Objetivos de Aprendizaje

Pontificia
Universidad Javeriana
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Geriatría y Gerontología de Hazzard, 7e
Capítulo 92: Enfermedad biliar y pancreática
Sean G. Kelly; Justin C. Rice; Mark Benson; Michael R. Lucey
OBJETIVOS DE APRENDIZAJE
Objetivos de aprendizaje
Aprenda la epidemiología, genética, etiología y patogénesis de enfermedades biliares y pancreáticas comunes en adultos
mayores.
Comprender las manifestaciones comunes y atípicas y las pruebas para diagnosticar enfermedades comunes de la vesícula
biliar y el páncreas en pacientes mayores.
Conozca los tratamientos emergentes y de vanguardia para los trastornos biliares y pancreáticos en la población mayor.
Adquirir conocimientos sobre los síntomas, el diagnóstico y el tratamiento de los cánceres de vesícula biliar y páncreas en
adultos mayores.
Puntos clínicos clave
1. La edad es un factor de riesgo importante para los cálculos biliares, que son más comunes entre los adultos mayores,
especialmente las mujeres.
2. La colecistitis aguda puede presentarse de forma atípica en pacientes de edad avanzada sin fiebre, náuseas, vómitos o dolor
abdominal intenso.
3. La ecografía es la prueba diagnóstica inicial de elección y el descubrimiento accidental de cálculos biliares no es una
indicación de tratamiento. Cuando sea apropiado, la colecistectomía laparoscópica temprana es el tratamiento de elección en
pacientes mayores.
4. En ausencia de cálculos biliares y abuso de alcohol , la causa más común de pancreatitis aguda en adultos mayores es la
malignidad.
5. El abuso de alcohol es la causa más común de pancreatitis crónica en pacientes mayores.
ENFERMEDAD BILIAR
Cholelithiasis
Table 921 outlines the risk factors associated with gallstone formation. Age is a major factor, although the reasons for this are unclear. By the ninth
decade of life, the prevalence of gallstones is 38% in women and 22% in men. In men older than 90 years, the incidence increases to 31%. The
prevalence of gallstones in the US population increases by 1% per year in women and by 0.5% per year in men after age 15. Native Americans are
predisposed to gallstone formation at an earlier age. At age 50, the prevalence of gallstones in Native Americans is 80% in women and 70% in men. The
increase in risk in women is related to increased biliary cholesterol excretion by estrogen. Approximately 500,000 people in the United States develop
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symptomatic gallstones each year.
Chapter 92: Biliary and Pancreatic Disease, Sean G. Kelly; Justin C. Rice; Mark Benson; Michael R. Lucey Page 1 / 12
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TABLE 921
RISK FACTORS FOR GALLSTONE FORMATION
Pontificia Universidad Javeriana
Table 921 outlines the risk factors associated with gallstone formation. Age is a major factor, although the reasons for this are unclear. By the ninth
decade of life, the prevalence of gallstones is 38% in women and 22% in men. In men older than 90 years, the incidence increases to 31%. The
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prevalence of gallstones in the US population increases by 1% per year in women and by 0.5% per year in men after age 15. Native Americans are
predisposed to gallstone formation at an earlier age. At age 50, the prevalence of gallstones in Native Americans is 80% in women and 70% in men. The
increase in risk in women is related to increased biliary cholesterol excretion by estrogen. Approximately 500,000 people in the United States develop
symptomatic gallstones each year.
TABLE 921
RISK FACTORS FOR GALLSTONE FORMATION
Increasing age
Female sex
Obesity
Dyslipidemia
Rapid weight loss
Medications
Ethnicity—Caucasian, Native American and Hispanic
The great majority of patients with gallstones remain asymptomatic. Gallstones are frequently found incidentally when a patient undergoes abdominal
imaging. It is often a challenge to the medical practitioner to determine whether the symptoms that led to the discovery of gallstones, such as mildly
abnormal liver tests, or chronic nonsevere abdominal pain are causally related to the newly discovered gallstones. Serious complications that may
arise from cholelithiasis include severe abdominal pain (“biliary colic”), sepsis, pancreatitis, or cancer of the gallbladder.
