatic exocrine function becomes abnormal only when >60% of exocrine function has been lost

• Acute pancreatitis: severe, constant epigastric, belt-like pain that radiates through to the back, along with an elevated blood amylase level

• Chronic pancreatitis: hypertriglyceridemia, vitamin B12 malabsorption, hypercalcemia, hypocalcemia, hyperglycemia, ascites, pleural effusion, and chronic abdominal pain with normal blood amylase levels.

Cullen’s sign in acute panrcreatitis

Source: Images MD

Peritoneal aspirates in acute pancreatitis

The color of the peritoneal aspirate of patients with acute pancreatitis can

differentiate mild from severe disease. The darker the color (caused by blood,

due to hemorrhagic pancreatitis), the greater the severity of the disease is.Source: Images MD

Fat necrosis

seen at

surgery

Acute

necrotizing

pancreatitis

Source: Images MD

Pancreatic enzymes in body fluids 1 (frequently used)

Test Principle Comment

Serum

amylase

Pancreatic inflammation

leads to increased

enzyme levels

Simple; 20-40% false positives

and negatives; reliable if test

results are 3 times the upper limit

of normal

Urine

amylase

Renal clearance of

amylase is increased in

acute pancreatitis

Inferquently used

Ascitic fluid

amylase

Disruption of gland or

main pancreatic duct

leads to increased

amylase concentration

Can help establish diagnosis of

acute pancreatitis; false positives

occur with intestinal obstruction

and perforated ulcer

Pleural fluid

amylase

Exudative pleural effusion

with pancreatitis

False positives occur with

carcinoma of the lung and

esophageal perforation

Serum

lipase


leads to increased

enzyme levels

Positive in 70-85% of cases


Causes of hyperamylasemia and hyperamylasuria

Pancreatic disease

• Acute and chronic pancreatitis

• Complications of pancreatitis:

pseudocyst, ascites, abscess,

necrosis

• Pancreatic trauma and cc.

Other abdominal disorders

• Biliary tract disease:

• Perforated or penetrating ulcer

• Intestinal obstruction or infarction

• Ruptured ectopic pregnancy

• Peritonitis

• Abdominal aneurysm

• Chronic liver disease

• Postoperative hyperamylasemia

Nonpancreatic diseases

• Renal insufficiency

• Salivary gland lesions: mumps,

calculus, irradiation sialadenitis,

maxillofacial surgery

• „Tumor” hyperamylasemia: lung,

esophagus breast, ovarian cc.

• Macroamylasemia

• Burns

• Diabetic ketoacidosis

• Pregnancy

• Renal transplantation

• Cerebral trauma

• Drugs: morphine


Pancreatic enzymes in body fluids 2 (rarely used)


Amylase

isoenzymes

P isoamylases arise from

the pancreas; S

isoamylases are from

other sources

More sensitive than total amylases

in diagnosis of acute pancreatitis;

useful in identifying nonpancreatic

causes of hyperamylasemia

Serum

trypsinogen


leads to increased enzyme

levels

Elevated in acute pancreatitis;

decreased in chronic pancreatitis

with steatorrhea; normal in chronic

pancreatitis without steatorrhea

and in steatorrhea with normal

pancreatic function

Pancreatic

polypeptide

(PP)

PP confined almost totally

to the pancreas; release

stimulated by nutrients

and hormones; such

release correlates with

pancreatic enzyme

secretion

Basal, meal- and hormone-

stimulated (by secretin or CCK) PP

levels decreased in chronic

pancreatitis; a fasting PP level >

125 pg/mL argues against chronic

pancreatitis and pancreatic cancer


Serum

trypsin levels

in chronic

pancreatitis

Source: Images MD

Morphological studies of the pancreas 1


Abdominal

plain film

Can be abnormal in

acute and chronic

pancreatitis

Simple; normal in > 50% of

cases of both acute and chronic

pancreatitis

Upper GI X-

rays

Now obsolete

Ultrasono-

graphy

(USG)

Can provide information

on edema, inflammation,

calcification,

pseudocysts, and mass

lesions

Simple, noninvasive; sequential

studies quite feasible; useful in

diagnosis of pseudocyst limited

by interference with bowel gas

CT scan Permits detailed

visualization of pancreas

and surrounding

structures, pancreatic

fluid collection,

pseudocyst, degree of

necrosis

Useful in the diagnosis of

pancreatic calcification, dilated

pancreatic ducts, and pancreatic

tumors; may not be able to

distinguish between

inflammatory and neoplastic

mass lesionsSource: Harrison's Principles of Internal Medicine 18th Ed. McGraw-Hill 2012

