Gallbladder & Pancreas Path

Diseases of the Biliary Tract

• Include cholelithiasis, cholecystitis, primary biliary cholangitis, and primary sclerosing cholangitis.

Disorders of the Pancreas

• Pancreatitis, cystic fibrosis, and pancreatic carcinoma are examples

Cholelithiasis (Gall Stones)Definition

• Cholelithiasis means "chole" = bile or gall, “lithiasis" = stones
• Collections of solid material form in the gallbladder
• Solid material 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, with 70-80% of the First Nations population in Canada being affected
• More common in females than males
• Gallstones occur in up to 20% of Canadian women and 10% of men by age 60

Cholelithiasis Risk factors

• The "4 F": Female, forty, overweight, and fertile were formerly used to describe the patient
• Other risk factors include SAD diet, and family history

Cholelithiasis Etiology

• There are two main types of stone: cholesterol stones and pigment stones
• Most common (MC) stones are cholesterol stones
• Cholesterol is a lipid created in the liver that dissolves in bile
• Bile becomes oversaturated and crystals can form, if the liver secretes too much cholesterol
• Pigment stones are made of bilirubin from excess hemolysis

Cholelithiasis Signs and Symptoms

• 80% of patients are asymptomatic and gallstones remain 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 minutes
• Most pain episodes last less than 6 hours but can persist for up to 12 hours
• Usually severe enough to go to the ER
• A complication is cholecystitis

Cholelithiasis Diagnosis

• Abdominal ultrasound

Cholelithiasis Treatment

• No treatment is required if there are no symptoms
• Watch and wait, even in early episodes
• Disruptive, recurring episodes usually result in laparoscopic cholecystectomy
• Cholecystectomy usually has little to no affect on digestion
• Cholecystectomy may increase bowel transit time
• Low fat diet to reduce strain on the gallbladder
• Extremely low fat diets may increase gallstone formation in some cases

Cholelithiasis Massage considerations

• No absolute contraindications for patients that currently have or have had cholelithiasis
• Massage is contraindicated if signs and symptoms of obstruction are present, like nausea/vomiting, or colicky RUQ pain

Cholecystitis Definition

Inflammation of the gallbladder, typically occurs in those with a history of symptomatic gallstones

• The cystic duct being blocked by gallstones causes inflammation of the gallbladder
• Cholecystitis can be acute or chronic

Cholecystitis Etiology

• Most commonly secondary to gallstones
• Other causes include tumors, or certain viral infections

Acute Cholecystitis

• Sudden, severe, steady pain in the RUQ
• Most common cause is gallstones (95%)
• Acalculous (without stones) cholecystitis is rare, but is more serious and related to major surgery, severe burns, sepsis, or prolonged parenteral nutrition (fasting)
• The Gallbladder fills with fluid and the walls thicken
• Can occur in children and adults

Chronic Cholecystitis

• Chronic inflammation of the gallbladder, with repeated attacks of biliary colic
• Gallstones are the most common cause of chronic cholecystitis
  • The stone are directly irritating the lining
• The gallbladder becomes thick-walled, scarred, and small
• The gallbladder contains sludge or stones that block the opening to the cystic duct or the duct itself

Cholecystitis Signs and Symptoms

• RUQ steady pain that lasts 6-12 hours or more and is quite severe
• Pain peaks at 15-60 minutes and remains constant
• Pain can spread to the right shoulder or between the scapulae
• Increased pain with deep breaths
• Nausea and vomiting are common
• (+) Murphy’s sign
• May have abdominal rigidity and guarding
• Typically ~1/3 have a fever of over 38°C and chills if it is acute

Cholecystitis Murphy’s sign

• Not diagnostic, but provides useful information
• If you place the hand over the gallbladder, you will be able to move the gallbladder. This will cause the patient to stop breathing due to the pain

Cholecystitis diagnosis

• Ultrasound is the best way to detect gallstones, fluid around the gallbladder, and thickening of the gallbladder walls

Cholecystitis Treatment

• Hospitalization is likely
  • Intravenous (IV) fluids while your digestive system rests
  • IV antibiotics to treat or prevent infections
  • IV analgesics
• A colecystectomy is the definitive treatment for both acute and chronic cholecystitis
  • They are more likely to colecystectomy is when the patient is getting repeated attacks of cholecystitis

Cholecystitis massage considerations

• Absolute contraindication for acute cholecystitis and severe chronic cholecystitis (flare up)

Primary Biliary Cholangitis

• Previously known as primary biliary cirrhosis

Primary Biliary Cholangitis Definition

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

Primary Biliary Cholangitis Epidemiology

• Incidence rates range from 0.33 to 5.8 per 100,000 inhabitants/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 Etiology

• Autoimmune disease thought to be a combination of genetic and environmental factors

Primary Biliary Cholangitis Signs and Symptoms

• More than half of people diagnosed with PBC are asymptomatic at the time
• Incidental findings on blood tests
• Symptoms eventually develop over the next 5 to 20 years which include:
  • Fatigue
  • Itchy skin
  • Jaundice
  • RUQ pain
  • Edema
• A complication is cirrhosis
  • can block the liver