Approximately 80% of gallstones in the United States contain cholesterol as their major constituent and are termed cholesterol stones. Cholesterol
crystals tend to precipitate and form stones or sludge when an excess of cholesterol is present in bile relative to the concentrations of bile acids and
phospholipids. Pigment stones develop in the setting of excess bilirubin in bile. In conditions such as hemolysis or cirrhosis with high heme turnover,
unconjugated bilirubin in the form of calcium bilirubinate crystallizes forming black pigment stones. These account for 10% to 20% of gallstones in the
United States. Bacterial colonization of normally sterile bile may lead to an increase in unconjugated bilirubin and in turn calcium bilirubinate.
Gallstones arising from this process are brown pigment stones. Black pigment stones are found primarily in the gallbladder, whereas brown pigment
stones may be found not only in the gallbladder but also in the intrahepatic or extrahepatic bile ducts.
Choledocholithiasis
With gallbladder contraction, gallstones can enter and potentially obstruct the common bile duct. Such obstruction can lead to jaundice, ascending
cholangitis, liver abscess, and pancreatitis. Stones are present in the common bile duct in approximately 15% of patients undergoing cholecystectomy
for chronic cholecystitis with gallstones. The prevalence of stones in the common bile duct increases with age. Although dilatation of the common bile
duct correlates with choledocholithiasis, the common bile duct may become dilated as a result of the normal aging process or following
cholecystectomy. In general, 6 mm is considered the upper limit of normal for the common bile duct measured by ultrasound. Perhaps a more useful
tool, especially in older adults, is a common bile duct measurement of 1 mm per decade of life. For example, a patient who is 70 years old may have a
common bile duct measurement of 7 mm in the absence of choledocholithiasis. Comparison to previous imaging studies for interval change is
important as well.
The classical signs and symptoms of biliary obstruction are called biliary colic and include epigastric or right upper quadrant pain, nausea, vomiting,
and pruritus. Patients may develop dark urine and acholic stools. Tender hepatomegaly may develop because of the increased pressure in the biliary
tree. The presence of fever and jaundice is concerning for ascending cholangitis. The constellation of abdominal pain, jaundice, and fever, known as
Charcot triad, is helpful in making the diagnosis of ascending cholangitis.
Acute Cholecystitis
Approximately 50% to 70% of cases of acute cholecystitis occur in the geriatric population. This condition in characterized by prolonged obstruction of
the cystic duct by one or more gallstones. This leads to inflammation and possibly infection of the gallbladder. Acalculous cholecystitis refers to
inflammation of the gallbladder in the absence of gallstones. It is usually idiopathic, but tends to occur in debilitated and or vasculopathic patients.
Acalculous cholecystitis accounts for 5% to 10% of cases of cholecystitis. The severity of cholecystitis varies from mild edema to severe inflammation
and, at its most catastrophic, necrosis, or perforation of the gallbladder.
Acute cholecystitis has several classic clinical manifestations. The usual symptoms include abdominal pain, especially in the right upper quadrant or
epigastrium. This pain may radiate to the back or shoulder. It is typically continuous and severe. Patients may notice the onset of such pain after eating
a fatty meal. Fevers, chills, nausea, and vomiting are common as well.
Approximately 50% to 70% of cases of acute cholecystitis occur in the geriatric population. This condition in characterized by prolonged obstruction of
the cystic duct by one or more gallstones. This leads to inflammation and possibly infection of the gallbladder. Acalculous cholecystitis refers to
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inflammation of the gallbladder in the absence of gallstones. It is usually idiopathic, but tends to occur in debilitated and or vasculopathic patients.
Acalculous cholecystitis accounts for 5% to 10% of cases of cholecystitis. The severity of cholecystitis varies from mild edema to severe inflammation
and, at its most catastrophic, necrosis, or perforation of the gallbladder.
Acute cholecystitis has several classic clinical manifestations. The usual symptoms include abdominal pain, especially in the right upper quadrant or
epigastrium. This pain may radiate to the back or shoulder. It is typically continuous and severe. Patients may notice the onset of such pain after eating
a fatty meal. Fevers, chills, nausea, and vomiting are common as well.
Physical examination often shows a patient who appears ill and uncomfortable. Pain is usually elicited by palpating the right upper quadrant and/or
epigastrium of the abdomen. A Murphy sign is characterized by cessation of inspiration while palpating the area of the gallbladder because of extreme
discomfort.
Acute cholecystitis may present atypically in older adults and with delayed recognition results in a greater risk of complications. Older patients usually
have right upper quadrant or epigastric pain and tenderness, but other signs and symptoms may be lacking. Older patients may present without fever,
nausea, or vomiting in more than 50% of acute cases. These signs may not be present in 33% even in the setting of gallbladder gangrene or
perforation. Acalculous cholecystitis is more common in older adults, and diagnosis of such cases may be more difficult because of the lack of stones
on imaging studies.
