1. Gallbladder and Pancreas Gallbladder  Anatomy and physiology  Calculous biliary disease  Benign acalculous biliary disease  Malignant biliary disease

2. Pancreas  Anatomy, embryology and histology  Physiology  Pancreatitis  Neoplasms

5. Calculous Biliary Disease  Incidence age and sex related  More common in females  Incidence increases with age  May remain silent  Complications include  Acute cholecystitis  Choledocholithiasis  Cholangitis  Gallstone pancreatitis  Gallstone ileus  Gallbladder adenocarcinoma

6. Gallstone Incidence

7. Gallbladder with Stones

8. CT of Gallbladder Thickened wall and pericholecystic fluid

15. Acalculous Biliary Disease  5-10% of patients with cholecystitis  Typical patient  Critically ill  Burns  Long-term TPN  Major non-biliary operations (AAA, Cardiac bypass)

16. Acalculous Biliary Disease  Etiology  Unclear  Stasis and ischemia ?  Symptoms and Signs  Similar to calculous presentation  May be masked by other critical illness

17. Acalculous Biliary Disease  Treatment usually open cholecystectomy  Incidence of gangrene, perforation, and empyema high  Mortality 40%

18. 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

19. Choledocholithiasis

20.  Usually due to gallstones from gallbladder  May be primary  Cholangitis (Charcot’s triad)  Fever and chills  RUQ pain  Jaundice

21. Choledocholithiasis  Treatment of cholangitis  IV fluids  Antibiotics  Gram negatives  Enterococcus  ERCP  Open common duct exploration

22. Malignant Biliary Disease  Gall bladder cancer  Bile duct cancer

23. CT of Gallbladder Cancer

24. Survival Following Resection of T2 Gallbladder Cancer

25. Bile Duct Carcinoma

26. ERCP showing hilar tumor

27. Pancreas  Anatomy, embryology and histology  Physiology  Pancreatitis  Neoplasms

29. Pancreatic Physiology

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

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

32. Ranson’s Prognostic Signs (Alcoholic Pancreatitis) Admission Initial 48 hours Age > 55 yrs WBC > 16 K Glu > 200 mg/dl LDH > 350 IU/L AST > 250 U/dl Hct fall > 10 BUN rise > 5 mg/dl Ca 2+ < 8 mg/dl PaO 2 < 55 mg/dl Base deficit >4 mEq/L Fluid > 6L

33. Pancreatitis Complications  Pseudocyst  Hemorrage  Rupture  Infection  Pancreatic necrosis  Infected pancreatic necrosis  Shock and respiratory failure

34. Large Pancreatic Pseudocyst

35. Pancreatitis Treatment  IV fluids  Pancreatic rest  NPO  NG suction if vomitting  ? Antibiotics  ? Octreotide  TPN

36. Pancreatitis Treatment Severe  Antibiotics  ? Debridement  ? Peritoneal lavage

41. 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

42. Pancreas Neoplasms Benign Lesions  Serous cystadenoma  Mucinous cystadenoma  Intraductal papillary mucinous tumor (IPMT)

43. 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

44. CT scan of serous cystadenoma

45. 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

46. 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

47. CT scan of mucinous cystadenoma

48. 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

49. Malignant Neoplasms Ductal Adenocarcinoma Risk factors Age > 60 yrs Cigarette smoking History of hereditary pancreatitis Occupational exposure to carcinogens ? Diabetes ? Chronic pancreatitis

50. Progression Model for Pancreatic Cancer

51. ERCP showing double duct sign

52. Ca Uncinate Process

53. Surgical Therapy – Whipple’s Operation

54. Trimble’s Procedure

56. Pyloric Preservation

67.  Initially recommended for pancreatitis  Less extensive resection  No difference in cancer survival  Fewer long-term GI side effects  Now standard operation for cancer

68. Pancreatic adenocarcinoma Adjuvant therapy  Chemotherapy in all patients  Agents evolving  Gemcitibine becoming standard  Immunotherapy with interferon?  Radiation therapy in margin positive patients

69. 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

70. Endocrine Neoplasms  Insulinoma  Gastrinoma  VIPoma (Verner-Morrison Syndrome)  Glucagonoma  Somatostatinoma  Nonfunctional

71. Insulinoma  Most common of endocrine tumors  Whipple triad  Presentation  Fatigue  Weakness  Hunger  Tremor  Diagnosis  Monitored fasting  Measurements of insulin and glucose with symptoms

72. Localization  Small (usually < 1.5 cm)  Usually benign  Hard to find

73. Arteriogram of insulinoma

74. CT of insulinoma

75. Portal venous sampling

76. Intraoperative US of insulinoma

77. Gallbladder and Pancreas

78. Questions?