Pancreatic calcification on plain abdominal

radiograph

Source: Images MD

Barium studies of the GI tract to evaluate patients

with suspected pancreatic cancer

Source: Images MD

Pancreatic ultrasonography: calcification and

dilated, segmented pancreatic duct (left) and a

pseudocyst (right)

Source: Images MD

A CT scan of the pancreas indicating gas bubbles

within the substance of the pancreas

Source: Images MD

CT: diffuse pancreatic calcification (left) and a

pseudocyst in the head of the pancreas (right)

Source: Images MD



Endoscopic

retrograde

cholangio-

pancreatography

(ERCP)

Cannulation of pancreatic

and common bile duct

permits visualization of

pancreatic-biliary ductal

system

Provides diagnostic

data in 60-85% of

cases; differentiation

of chronic pancreatitis

from pancreatic

carcinoma may be

difficult; now

considered primarily a

therapeutic procedure

Endoscopic

ultrasonography

(EUS)

High-frequency transducer

employed with EUS can

produce very high-resolution

images and depict changes

in the pancreatic duct and

parenchyma with great

detail

Can be used to

assess chronic

pancreatitis and

pancreatic carcinoma


Arteriogram: „leaking” contrast material from the

splenic artery into large pseudocyst

Source: Images MD

ERCP: primary sclerosing cholangitis (left)

and tapering of distal common bile duct

resulting from pseudocyst or fibrosis in the

head of the gland (right)

Source: Images MD

ERCP: Minimal dilatation of the pancreatic duct

(left) advanced chronic pancreatitis, „chain-of-

lakes” (right)

Source: Images MD

Endosonographic

(EUS) image of the

body of the

pancreas with a

visible pancreatic

duct (thin arrow)

and calcifications

within the gland

(thick arrow). The

circular target

structure in the

center is the

instrument

Source: Images MD



Magnetic

resonance

cholecysto-

pancreatography

(MR)

3D rendering has been

used to produce very

good images of the

pancreatic duct by a

noninvasive technique

Has largely replaced

ERCP as a diagnostic

test

Pancreatic

biopsy with USG

or CT guidance

Percutaneous biopsy with

skinny needle and

localization of lesion by

USG

High diagnostic yield;

laparotomy avoided;

requires special

technical skills


MR of the pancreas: duct abnormalities

Source: Images MD

Computed

tomography can also

direct a needle

aspiration to obtain a

tissue diagnosis from

a pancreatic mass

Source: Images MD

Tests of exocrine pancreatic function 1


Direct stimulation of the pancreas with analysis of duodenal contents

1. Secretin-

pancreozymin

(CCK) test

Secretin leads to

increased output of

pancreatic juice and

HCO3-; CCK leads to

increased output of

pancreatic enzymes;

pancreatic secretory

response is related to

the functional mass of

pancreatic tissue

Sensitive enough to detect

occult disease; involves

duodenal intubation and

fluoroscopy; poorly defined

normal enzyme response;

overlap in chronic pancreatitis;

large secretory reserve capacity

of the pancreas, currently done

at only few medical centers

2. Endoscopic

secretin-CCK

test

Replaces need for

tube replacement

duodenum

Sensitive enough to detect

occult disease; avoids intubation

and fluoroscopy; requires

seadation




Measurement of intraluminal digestion products

1. Microscopic

examination of

stool for

undigested meat

fibers and fat

Lack of proteolytic and

lipolytic enzymes causes

decreased ingestion of

meat fibers and

triglycerides

Simple, reliable; not

sensitive enough to detect

milder causes of

pancreatic insufficiency

2. Quantitative

stool fat

determination

Lack of lipolytic enzymes

brings about impaired fat

digestion

Reliable, reference

standard for defining

severity of malabsorption;

does not distinguish

between maldigestion and

malabsorption

3. Fecal nitrogen Lack of proteolytic

enzymes leads to

impaired protein digestion;

resulting in an increase in

stool nitrogen

Does not distinguish

between maldigestion and

malabsorption; low

sensitivity


Steatorrhea and diabetes associated with chronic

pancreatitis

Source: Images MD

Stimulated pancreatic lipase output and fecal fat

excretion and stimulated pancreatic trypsin output

and fecal nitrogen excretion

Source: Images MD



Measurement pancreatic enzymes in feces

1. Elastase Pancreatic secretion

of proteolytic enzymes

Good sensitivity if stools

not liquid

2. Chymotrypsin Pancreatic secretion

of proteolytic enzymes

Unable to detect chronic

pancreatitis in the absence

of steatorrhea


Diagnosis of the biliary tract and the pancreas 3 -...

Documents

Transcript of Diagnosis of the biliary tract and the pancreas 3 -...