Chronic Cholecystitis
Chronic cholecystitis refers to biliary pain caused by recurrent episodes of cystic duct obstruction leading to a chronic inflammatory response.
Ultimately this may lead to scarring and gallbladder dysfunction. On ultrasound, chronic cholecystitis has a more subtle appearance than acute
cholecystitis. A review of 412 patients with histologically proven acute or chronic cholecystitis showed gallbladder wall thickening in 80% of those with
acute cholecystitis as opposed to 18% of those with chronic cholecystitis. Dilated gallbladder was seen in 60% of acute versus 12% of chronic. Thus,
preoperatively, chronic cholecystitis may be difficult to distinguish from noninflammatory symptomatic gallstone disease. As with acute cholecystitis,
elective cholecystectomy is the treatment of choice.
Investigations
In acute cholecystitis, ultrasound typically shows gallstones and pericholecystic fluid and/or edema. A sonographic Murphy sign is helpful in
establishing the diagnosis. Ultrasonography will demonstrate the presence of stones with an accuracy of 90%. A HIDA (99mtechnetiumNsubstituted
hepatoiminodiacetic acid) scan will show opacification of the bile ducts, but not of the gallbladder, in cholecystitis.
Ultrasound is the usual initial diagnostic test of choice for choledocholithiasis with a sensitivity of 20% to 38% and specificity of 80% to 100% (Table
922). It has the advantage of being noninvasive, easily tolerated by the patient, widely available, and inexpensive. Abdominal CT has higher sensitivity
than ultrasound (50%–88%), but often fails to identify stones less than 5 mm. Magnetic resonance cholangiopancreatography (MRCP) allows for
visualization of biliary anatomy as well as stones and has sensitivity of 57% to 100% and specificity of 73% to 100% for common bile duct stones. It also
has the advantage of being noninvasive, but its disadvantages include cost and potential patient discomfort from claustrophobia.
TABLE 922
IMAGING AND THERAPIES FOR CHOLEDOCHOLITHIASIS
TEST SENSITIVITY SPECIFICITY ADVANTAGES DISADVANTAGES
Ultrasound 20%–38% 80%–100% Noninvasive, low cost Low sensitivity, nontherapeutic
CT 50%–88% 84%–98% Ease for patient Expensive, nontherapeutic
MRCP 57%–100% 93%–97% Highly sensitive Expensive, nontherapeutic, may cause claustrophobia
EUS 94% 95% High precision Expensive, nontherapeutic, sedation
ERCP 57%–100% 73%–100% Therapeutic Expensive, may cause pancreatitis
PTC Therapeutic Bleeding, pain (especially in the absence of dilated bile ducts)

ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; MRCP, magnetic resonance cholangiopancreatography; PTC, Page 3 / 12
Chapter 92: Biliary and Pancreatic Disease, Sean G. Kelly; Justin C. Rice; Mark Benson; Michael R. Lucey
percutaneous transhepatic cholangiography.
922). It has the advantage of being noninvasive, easily tolerated by the patient, widely available, and inexpensive. Abdominal CT has higher sensitivity
than ultrasound (50%–88%), but often fails to identify stones less than 5 mm. Magnetic resonance cholangiopancreatography (MRCP) allows for
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visualization of biliary anatomy as well as stones and has sensitivity of 57% to 100% and specificity of 73% to 100% for common bile duct stones. It also
has the advantage of being noninvasive, but its disadvantages include cost and potential patient discomfort from claustrophobia.
TABLE 922
IMAGING AND THERAPIES FOR CHOLEDOCHOLITHIASIS
TEST SENSITIVITY SPECIFICITY ADVANTAGES DISADVANTAGES
Ultrasound 20%–38% 80%–100% Noninvasive, low cost Low sensitivity, nontherapeutic
CT 50%–88% 84%–98% Ease for patient Expensive, nontherapeutic
MRCP 57%–100% 93%–97% Highly sensitive Expensive, nontherapeutic, may cause claustrophobia
EUS 94% 95% High precision Expensive, nontherapeutic, sedation
ERCP 57%–100% 73%–100% Therapeutic Expensive, may cause pancreatitis
PTC Therapeutic Bleeding, pain (especially in the absence of dilated bile ducts)
ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; MRCP, magnetic resonance cholangiopancreatography; PTC,
percutaneous transhepatic cholangiography.
