Sys Path Gallbladder & pancreas

Cirrhosis

• Irreversible replacement of normal liver tissue with non-functional scar tissue
• Damage is typically irreversible
• Can lead to Portal hypertension which causes Esophageal varices that may lead to mass hematemesis.
• Portal hypertension can cause Rectal varices, Ascites, Kidney failure and Hepatic encephalopathy

Diseases of the Biliary Tract

• Include Cholelithiasis, Cholecystitis, Primary Biliary Cholangitis, and Primary Sclerosing Cholangitis

Disorders of the Pancreas

• Include Pancreatitis, Cystic Fibrosis, and Pancreatic Carcinoma

Cholelithiasis Definition

• "chole" means bile or gall and "lithiasis" means stones
• Collections of solid material located in the gallbladder
• Can be dislodged and get stuck in the cystic duct, common bile duct, or hepatopancreatic ampulla

Cholelithiasis Epidemiology

• More common in Indigenous and Hispanic populations
• In Canada 70-80% of the First Nations population is affected
• More common in females than males
• Gallstones occur in up to 20% of Canadian women and 10% of men by the age of 60
• "Four F's" of gallstones formerly used to describe patient; female, forty, overweight, and fertile
• Other risk factors include SAD diet and family history

Cholelithiasis Etiology

• Two main types of stones exist; cholesterol stones, and pigment stones
• Most Common Stones are cholesterol stones.
• Cholesterol is a lipid that is created in the liver and dissolves in bile
• If the liver secretes excess cholesterol into the bile, bile becomes oversaturated and crystals can form
• Excess hemolysis can form pigment stones made of bilirubin

Cholelithiasis Signs and Symptoms

• 80% are asymptomatic, with gallstones remaining in the gallbladder
• As a stone passes from the gallbladder into the cystic duct, common bile duct, and/or hepatopancreatic ampulla the gallbladder swells and causes colicky RUQ pain
• Pain is diffuse and hard to localize, usually RUQ or epigastric
• Pain can radiate to the right shoulder or between the scapulae
• Pain increases over 15 minutes then plateaus at about 30-60 min
• Most episodes last less than 6 hours but can last up to 12 hours
• Usually severe enough to require in person care at ER
• Cholecystitis can occur as a complication

Cholelithiasis Diagnosis and Treatment

• Diagnosis is made with abdominal ultrasound
• No treatment is required if there are no symptoms
• Watch and wait for even early episodes with symptoms
• Disruptive, recurring episodes require laparoscopic cholecystectomy
• Gallstones usually have little to no affect on digestion
• Gallstones may increase transit time of bowel ie. affect how fast things move during digestion
• Low-fat diet can reduce strain on the gallbladder
• Extremely low fat diets may increase gallstone formation

Cholelithiasis Massage Considerations

• No absolute contraindications exist for patients that currently have or have had cholelithiasis
• Massage is contraindicated if obstruction symptoms are present, such as nausea and vomiting, or colicky RUQ pain

Cholecystitis Definition

• Inflammation of the gallbladder, typically occurring in those with a history of symptomatic gallstones
• Blockage of the cystic duct by gallstones causes inflammation of the gallbladder
• Acute or chronic

Cholecystitis Etiology

• Secondary to gallstones is most common
• Other causes include tumors, certain viral infections

Cholecystitis - Acute

• Sudden, severe, steady pain in the RUQ
• Most common cause is gallstones, 95%
• Acalculous cholecystitis is rare, more serious, and related to major surgery, severe burns, sepsis, prolonged parenteral nutrition, or prolonged fasting
• The gallbladder fills with fluid and walls thicken
• Can occur in children and adults

Cholecystitis - Chronic

• Chronic inflammation of the gallbladder with repeated attacks of biliary colic
• Most common cause is gallstones
• Gallbladder becomes thick-walled, scarred, and small
• The gallbladder contains sludge or stones that block the opening to the cystic duct or the duct

Cholecystitis Signs and Symptoms

• RUQ colicky pain lasts 6-12 hours or more and is quite severe
• Pain peaks at 15-60 minutes and remains constant
• Can spread to the right shoulder or between the scapulae
• Increased pain with deep breaths
• Nausea and vomiting are common
• Murphy’s sign will be positive
• Abdominal rigidity and guarding possible
• In acute cases, approximately 1/3 have fever of over 38°C and chills

Cholecystitis Diagnostic and Treatment

• A positive Murphy’s sign is not diagnostic, but provides useful information
• Ultrasound is the best way to detect gallstones, fluid around the GB, and thickening of GB walls
• Hospitalization is likely.
• Intravenous or IV fluids will be administered while the digestive system rests
• IV antibiotics treat or prevent infections
• IV analgesics manage pain
• Definitive treatment for both acute and chronic cholecystitis is colecystectomy

Cholecystitis Massage Considerations

• Absolute contraindication for acute and severe chronic cholecystitis

Primary Biliary Cholangitis (PBC)

• Previously known as primary biliary cirrhosis

Primary Biliary Cholangitis (PBC) Definition

• Autoimmune disease causing inflammation and destruction of the bile ducts in the liver

