Page 222 - Medicine and Surgery

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218 Chapter 5: Hepatic, biliary and pancreatic systems

ducts down to the common bile duct. Histologically it is The endocrine pancreas
an adenocarcinoma. The islets of Langerhans are islands of endocrine cells
scattered throughout the pancreas. They are clustered
Investigations around a capillary network into which they secrete their
Ultrasound may show dilated intrahepatic ducts and hormones.Theisletscontainthreemaincelltypes,which

acollapsed gallbladder. cannot be distinguished histologically but secrete differ-
Percutaneous transhepatic cholangiogram shows a ent hormones:

stricture, may show multifocal disease. α cells secrete glucagon.
CT scan may show hepatic metastases and nodal in- β cellssecrete insulin.

volvement. δ cellssecrete stomatostatin.
Management Acute pancreatitis
Curative treatment is only attempted if the tumour is
localised and the patient is fit for radical resection. Definition
Carcinoma of the common bile duct is treated by the Acute inflammation of the pancreas with variable in-

Whipple’s operation (see page 221). volvement of local tissue and other organs.
Carcinoma of the upper biliary tract is only resectable

in 10% of patients. Hepatic resection is often advised. Incidence
The remaining biliary tree is anastomosed to a Roux Almost 5–25 per 100,000 per year and rising.
loop of jejunum.
Palliative treatments include insertion of a stent or anas- Age
tomosis of a Roux loop of jejunum to a biliary duct in More common >40 years.
the left lobe of the liver.
Sex
Prognosis M > F
The majority of patients die within 1 year of diagnosis.
The prognosis is better for patients with carcinoma of Aetiology
the common bile duct who are suitable for a Whipple’s Biliary tract disease (80%), especially cholelithiasis, gall-
operation. stones are present in up to half of all cases although of-
tenin the gallbladder rather than impacted. Alcoholism
is the second most common cause (20% in the United
Disorders of the pancreas Kingdom). Causes are as follows:
Obstruction: Gallstones, biliary sludge, carcinoma of

the pancreas.
Introduction to the pancreas
Drugs/toxins: Alcohol, azathioprine, steroids, diuret-
The pancreas has two important functions: the produc- ics.
tion of pancreatic juice, which contains enzymes vital Metabolic: Hypercalcaemia, hyperlipidaemia.
for normal digestion and absorption of food, and the Infections: Coxsackie, mumps, Mycoplasma.
production of the hormones insulin and glucagon in Trauma: Blunt or penetrating injury, post-surgery,
the islets of Langerhans, which are released into the post-ERCP.
blood and have numerous effects on cell metabolism. Autoimmune: Polyarteritis nodosa, systemic lupus
Inflammation of the pancreas, which may be due to erythematosus.
many causes, including pancreatic duct obstruction, al-
cohol and viruses causes an initial insult to pancreas, but Pathophysiology
further damage results from the release of intracellular The pancreatic acini and ducts become damaged, this
enzymes and their abnormal activation, so that the pan- leads to release and activation of the digestive enzymes
creas autolyses itself. of the pancreas which autolyse the tissues. Proteolysis