Endoscopic ultrasound (EUS) has become a useful imaging modality in cases where the presence of stones in the common bile duct is suspected, but
remains uncertain. EUS has sensitivity and specificity of 94% and 95%, respectively, and sedation needs are similar to an upper endoscopy. Endoscopic
retrograde cholangiopancreatography (ERCP) is both a diagnostic and therapeutic modality for choledocholithiasis. Though there are varying
estimates of precision with ERCP, multiple studies report a sensitivity and specificity of greater than 95%. The injection of contrast material into the
biliary tree allows visualization of all but very small stones. A sphincterotomy is often performed to prevent recurrent obstruction. In the case of
cholangitis, a stent is often left in the common bile duct to drain purulent material, stones, and sludge. The disadvantages of ERCP include the
potential for acute pancreatitis, technical and infrastructural requirements, and cost. However, ERCP poses no greater risk in older adults than in the
younger population. One study of ERCP in the geriatric population showed no difference in the rate of therapeutic ERCP complications in patients
older than 80 years (6.8%) versus those younger than 80 years (5.1%). In a retrospective cohort between 2002 and 2005, there were no significant
differences in successful biliary drainage, complications or mortality in a group of 178 patients over 75 years of age compared to 159 patients less than
75 years. Another study evaluated the safety of ERCP in patients older than 90 years, and the complication rate in this age group was 6.3% compared to
8.4% in patients 70 to 89 years of age. Therefore, ERCP is a safe procedure even in those with very advanced age. The rate of recurrence of symptomatic
CBD stones after ERCP was higher in patients older than 80 years (20%) versus 4% in patients 50 years old or younger. Thus, older adults are at higher
risk for needing a repeat ERCP. A study of 206 patients from 2006 to 2010 demonstrated that combined EUS/ERCP in one session is safe in the geriatric
population with no increased risk of adverse events compared to younger patients. Refer to Figure 921 for review of multiple ERCP images.
FIGURE 921
A–D. Multiple ERCP images. A . Normal ampulla with cannulation. B . Bulging, ulcerated ampulla found to be adenocarcinoma s/p sphincterotomy and

plastic biliary stent placement. C . Common bile duct stone removed with balloon D . Common hepatic duct stricture due to cholangiocarcinoma.
Endoscopic and fluoroscopic images s/p metal biliary stent placement. (Images courtesy of Deepak Gopal, MD, University of Wisconsin, Madison, WI.)
FIGURE 921
A–D. Multiple ERCP images. A . Normal ampulla with cannulation. B . Bulging, ulcerated ampulla found to be adenocarcinoma s/p sphincterotomy and
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plastic biliary stent placement. C . Common bile duct stone removed with balloon D . Common hepatic duct stricture due to cholangiocarcinoma.
Endoscopic and fluoroscopic images s/p metal biliary stent placement. (Images courtesy of Deepak Gopal, MD, University of Wisconsin, Madison, WI.)
Treatment
Incidental discovery of gallstones is not an indication for therapy. In a study of 123 subjects with silent gallstones, biliary pain occurred in only 16
persons in the followup period of up to 24 years. Of those 16 subjects, only three had significant complications: one with acute pancreatitis and two
with acute cholecystitis. The cumulative probability of developing biliary pain in this population was 10% at 5 years, 15% at 10 years, and 18% at 15 and
20 years. None of these subjects died as a consequence of gallstone disease. Because asymptomatic gallstones tend to follow a benign course,
cholecystectomy should be considered primarily in those with symptoms or complications.
Prompt treatment of acute cholecystitis is warranted to prevent deterioration, complications, and progression to chronic cholecystitis. In addition to
Treatment
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Incidental discovery of gallstones is not an indication for therapy. In a study of 123 subjects with silent gallstones, biliary pain occurred in only 16
persons in the followup period of up to 24 years. Of those 16 subjects, only three had significant complications: one with acute pancreatitis and two
with acute cholecystitis. The cumulative probability of developing biliary pain in this population was 10% at 5 years, 15% at 10 years, and 18% at 15 and
20 years. None of these subjects died as a consequence of gallstone disease. Because asymptomatic gallstones tend to follow a benign course,
cholecystectomy should be considered primarily in those with symptoms or complications.