Primary Biliary Cholangitis (PBC) Epidemiology

• Incidence rates range from 0.33 to 5.8 per 100,000 inhabitants per year
• Women are predominantly affected with a sex ratio of 9:1
• Onset is generally in the 4th to 6th decades of life

Primary Biliary Cholangitis (PBC) Etiology

• Autoimmune disease
• Thought to be a combination of genetic and environmental factors that trigger the disease

Primary Biliary Cholangitis (PBC) Signs and Symptoms

• More than half of people diagnosed with PBC are asymptomatic at the time
• Incidental findings possible as discovered on blood tests
• Symptoms eventually develop over the next 5 to 20 years which include fatigue, itchy skin, jaundice, RUQ pain, and edema
• Complications possible with Cirrhosis

Primary Biliary Cholangitis (PBC) Diagnosis

• Liver function tests
• Antibody serology
• Blood tests may be done to check for anti-mitochondrial antibodies (AMA)

Primary Biliary Cholangitis (PBC) Imaging and Confirmatory tests

• Diagnostic imaging with ultrasound
• Special type of MRI available can view structure of bile ducts, otherwise use liver biopsy

Primary Biliary Cholangitis (PBC) Treatment

• There is no cure.
• Medications slow progression of the disease
• Ursodeoxycholic acid reduces liver scarring and helps move bile through your liver
• Symptomatic treatment of itching and fatigue with antihistamines
• Liver transplant may be necessary.

Primary Biliary Cholangitis (PBC) Prognosis

• Once symptoms develop life expectancy is about 10 years
• Successful liver transplants offer a 10-year survival rate of 65%

Primary Sclerosing Cholangitis Definition

• Inflammatory disease of the bile ducts, both intrahepatic and extrahepatic
• Scarring of the ducts causes narrowing, which gradually causes serious liver damage

Primary Sclerosing Cholangitis Etiology

• Cause is unclear
• Immune system reaction to infection or toxin may be a trigger in people who are genetically predisposed to it
• Large proportion also have IBD

Primary Sclerosing Cholangitis Epidemiology

• Fairly rare disease
• Estimated incidence of 1 per 100,000 per year in Europe and North America
• Can occur at any age, the median age of diagnosis is 41
• More common in males than females
• More common in people of Northern European descent

Primary Sclerosing Cholangitis Signs and Symptoms

• Usually asymptomatic at diagnosis
• Early signs and symptoms include fatigue, itching, jaundice, and RUQ pain
• Complications include cirrhosis and liver failure

Primary Sclerosing Cholangitis Diagnosis

• Liver function tests
• Diagnostic Imaging with Ultrasound
• A special type of MRI can view of bile duct structure
• Liver biopsy may be needed to confirm

Primary Sclerosing Cholangitis Treatment and Prognosis

• There is no cure, medication can slow progression
• Ursodeoxycholic acid helps move bile through your liver and improves liver function and reduces liver scarring
• Symptomatic treatment of itching and fatigue with antihistamines
• Liver transplant may be necessary
• Once symptoms develop life expectancy is between 10 and 20 years
• Successful liver transplants can lengthen life expectancy, though Primary Sclerosing Cholangitis returns in 15/20% of post-transplant patients

Pancreatitis Definition

• Inflammation of the pancreas ranges from mild to life threatening
• Causes the activation and possible release of enzymes
• Activation begins digesting and attacking the pancreas
• Enzymes could enter the bloodstream and cause more complications
• Can be acute or chronic

Pancreatitis Etiology

• Most common causes include alcoholism in chronic cases and gallstones in acute cases
• Alcohol is linked to 80% of pancreatitis cases
• Smoking has also been linked to chronic pancreatitis

Pancreatitis - Acute

• Most common cause is gallstones
• Think of it as a single event
• Attacks are often precipitated by alcoholic binge, smoking or excessively large meal
• More common in females than males

Pancreatitis - Chronic

• Most common cause is alcohol
• Think of it as an ongoing process of pathologic response to pancreatic injury
• More common in males than females

Pancreatitis Signs and Symptoms

• Severe epigastric and LUQ pain often radiates to the back
• Gallstones presents with sudden pain that reaches max intensity in 10-20 minutes, acute onset of persistent severe LUQ
• Alcohol presents with less abrupt pain onset and is poorly localized
• Aggravating factors include coughing, deep breathing, and vigorous movement
• Can be partially relieved by sitting up or bending forward
• 90% experience nausea and vomiting, which may persist for several hours

Pancreatitis - Advanced Signs and Symptoms

• Tenderness of epigastrium depends on severity of pancreatitis
• Abdominal distention
• Hypoactive bowel sounds indicate inflammation
• Scleral icterus or jaundice, present if obstructive jaundice occurring
• In 3% of patients with acute pancreatitis, bruising along the flank may be present, known as Grey Turner Sign
• Grey Turner Sign is caused by retroperitoneal bleeding

