Hepato-biliary and pancreatic disorders

 

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Hepatobiliary disorders

1. Hepatitis

• Viral hepatitis :

  • Hepatitis A :

    • Transmission: Fecal-oral via ingestion of contaminated water or food.

    • Symptoms: Fatigue, nausea, abdominal pain, jaundice.

    • Prevention: Vaccination, hand hygiene.

    • Treatment: Supportive, generally self-limiting.

  • Hepatitis B :

    • Transmission: Contact with infected body fluids (blood, semen).

    • Symptoms: Symptoms similar to hepatitis A but more likely to become chronic.

    • Prevention: Vaccination, universal precautions in medical environments.

    • Treatment: Antivirals for chronic forms (entecavir, tenofovir).

  • Hepatitis C :

    • Transmission: Mainly via blood (transfusions, sharing needles).

    • Symptoms: Often asymptomatic in an acute state, can progress to chronic hepatitis.

    • Prevention: Avoid sharing injection equipment, monitor blood donations.

    • Treatment: Direct-acting antivirals (DAAs) with high cure rates.

  • Hepatitis D :

    • Transmission: Co-infection or superinfection with the hepatitis B virus.

    • Symptoms: Worsens the course of hepatitis B.

    • Prevention: Hepatitis B vaccination.

    • Treatment: Hepatitis B treatment, peginterferon alpha.

  • Hepatitis E :

    • Transmission: Via the faecal-oral route, often through contaminated water.

    • Symptoms: Symptoms similar to hepatitis A, may be severe in pregnant women.

    • Prevention: Food hygiene, clean drinking water.

    • Treatment: Supportive, generally self-limiting.

• Alcoholic hepatitis :

  • Causes: Excessive and prolonged alcohol consumption.

  • Symptoms: Abdominal pain, jaundice, ascites, hepatic encephalopathy.

  • Treatment: Cessation of alcohol consumption, corticosteroids for severe cases, liver transplantation as a last resort.

2. Cirrhosis

• Causes: Chronic hepatitis (B, C), alcoholism, non-alcoholic fatty liver (NASH), autoimmune diseases.

• Clinical signs: jaundice, ascites, stellate angiomas, palmar erythrosis, gynaecomastia.

• Complications :

  • Portal hypertension: Causes oesophageal varices and splenomegaly.

  • Ascites: accumulation of fluid in the abdominal cavity, risk of spontaneous bacterial peritonitis.

  • Hepatic encephalopathy: Impaired brain function due to the accumulation of toxins.

  • Hepatocellular carcinoma: Monitoring by ultrasound and alpha-fetoprotein assay.

• Treatment :

  • Management of portal hypertension: beta-blockers, variceal ligation, TIPS (transjugular intrahepatic portosystemic shunt).

  • Treatment of ascites: diuretics (spironolactone, furosemide), paracentesis.

  • Hepatic encephalopathy: Lactulose, non-absorbable antibiotics (rifaximin).

3. Cholestasis

• Definition: Reduction or cessation of intra- or extra-hepatic bile flow.

• Intrahepatic causes: viral hepatitis, cirrhosis, primary sclerosing cholangitis.

• Extra-hepatic causes: Gallstones, tumours, strictures.

• Symptoms: Jaundice, pruritus, discoloured stools, dark urine.

• Diagnosis: Elevated bilirubin, alkaline phosphatase, GGT, imaging (ultrasound, MRI).

• Treatment: Depends on underlying cause, treatment of symptoms (ursodeoxycholic acid for pruritus).

Biliary disorders

1. Biliary lithiasis

• Types of gallstones :

  • Cholesterol: The most common, formed by the precipitation of cholesterol.

  • Pigmentary: Less frequent, linked to the breakdown of haemoglobin.

• Symptoms :

  • Biliary colic: sudden, intense pain in the right hypochondrium, sometimes radiating to the right shoulder.

  • Associated symptoms: Nausea, vomiting, intolerance to fatty foods.

• Complications :

  • Acute cholecystitis: Inflammation of the gallbladder, often requiring cholecystectomy.

  • Cholangitis: Infection of the bile ducts requiring antibiotic treatment and sometimesbiliary drainage.

  • Biliary pancreatitis: inflammation of the pancreas caused by a gallstone blocking the pancreatic duct.

• Diagnostic :

  • Abdominal ultrasound: first-line examination.