Prompt treatment of acute cholecystitis is warranted to prevent deterioration, complications, and progression to chronic cholecystitis. In addition to
intravenous fluids, antibiotics, and pain control, surgery is the mainstay of treatment. Each patient’s clinical status and comorbidities must be
considered in the decision to proceed with general anesthesia and surgery. Laparoscopic cholecystectomy has several advantages over open
cholecystectomy including less discomfort, shorter hospital stay, and lower cost. Complications from this procedure often involve biliary trauma.
Agrusa and colleagues performed a retrospective study involving 1227 patients who underwent cholecystectomy at their institution between 2010 and
2014. Among this cohort, 351 patients were 65 to 79 years of age and 65 patients were 80 years of age or older. There was no significant difference in
the conversion rate from laparoscopic to open cholecystectomy between those under 65 years of age and those over 80 years of age, 0.7% versus 1.5%,
respectively. Most of the procedures done for those under 65 years were done on an elective basis (89.7%), whereas a much higher percentage of
procedures done in those older than 80 years were done emergently (43.1%). There were two deaths in the older population. Age and comorbidities
are predictors of surgical outcomes. Timing of intervention is also important with better outcomes in patients who undergo early laparoscopic
cholecystectomy for acute cholecystitis. Whenever possible, this should be performed within the same hospital stay for definitive treatment of
gallstone disease.
As discussed above, in older patients with acute cholecystitis who are felt to be suitable surgical candidates, laparoscopic cholecystectomy is a
reasonable option. However, for older patients who are very ill or have significant comorbidities, gallbladder drainage prior to surgery may be a viable
alternative. This was evaluated in a case series of 84 patients with acute cholecystitis older than 70 years with severe cholecystitis or an American
Society of Anesthesiologist score of II to IV. In 83 of these patients, a percutaneous cholecystostomy drain was placed. A transcatheter cholangiogram
was done and those with common bile duct stones underwent endoscopic sphincterotomy. Elective cholecystectomy was then performed in 70
patients with no deaths and a 24% morbidity rate. Percutaneous cholecystostomy drainage is an effective and often definitive treatment for acalculous
cholecystitis as well. In a study of 15 patients with acute acalculous cholecystitis, prompt improvement was seen in 14 patients after placement of a
pigtail catheter into the gallbladder. Morbidity rate after this procedure was 13%, and no deaths were seen.
Patients with symptomatic gallstone who cannot or do not wish to undergo invasive procedures may benefit from dissolution of gallstones with
ursodiol. This medication is only useful in the setting of cholesterol gallstones. A metaanalysis of randomized trials using ursodiol for treatment of
gallstones found a dissolution rate of 37% after 6 months with doses of at least 7 mg/kg or greater than 500 mg/day. However, at least 50% of patients
treated with ursodiol for gallstones will have recurrent stone formation.
Carcinoma
Gallbladder cancer
Cancer of the gallbladder is uncommon in the United States and carries a poor prognosis. Often, this diagnosis is not made until late in its course. The
5year survival for local disease is 42%, but drops to 0.7% with distant spread of disease. SEER data show that gallbladder cancer occurs primarily in
older adults. Approximately 75% of cases occur in patients older than 65 years. Ninety percent of all gallbladder cancers are carcinomas and occur in
approximately 3:1 femaletomale ratio. Ethnic background and geographic distribution appear to influence the development of gallbladder cancer, as
the highest incidence rates are found in those of Native American and Mexican descent and those living in the region of the Andes. It has been noted
that 80% of patients with gallbladder cancer have a history of cholelithiasis. Chronic inflammation from gallstones is thought to induce metaplasia of
the gallbladder. Size and duration of gallstones appear to be important in carcinogenesis. Prophylactic cholecystectomy in certain higher risk groups is
controversial. Among those who may benefit from this procedure include patients with a porcelain gallbladder and patients with a congenital defect in
the junction of the pancreatobiliary duct.
Cholangiocarcinoma—cancer of the bile ducts
Primary bile duct cancers account for less than 3% of all cancers diagnosed in the United States. Cancer of the extrahepatic bile ducts is more common
in older adults, as 65% of cases are found in those older than 65 years and 69 is the median age. Ninetynine percent of these are carcinomas. The 5
year survival rate ranges from 26.5% with localized disease to 1.3% with distant spread. The incidence is 1.2 per 100,000 in males and 0.8 per 100,000 in
females. The tumors tend to infiltrate along the wall of the bile duct and may be difficult to differentiate from benign strictures. Patients present with
signs and symptoms of biliary obstruction with jaundice, pruritus, and weight loss. Treatment is primarily surgical, most commonly with a Whipple
procedure. Rare patients may be suitable for liver transplantation. For those who are not surgical candidates, biliary decompression by stent
placement is a reasonable option for palliation to maintain patency of biliary drainage.