Primary Biliary Cholangitis Diagnosis

• LFTs (Liver Function Tests)
• Antibody serology:
  • Through blood tests to check for anti-mitochondrial antibodies (AMA) which are common in PBC
• Imaging via ultrasound, or a special type of MRI to view structure of bile ducts
• Liver biopsy may be needed to confirm

Primary Biliary Cholangitis Treatment

• No cure, but some medications can help slow the progression
• Ursodeoxycholic acid (UDCA or ursodiol)
  • helps move bile through the liver, and improves liver function and reduce liver scarring
• Symptomatic treatment of itching and fatigue uses antihistamines
• A liver transplant may be necessary if other methods fail

Primary Biliary Cholangitis Prognosis

• The average life expectancy is about 10 years once signs and symptoms develop
• Successful liver transplants offer a 10-year survival rate of 65%

Primary Sclerosing Cholangitis Definition

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

Primary Sclerosing Cholangitis Etiology

• Cause is unclear
• It is believed an immune system reaction to infection or toxin may be a trigger in people who are genetically predisposed
• A large proportion also have IBD
• Can lead to cirrhosis

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, with median age of diagnosis of 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

• LFTs
• Imaging with ultrasound
• Can use a special type of MRI to view the structure of bile ducts
• A liver biopsy may be needed to confirm

Primary Sclerosing Cholangitis Treatment

• No cure
• Can use medications available to help slow the progression
• Ursodeoxycholic acid (UDCA or ursodiol) can help move bile through your liver, and improve liver function and reduce liver scarring
• Symptomatic treatment of itching and fatigue often involves antihistamines
• A liver transplant may be necessary

Primary Sclerosing Cholangitis Prognosis

• The average life expectancy is between 10 and 20 years once symptoms develop
• Successful liver transplants can lengthen life expectancy
• PSC returns in 15/20% of patients post transplant

Gallbladder Cancers

• very rare form of cancer

Pancreatitis Definition

• Inflammation of the pancreas that can be mild or life threatening
• Causes the activation and possible release of enzymes
• The enzymes begin digesting and attacking the pancreas, and possibly other tissues if they enter the blood stream
• Can be acute or chronic

Pancreatitis Etiology

• Most common causes are alcoholism, or gallstones
• Alcoholism is associated with chronic pancreatitis
• Gallstones are associated with acute pancreatitis
• Alcohol is linked to 80% of pancreatitis cases

Pancreatitis Risk factors

• Smoking is linked to chronic pancreatitis

Acute Pancreatitis

• Most common cause is gallstones
• Think of acute pancreatitis as an event
• Acute attacks of pancreatitis can be precipitated by an alcoholic binge, smoking or excessively large meals
• More common in females than males

Chronic Pancreatitis

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

Pancreatitis Signs and Symptoms

• Severe epigastric and LUQ pain that often radiates to the back
• Gallstones may be present resulting in acute pain
• Acute cases may cause pain starts suddenly and reach max intensity in 10-20 minutes
• Acute pain is persistent, and severe in the LUQ
• Alcohol abuse is associated with chronic pain
• Chronic pain onset may be less abrupt
• Chronic pain may be poorly localized
• Aggravating factors: coughing, deep breathing, and vigorous movement
• Partial relief: sitting up or bending forward
• 90% have nausea/vomiting which may persist for several hours
• Tenderness of epigastrium, where severity of pain depends on severity of pancreatitis
• Abdominal distention
• Hypoactive bowel sounds due to inflammation
• Scleral icterus, if obstructive jaundice is present
• In 3% of patients with acute pancreatitis, bruising along the flank may be exhibited, known as Grey Turner Sign resulting from retroperitoneal bleeding

Pancreatitis Diagnosis

• Characteristic pain leads to pancreatitis suspicion, with acute onset of persistent, severe, epigastric pain with tenderness on palpation on PE
• Blood tests may support diagnosis, due to increased serum lipase and amylase (3x) and increases in leukocytosis
• Ultrasound may be used to visualize the pancreas, and to see gallstones

Pancreatitis Treatment

• Mild or severe cases usually require hospitalization
• Chronic pancreatitis treatment may include Analgesics and antioxidants (E, C, selenium, methionine) for pain control
• Also Pancreatic enzyme supplementation
• Acute pancreatitis treatment may include Fasting, IV fluids, analgesics and;
  • Antiemetics are medications used to prevent or treat nausea and vomiting. They are often given during the treatment of conditions such as pancreatitis to manage symptoms.
• Normal eating may be allowed w/in 2-3 days w/o further treatment
• Must treat underlying cause, whether alcohol abuse, or gallstones

Pancreatitis Prognosis

• In most patients with acute pancreatitis, the disease is mild in severity and patients recover in 3-5 days without complications or organ failure
• Recurring attacks of acute pancreatitis are also known as chronic pancreatitis