Pancreatitis Diagnosis and Treatment - Acute

• Characteristic pain leads pancreatitis suspicion, acute onset of persistent, severe, epigastric pain with tenderness on palpation
• Increased serum lipase and amylase detected (3x)
• Leukocytosis can be detected
• US: pancreas may appear diffusely enlarged, can visualize gallstones

Pancreatitis Medical Treatment and Prognosis

• Whether mild or severe the condition usually requires hospitalization
• Chronic requires analgesics and antioxidants such as E, C, selenium, and methionine for pain control
• Chronic requires Pancreatic enzyme supplementation
• Acute requires fasting, IV fluids, analgesics, and antiemetics
• Those with acute can resume normal eating within 2-3 days without further treatment
• Underlying cause if known may be treated such as removing gallstones or cessation of alcohol use
• With acute it is common for the disease to be mild in severity
• Most patients recover without complications in 3-5 days
• Recurring attacks of acute pancreatitis can lead to chronic pancreatitis

Pancreatitis Massage Considerations

• Acute pancreatitis is an absolute contraindication, medical emergency and requires treatment
• Chronic pancreatitis may be a possible local contraindication
• Avoid abdominal massage if pressure produces pain or discomfort

Cystic Fibrosis Definition

• Multisystem genetic disorder resulting in dysfunction of a CFTR protein that regulates water and chloride channels
• Water and chloride are unable to leave cells and enter lumen, causing thick mucus buildup
• Most commonly effect lungs, liver pancreas and sweat glands.
• Thickening of pancreatic secretions blocks the duct or even the gland completely, causing scarring of the pancreas
• Approximately 15% of those with cystic fibrosis develop insulin-dependent diabetes

Cystic Fibrosis Etiology

• Genetic disease
• Mutation of CFTR gene on the 7th chromosome

Cystic Fibrosis Epidemiology

• Affects over 4,400 Canadians with roughly 1 in 3,848 live births resulting in diagnosis
• More common in Caucasians

Cystic Fibrosis Signs and Symptoms

• In infants and children includes
  • Respiratory symptoms with Productive cough, repeated lung infections, and chronic bronchitis
  • Meconium ileus
  • Pancreatic disease such as pancreatitis, and pancreatic insufficiency
  • Liver disease is possible such as cirrhosis, and portal hypertension
• In adults
  • Atypical symptoms more likely if life presenting later in life
  • Gl symptoms, diabetes mellitus and infertility may present

Cystic Fibrosis Diagnosis

• Early diagnosis through newborn screening programs, small blood sample taken from baby and tested after birth
• Sweat test to test for high chloride indicating limited transport into cells

Cystic Fibrosis Treatment

• No cure exists, but treatment can ease symptoms, reduce complications and improve quality of life.
• Treatment goals include preventing and controlling infections that occur in the lungs, removing and loosening mucus from the lungs, and treating and preventing intestinal blockage

Cystic Fibrosis Prognosis

• Most children with it stay in good health until they reach adulthood, where lung disease worsens and death is most often caused by lung complications
• Currently average life span for people who live to adulthood is about 44 years
• People born between 2019 and 2023 have predicted median age of survival is 61 years and steadily improving

Cystic Fibrosis Massage Considerations

• No contraindications, but some adjustments may be necessary
• Cystic Fibrosis Foundation recommends massage techniques that may loosen mucus
• Therapists should not see patients if they are ill, due to the risk of infection

Carcinoma of the Pancreas Definition

• Malignant tumours of the pancreas
• 95% are adenocarcinomas
• Most commonly near pancreatic head

Carcinoma of the Pancreas Epidemiology

• 11th most common cancer in Canada and 4th amongst cancer-related deaths
• More common over 45 yo
• Slightly more common in males than females

Carcinoma of the Pancreas Etiology

• Environmental risk factors include smoking, chronic pancreatitis, diabetes mellitus, and obesity
• Hereditary factors include cystic fibrosis, and family history of pancreatic cancer

Carcinoma of the Pancreas Signs and Symptoms

• Abdominal pain with gnawing quality that is insidious and generally epigastric
• Frequently worse at night, after eating, and when lying supine
• Jaundice blocks duct resulting in jaundice and pruritits
• Weight loss can occur with pressure on pylorus of stomach resulting in vomiting
• Obstruction of small intestine

Carcinoma of the Pancreas Diagnosis and Prognosis

• Early diagnosis is difficult due to general lack of symptoms and bloodwork that return as being within normal limits
• Bloodwork is performed to evaluate for cholestasis and/or acute pancreatitis
• CT is the preferred initial imaging test, but US and MRI can be used
• Biopsy is done for confirmation
• Prognosis: Late stage diagnosis is common and metastasis is present in 90% of cases, resulting in a 5-year survival rate of 7%

Carcinoma of the Pancreas Treatment

• Pancreaticoduodenectomy, or Whipple procedure is performed on those patients without metastasis
• The procedure removes the head of the pancreas, the duodenum, the gallbladder, and the bile duct
• 5-year survival after Whipple is approximately 20%, and 40% if the cancer has no lymph involvement
• Chemotherapy and radiation are mostly palliative

Carcinoma of the Pancreas Massage Considerations

• No contraindications