ENFERMEDAD PANCREÁTICA
Primary bile duct cancers account for less than 3% of all cancers diagnosed in the United States. Cancer of the extrahepatic bile ducts is more common
in older adults, as 65% of cases are found in those older than 65 years and 69 is the median age. Ninetynine percent of these are carcinomas. The 5
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year survival rate ranges from 26.5% with localized disease to 1.3% with distant spread. The incidence is 1.2 per 100,000 in males and 0.8 per 100,000 in
females. The tumors tend to infiltrate along the wall of the bile duct and may be difficult to differentiate from benign strictures. Patients present with
signs and symptoms of biliary obstruction with jaundice, pruritus, and weight loss. Treatment is primarily surgical, most commonly with a Whipple
procedure. Rare patients may be suitable for liver transplantation. For those who are not surgical candidates, biliary decompression by stent
placement is a reasonable option for palliation to maintain patency of biliary drainage.
ENFERMEDAD PANCREÁTICA
Anatomía
La figura 922 muestra la anatomía macroscópica del páncreas. El páncreas se puede dividir en páncreas endocrino y exocrino. Cuatro tipos
diferentes de células de los islotes que comprenden el páncreas endocrino producen hormonas como la insulina , el glucagón , el polipéptido
pancreático y la somatostatina. El páncreas exocrino es el tema central de este capítulo. El páncreas exocrino se compone principalmente de células
acinares y de conductos. Las células acinares producen las enzimas digestivas. La enzima clave es el tripsinógeno. Las células del conducto producen
el líquido rico en bicarbonato para su secreción.
FIGURA 922.
Anatomía normal del páncreas. (De Morton DA, Foreman KB, Albertine KH. The Big Picture: Gross Anatomy . Nueva York: McGrawHill, 2011.)
Fisiología
El páncreas exocrino tiene proteasas, lipasas, glicosidasas (amilasa) y nucleasas. Las proteasas y nucleasas se almacenan en forma inactiva. Las
proteasas constituyen más del 75% del páncreas en peso. El tripsinógeno es la proteasa principal. El tripsinógeno se activa a tripsina en el duodeno
por la enteroquinasa, la única función fisiológica de esta enzima. Posteriormente, la tripsina activa las otras enzimas digestivas y, en presencia de
calcio, activa el tripsinógeno a tripsina. En ausencia de calcio, la tripsina tiene retroalimentación negativa al degradar otras moléculas de tripsina. El
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Fisiología
El páncreas exocrino tiene proteasas, lipasas, glicosidasas (amilasa) y nucleasas. Las proteasas y nucleasas se almacenan en forma inactiva. Las
proteasas constituyen más del 75% del páncreas en peso. El tripsinógeno es la proteasa principal. El tripsinógeno se activa a tripsina en el duodeno
por la enteroquinasa, la única función fisiológica de esta enzima. Posteriormente, la tripsina activa las otras enzimas digestivas y, en presencia de
calcio, activa el tripsinógeno a tripsina. En ausencia de calcio, la tripsina tiene retroalimentación negativa al degradar otras moléculas de tripsina. El
sitio de acción principal de la tripsina son los aminoácidos arginina y lisina. El defecto genético más común que facilita el desarrollo de pancreatitis
hereditaria se llama R122 H, en el que la argininaen la posición 122 de la molécula de tripsina (un sitio regulador importante) se sustituye por histidina.
Este defecto niega el mecanismo de seguridad de retroalimentación negativa para la regulación de la tripsina.
Hay dos mecanismos importantes adicionales que regulan la función pancreática. Primero, el ácido en el duodeno estimula la secreción de la
hormona secretina y, a través de la mediación vagal, hace que las células del conducto del páncreas secreten bicarbonato. El segundo mecanismo
regulador implica el circuito de retroalimentación de colecistoquinina (CCK). Los acinos pancreáticos humanos carecen de receptores CCK. La
presencia de proteína en el duodeno aumenta eficazmente el factor de liberación de colecistoquinina (CCK RF), que estimula la liberación de CCK. El
cerebro reconoce el nivel elevado de CCK, lo que lleva a la estimulación vagal de las células acinares del páncreas para que secreten más enzimas
digestivas.