Pancreatitis Massage considerations

• Acute pancreatitis is an ABSOLUTE contraindication, and is a medical emergency that 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 that results in dysfunction of a protein (CFTR=cystic fibrosis transmembrane conductance regulator) that regulates water and chloride channels
• Water and chloride cannot leave cells and enter lumen, causing thick mucus build up
• Mainly effects lungs, but also effects liver, pancreas, and sweat glands
• Thickening of pancreatic secretions blocks the duct or even the gland completely, causing scarring of pancreas
• ~15% of persons with cystic fibrosis develop insulin-dependent diabetes d/t inability to produce insulin

Cystic Fibrosis Etiology

• Multisystem genetic disorder that results in dysfunction of a protein (CFTR) that regulates water and chloride channels ​

• Water and chloride cannot leave cells and enter lumen, causing thick mucus build up​

• Mainly effects lungs, but also effects liver, pancreas, and sweat glands​

• Thickening of pancreatic secretions blocks the duct or even the gland completely, causing scarring of pancreas​

• ~15% of persons with cystic fibrosis develop insulin-dependent diabetes d/t inability to produce insulin

Cystic Fibrosis Epidemiology

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

Cystic Fibrosis Signs and Symptoms

• Symptomatic presentation in infants and children includes respiratory Sx, Meconium ileus, Respiratory symptoms include Productive cough, repeated lung infections, and chronic bronchitis
  • Meconium Ileus is a bowel obstruction in newborns, typically associated with cystic fibrosis. It occurs when thickened meconium, the first stool of an infant, blocks the intestines, particularly the ileum. This condition can lead to abdominal distress, vomiting, and a lack of stool passage. Diagnosis is often through imaging and can require interventions such as enemas or surgery to clear the obstruction), pancreatic disease (pancreatitis, pancreatic insufficiency), and liver disease (cirrhosis, portal hypertension)
• Symptomatic presentation in adulthood, may present with Gl symptoms, diabetes mellitus and infertility
• Adults presenting later in life, may have atypical symptoms

Cystic Fibrosis Diagnosis

• Early diagnosis often happens through newborn screening programs, where shortly after birth, a small blood sample is taken and tested
• Sweat test checks for High chloride in sweat, where chloride can’t be transported into cells

Cystic Fibrosis Treatment

• There is no cure, but treatment can ease symptoms, reduce complications and improve quality of life
• Goals of treatment include preventing and controlling infections that occur in the lungs, removing and loosening mucus from the lungs via tapoment, and treating and preventing intestinal blockage

Cystic Fibrosis Prognosis

• Most children with CF stay in good health until they reach adulthood
• Lung disease eventually worsens to the point where the person is disabled and death is most often caused by lung complications
• The average life span for people with CF who live to adulthood is about 44 years
• People with CF who were born between 2019 and 2023 have a predicted median age of survival of 61 years
• This has been steadily improving

Cystic Fibrosis Massage considerations

• No contraindications, but some postural adjustments may be necessary
• The Cystic Fibrosis Foundation recommends massage techniques that may loosen mucus
• Do not see patients if you are ill

Carcinoma of the Pancreas Definition

• Malignant tumors of the pancreas
• 95% of malignant tumors of the pancreas are adenocarcinomas (glandular origins)
• Most commonly near pancreatic head

Carcinoma of the Pancreas Epidemiology

• It is the 11th most common cancer in Canada, and the 4th amongst cancer-related deaths (high death rate if acquired)
• More common in people over 45 years old
• Slightly more common in males than females

Carcinoma of the Pancreas Etiology

• Environmental risk factors include smoking, chronic pancreatitis (from alcohol), DMII, and obesity
• Hereditary risk factors include cystic fibrosis, and family history of pancreatic cancer

Carcinoma of the Pancreas Signs and Symptoms

• Signs & Symptoms are very vague
• Abdominal pain which is insidious in onset, gnawing in quality, and generally epigastric
  • Abdominal pain may be Frequently worse at night, worse after eating, and worse laying supine
• Jaundice due to a blocked duct resulting in jaundice and pruritus
  • Jaundice is one of few early symptoms
• Weight loss
• Pressure on pylorus of stomach resulting in vomiting
• Obstruction/Compression of small intestine

Carcinoma of the Pancreas Diagnosis

• Early dx is difficult due to lack of signs and symptoms with PE/blood work often WNL
• Can do bloodwork to evaluate for cholestasis and/or acute pancreatitis
• A CT test is preferred for initial imaging
• US and MRI are sometimes used
• If pancreatic mass is seen on abdominal US, a CT scan is the next step
• A Biopsy can be done for confirmation of cancer

Carcinoma of the Pancreas Prognosis

• Late stage diagnosis is common, and metastasis is present in 90% of cases, resulting in a five year survival rate of 7%

Carcinoma of the Pancreas Treatment

• A Pancreaticoduodenectomy, known as the Whipple procedure, on those without metastasis
• It involves the removal of the head of the pancreas, the duodenum, gallbladder and bile duct
• 5 year survival is only ~20% after the Whipple procedure, or 40% if no lymph involvement
• Chemotherapy and radiation are mostly palliative

Carcinoma of the Pancreas massage considerations

• There are no contraindications