  • Endoscopic retrograde cholangiopancreatography (ERCP): To visualise and treat stones in the bile ducts.

• Treatment :

  • Symptomatic: analgesics, anti-inflammatories.

  • Surgical: Laparoscopic or open cholecystectomy is the treatment of choice for symptomatic stones.

2. Cholecystitis

• Definition: Acute or chronic inflammation of the gallbladder, often secondary to lithiasis.

• Symptoms :

  • Persistent pain in the right hypochondrium.

  • Fever, nausea, vomiting.

  • Sensitivity to palpation (positive Murphy's sign).

• Diagnostic :

  • Abdominal ultrasound: thickening of the vesicular wall, presence of stones.

  • Biological tests: Leukocytosis, elevated CRP.

• Treatment :

  • Antibiotics: To treat infection.

  • Cholecystectomy: Often performed as an emergency or after initial stabilisation.

3. Cholangite

• Definition: Infection of the bile ducts, often due to obstruction by a stone.

• Symptoms :

  • Charcot's triad: fever with chills, abdominal pain, jaundice.

  • Reynolds pentad (if severe): Hypotension and altered mental state.

• Diagnostic :

  • Biological tests: Leukocytosis, biological cholestasis (alkaline phosphatases, GGT, bilirubin).

  • Imaging: Ultrasound, CT scan or ERCP to confirm the diagnosis and treat the obstruction.

• Treatment :

  • Antibiotics: Broad spectrum to cover Gram-negative and anaerobic bacteria.

  • Biliary drainage: ERCP with sphincterotomy and stone extraction, percutaneous drainage if necessary.

Pancreatic disorders

1. Acute pancreatitis

• Causes :

  • Biliary lithiasis, alcoholism.

  • Hypertriglyceridaemia, hypercalcaemia.

  • Medications (certain diuretics, azathioprine).

• Symptoms :

  • Intense epigastric pain radiating to the back.

  • Nausea, vomiting, abdominal distension.

• Complications :

  • Pancreatic necrosis: necrosis of pancreatic tissue which may lead to secondary infection.

  • Pseudocysts : Accumulation of fluid surrounded by a fibrous wall.

  • Pancreatic insufficiency: malabsorption, secondary diabetes.

• Diagnostic :

  • Serum amylase and lipase: High.

  • Imaging: abdominal CT scan to assess the extent of necrosis.

• Treatment :

  • Supportive: intravenous rehydration, analgesics.

  • Nutrition: Initial fasting followed by early enteral feeding if possible.

  • Complications: Antibiotics for infections, drainage of fluid collections if necessary.

2. Chronic pancreatitis

• Causes :

  • Chronic alcohol consumption, genetic diseases (e.g. cystic fibrosis), hypercalcaemia.

• Symptoms :

  • Chronic abdominal pain, exocrine and endocrine pancreatic insufficiency (diabetes).

• Complications :

  • Pseudocysts, biliary stenosis, pancreatic cancer.

• Diagnostic :

  • Biological tests: Pancreatic function (low levels of lipase and amylase).

  • Imaging: CT, MRI, endoscopic ultrasound.

• Treatment :

  • Pain: analgesics, endoscopic or surgical procedures.

  • Pancreatic insufficiency: pancreatic enzymes, glycaemic control.

  • Complications: Monitoring and treatment of pseudocysts, stenoses and other complications.

3. Pancreatic cancer

• Risk factors: Smoking, chronic pancreatitis, family history, genetic mutations (BRCA2).

• Symptoms :

  • Obstructive jaundice, weight loss, abdominal pain radiating to the back, de novo diabetes.

• Diagnostic :

  • Imaging: CT, MRI, endoscopic ultrasound with biopsy.

  • Tumour markers: CA 19-9.

• Treatment :

  • Surgery: Whipple's resection for resectable tumours.

  • Chemotherapy: Gemcitabine, FOLFIRINOX.

  • Radiotherapy: As adjuvant treatment or to alleviate symptoms.

Conclusion

Hepato-biliary and pancreatic disorders cover a wide range of pathologies, from acute infections to chronic diseases and cancers. A thorough understanding of these conditions enables early diagnosis, appropriate management and effective treatment of patients. Multidisciplinary management is often required, including consultations with hepatologists, gastroenterologists, radiologists and surgeons.