Envejecimiento y páncreas
El cuadro 923 describe los cambios del páncreas relacionados con la edad. El volumen máximo de jugo pancreático excretado en respuesta a
laestimulacióncon secretina y CCK aumenta hasta la quinta década y luego disminuye de manera constante. El bicarbonato disminuye de manera
constante después de la cuarta década de la vida. Además, en los estudios de CPRE, se ha observado un ligero aumento en el tamaño del conducto
pancreático en la cabeza y el cuerpo, pero no en la cola, con el envejecimiento. A pesar de estos cambios anatómicos y fisiológicos, solo los casos raros
de deficiencia exocrina pancreática son clínicamente evidentes en adultos mayores sanos.
CUADRO 923
EL ENVEJECIMIENTO Y EL PÁNCREAS
Grasa, fibrosis y reducción de peso después de la séptima década.
El bicarbonato disminuye de manera constante después de la cuarta década de la vida.
Deficiencia pancreática exocrina: rara en ancianos sin patología subyacente
Pancreatitis alcohólica: una enfermedad de la mediana edad.
La prevalencia de cálculos biliares y, por lo tanto, la pancreatitis por cálculos biliares, aumenta con la edad.
Mayor incidencia de malignidad, particularmente adenocarcinoma
Más allá de los cambios normales del envejecimiento, la edad avanzada presenta otras amenazas para la estructura y función del páncreas. La
pancreatitis secundaria al alcohol tiende a ser una enfermedad de la mediana edad, mientras que la enfermedad de cálculos biliares sigue teniendo
una incidencia relativamente alta en las cohortes de mayor edad. El mayor riesgo en la población de mayor edad es una mayor incidencia de
malignidad, en particular adenocarcinoma. Además, durante los estudios de imágenes del abdomen, ahora se encuentran con frecuencia pequeñas
lesiones quísticas y sólidas incidentales del páncreas.
Pancreatitis aguda
La pancreatitis aguda tiene una variedad de etiologías, pero todas eventualmente conducen a la activación de las enzimas digestivas, particularmente
la tripsina en las células acinares pancreáticas. Las etiologías más comunes de la pancreatitis aguda son los cálculos biliares y el alcohol . Sin embargo,
en un paciente anciano sin cálculos biliares o antecedentes de uso crónico excesivo de alcohol , la sospecha de malignidad subyacente debe ser
especialmente alta. Los defectos hereditarios en la vía del tripsinógeno a la tripsina pueden conducir a formas raras de pancreatitis aguda,
denominada "pancreatitis hereditaria". La obstrucción del conducto pancreático por un cálculo biliar es un mecanismo importante para iniciar la
lesión pancreática. Alcohol, por otro lado, provoca una disfunción mitocondrial, lo que permite un aumento de los niveles de calcio intracelular y la
posterior activación de la tripsina. La hipertrigliceridemia a menudo se pasa por alto como causa de pancreatitis aguda. Los triglicéridos deben
medirse al ingreso al hospital porque los niveles a menudo disminuyen rápidamente con el reposo intestinal y los líquidos. Muchos medicamentos
pueden causar pancreatitis aguda o elevar los niveles de triglicéridos. Consulte el cuadro 924 para conocer las etiologías de la pancreatitis aguda.
Chapter 92: Biliary and Pancreatic Disease, Sean G. Kelly; Justin C. Rice; Mark Benson; Michael R. Lucey
CUADRO 924
Page 8 / 12
ETIOLOGÍAS PARA LA PANCREATITIS
especialmente alta. Los defectos hereditarios en la vía del tripsinógeno a la tripsina pueden conducir a formas raras de pancreatitis aguda,
denominada "pancreatitis hereditaria". La obstrucción del conducto pancreático por un cálculo biliar es un mecanismo importante para iniciar la
lesión pancreática. Alcohol, por otro lado, provoca una disfunción mitocondrial, lo que permite un aumento de los niveles de calcio intracelular y la
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posterior activación de la tripsina. La hipertrigliceridemia a menudo se pasa por alto como causa de pancreatitis aguda. Los triglicéridos deben
medirse al ingreso al hospital porque los niveles a menudo disminuyen rápidamente con el reposo intestinal y los líquidos. Muchos medicamentos
pueden causar pancreatitis aguda o elevar los niveles de triglicéridos. Consulte el cuadro 924 para conocer las etiologías de la pancreatitis aguda.
