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Cystic neoplasms of the pancreas: Epidemiology, clinical features, assessment, and management

Introduction Cystic neoplasms of the pancreas have become a well-defined radiographic entity during the last decade. With the increasing use of cross-sectional imaging, the better quality of imaging modalities, and the aging population, the diagnosis rate has increased to an estimated 2.6 cystic lesions per 100 individuals per year. , Abdominal ultrasonography only detects pancreas cysts in 0.21% of tested individuals, whereas computed tomography (CT) can…

Tumors of the pancreas and ampulla

Tumors of the pancreatic duct or ductal-related origin Pancreatic intraepithelial neoplasia Pancreatic intraepithelial neoplasia (PanIN) is a noninvasive lesion confined to the pancreatic ducts and observed only microscopically (<0.5 cm). The mucin-containing duct epithelium exhibits a spectrum of architectural and cytologic atypia, which is designated as low-grade (PanIN-1 and PanIN-2) or high-grade dysplasia (PanIN-3). Low-grade PanIN may be associated with age, obesity, and diabetes mellitus (DM);…

Management of chronic pancreatitis: Conservative, endoscopic, surgical

Background Chronic pancreatitis (CP) is characterized by a progressive inflammatory process, the etiologies of which vary depending on geographic and sociocultural circumstances. Therefore incidence and prevalence of CP differs between the respective regions, which has been shown in studies that include Western and Asian countries as well as India. The reported rates show an incidence of approximately 5 to 15 per 100,000 and prevalence of 40…

Etiology, pathogenesis, and diagnosis of chronic pancreatitis

Pancreatitis, marked by inflammation of the pancreatic parenchyma and injury to the acinar cells, has been traditionally divided into categories of acute or chronic (see Chapter 54, Chapter 55, Chapter 56 and 58 ). Initial attempts to distinguish acute from chronic pancreatitis centered on the resolution of symptoms and inflammation in acute pancreatitis, contrasted with the permanent changes observed in chronic pancreatitis. Chronic pancreatitis, while broadly…

Management of acute pancreatitis and pancreatitis-related complications

Acute pancreatitis Acute pancreatitis (AP) is common with an incidence of 15 to 45 per 100,000 population per year. This has increased over the last two decades largely because of a rising prevalence of obesity and gallstone disease. Recurrent AP represents a subgroup of patients who have had at least two distinct episodes of pancreatitis with complete resolution in between and no evidence of chronic pancreatitis…

Etiology, pathogenesis, and diagnostic assessment of acute pancreatitis

Acute pancreatitis (AP) is an inflammatory condition of the pancreas that can lead to injury or destruction of acinar components and is clinically characterized by abdominal pain and elevated blood levels of pancreatic enzymes. The clinical spectrum is as diverse as its causes and pathogenesis, ranging from a relatively mild set of symptoms to a severe illness with potentially life-threatening complications. In the recent Atlanta classification…

Definition and classification of pancreatitis

Overview Despite five international consensus meetings over the last 40 years, the definition and classification of pancreatitis (see Chapter 55, Chapter 56, Chapter 57, Chapter 58 ) continues to evolve. The main reason is the actual difficulty, in contrast to other common inflammatory diseases of the gastrointestinal (GI) tract, of obtaining pancreatic tissue specimens to define the diagnosis during the inflammatory process. As a consequence, classifications…

Congenital disorders of the pancreas: Surgical considerations

The pancreas is a glandular organ that lies on the posterior abdominal wall in the retroperitoneum (see Chapter 2 ) It is an exocrine gland that secretes enzymes of digestion into the duodenum; it also performs endocrine functions, producing insulin, glucagon, somatostatin, pancreatic polypeptide, and ghrelin (see Chapter 3 ) Congenital abnormalities of the pancreas may be so severe that they are diagnosed in utero or…

Interventional techniques in hilar and intrahepatic biliary strictures

Malignant disease resulting in proximal or high bile duct obstruction ( Fig. 52.1 )—that is, in close proximity to or involving the biliary confluence—may arise from a variety of cancer types and is a common clinical problem. Historically, the proximal biliary tree was defined as above the level of the cystic duct insertion into the common hepatic duct (CHD). Given the wide anatomic variability of the…

Perihilar cholangiocarcinoma: Presurgical management

The perihilar region is among the most common site of origin of cholangiocarcinoma (perihilar cholangiocarcinoma [pCCA]). However, considering the incidence of 1 to 2 per 100,000 in Western countries, which is significantly lower than in Asia, the disease remains rare. , By the American Joint Cancer Committee (AJCC) definition, pCCA originates distal to the second-order intrahepatic bile ducts and proximal to the insertion of the cystic…

Extrahepatic biliary tumors

Overview Extrahepatic biliary tumors are rare. Patients classically present with painless jaundice secondary to biliary obstruction. Management of bile duct tumors is challenging and best approached with input from an experienced multidisciplinary team. This chapter focuses on the cause of most common of these tumors, cholangiocarcinoma. We describe its epidemiology, preoperative evaluation, management, surgical technique, and long-term outcomes. Epidemiology and risk factors Cholangiocarcinoma accounts for 3%…

Intrahepatic cholangiocarcinoma

Introduction Intrahepatic cholangiocarcinoma (IHCC) is a primary adenocarcinoma of the liver. Like other primary adenocarcinomas of the upper gastrointestinal tract, IHCC often presents with symptoms due to advanced local disease or metastatic disease. IHCC is a biologically aggressive disease; complete resection, where possible, is the only known potentially curative therapy. In addition, there are few effective systemic therapies. IHCC is also known as peripheral cholangiocarcinoma, cholangiolar…

Tumors of the gallbladder

Benign tumors of the gallbladder Although gallbladder cancer is a rare and aggressive malignancy that generally carries a dismal prognosis, there are a number of benign conditions of the gallbladder that can radiographically mimic malignancy and deserve consideration in a robust differential diagnosis because preoperative determination of a benign lesion may significantly alter treatment strategy. Gallbladder polyps Gallbladder polyps are found in approximately 3% to 7%…

Benign tumors and pseudotumors of the biliary tract

Although uncommon, benign tumors and pseudotumors may arise from the intrahepatic and extrahepatic biliary ducts and gallbladder. These lesions may originate from both the epithelial and nonepithelial structures that comprise the biliary ducts and gallbladder ( Box 48.1 ). Epithelial tumors include adenomas, cystadenomas, and biliary papillomatosis, and nonepithelial tumors consist of granular cell tumors, neurofibromas, and leiomyomas. Finally there are the tumor-like lesions and pseudotumors,…

Tumors of the bile ducts: Pathologic features

The biliary tract is lined by simple columnar epithelial cells of foregut origin ( Fig. 47.1 ). The vast majority of biliary neoplasms arise from this cell type and therefore show major similarities to other foregut tumors, particularly those of pancreatic ductal origin (see Chapter 1 ). By far the most common neoplasm of the biliary tract is adenocarcinoma, referred to collectively with pancreatic ductal adenocarcinoma…

Bile duct cysts in adults

First reported by Vater and Ezler in 1723, bile duct cysts represent a rare pathology. They exist most commonly as a pediatric surgical problem. The majority of bile duct cysts are diagnosed in infants and children within the first decade of life, and an estimated 25% are detected by 1 year of age with an additional 35% to 55% by the age of 10 years. Presentation…

Biliary parasitic disease

Parasitic infections of the biliary tract are a common cause of biliary obstruction in tropical developing countries and less frequently, in developed countries. These infections are important because they can lead to serious complications such as cholelithiasis (see Chapters 33 and 39 ), recurrent pyogenic cholangitis (see Chapter 44 ), cirrhosis (see Chapter 74 ), pancreatitis (see Chapters 54 , 55 , and 57 ), and…

Recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis (RPC) is a clinical condition caused by repeated episodes of cholangitis, with biliary sepsis secondary to the accumulation of pigmented stones inside the biliary system (see Chapters 39 and 43 ), and there may be associated stricture formation of the biliary tree (see Chapter 42 ). The term RPC was formulated after identification of a series of patients with similar clinical conditions and…

Cholangitis

Overview Cholangitis, also called acute cholangitis or ascending cholangitis, occurs when obstructed biliary flow leads to cholestasis and infection of the biliary tree. Cholangitis is commonly caused by choledocholithiasis and a variety of pathologies that obstruct the biliary tree. The severity of cholangitis ranges from mild to life-threatening, with mortality rates approaching 10% for the most severe cases. Prompt diagnosis followed by fluid resuscitation, administration of…

Benign biliary strictures and biliary fistulae

Overview In this chapter we cover biliary fistulae and strictures from benign etiologies. There is significant overlap in conditions that lead to benign biliary fistulae and strictures, thus these two topics are combined in one chapter. By definition, a biliary fistula is an abnormal communication between the biliary tract and another organ or potential space. In contrast, a biliary stricture is defined as an abnormal narrowing…