CUADRO 924
ETIOLOGÍAS PARA LA PANCREATITIS
Cálculos biliares
Alcohol
Hipertrigliceridemia
Medicamentos / toxinas
Pancreatitis hereditaria
Mutación del gen de la fibrosis quística
Pancreatitis autoinmune
Divisum pancreático
Trauma
PostCPRE
Tumores
Calcio elevado
Idiopático
The predominant symptom of acute pancreatitis is epigastric pain, commonly with radiation into the back. Nausea and vomiting are also frequently
present. Acute pancreatitis is a clinical diagnosis with support from elevated serum amylase and lipase. Levels at least 3 times the upper limit of normal
are typical of acute pancreatitis. Many other conditions cause minor elevations in amylase or lipase. Radiographic studies have little role in diagnosis,
but do play important roles in evaluating etiology (gallstones, neoplasia, pancreatic calcification indicating chronic pancreatitis) and complications
such as necrosis, and pseudocysts. Care needs to be taken in the acute setting not to add intravenous contrast load to a patient that is extremely
intravascularly depleted already. Acute pancreatitis can be divided into mild and severe pancreatitis. The range of disease is from selflimited disease
to multiorgan failure and death. A variety of grading systems including Ranson criteria, Apache score, Glasgow score, and the Baltazar CT grade ±
necrosis do correlate with morbidity and mortality.
Treatment of mild pancreatitis is accomplished with bowel rest, with or without parenteral feeding, intravenous fluids, and pain control. Gallstone
pancreatitis is treated with ERCP, sphincterotomy, and stone extraction if cholangitis or evidence of biliary obstruction is present. Severe pancreatitis
often becomes management of multiorgan failure. Early placement of nasojejunal tubes with subsequent enteral feedings is the standard of care.
Evidence of necrosis on CT scan warrants intravenous antibiotics with good pancreatic penetration such as imipenem. Patients who develop sepsis in
the setting of pancreatic necrosis should be surveyed by interventional radiology for biopsy, gram stain, and culture. Evidence of infection may require
temporary drain placement or surgical debridement.
Pseudocyst formation is an important complication of acute pancreatitis. Approximately 10% of patients with acute pancreatitis proceed to formation
of these fluid collections. Most pseudocysts resolve with time; however, if symptoms are present (early satiety, pain, infection, bleeding), then drainage
via interventional radiology, endoscopic cystgastrostomy, or surgery may be necessary.
Chronic Pancreatitis
Alcohol abuse accounts for approximately 70% of chronic pancreatitis. Idiopathic causes are the second most common cause of chronic pancreatitis.
Cystic fibrosis gene mutations are now frequently being identified as an etiology in approximately a third of idiopathic pancreatitis diagnosis.
Hereditary pancreatitis frequently leads to chronic pancreatitis at a young age. In older adults, it is important to evaluate for tumors compressing the
pancreatic duct as the etiology.
The diagnosis of chronic pancreatitis can be a challenging diagnosis to make. Amylase and lipase can be mildly elevated or normal. Evidence of
calcifications by xray or by CT scan is found in 30% to 40% of cases and can give a diagnosis. Often, more advanced imaging studies such as ERCP,
MRCP, or EUS are used to evaluate the anatomy of the pancreas and give a diagnosis. The major features of chronic pancreatitis include pain,
malabsorption, and frequently diabetes.
Treatment is based on resolving malabsorption with pancreatic enzyme replacement, which also downregulates the CCK feedback loop, decreasing
pancreatic stimulation. Narcotic pain medication is often needed. If a dilated main pancreatic duct is present, a pancreaticojejunostomy (Puestow
procedure) can be helpful. In some cases, near total pancreatectomy is needed with or without islet cell transplantation.
pancreatic duct as the etiology.
The diagnosis of chronic pancreatitis can be a challenging diagnosis to make. Amylase and lipase can be mildly elevated or normal. Evidence of
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calcifications by xray or by CT scan is found in 30% to 40% of cases and can give a diagnosis. Often, more advanced imaging studies such as ERCP,
MRCP, or EUS are used to evaluate the anatomy of the pancreas and give a diagnosis. The major features of chronic pancreatitis include pain,
malabsorption, and frequently diabetes.
Treatment is based on resolving malabsorption with pancreatic enzyme replacement, which also downregulates the CCK feedback loop, decreasing
pancreatic stimulation. Narcotic pain medication is often needed. If a dilated main pancreatic duct is present, a pancreaticojejunostomy (Puestow
procedure) can be helpful. In some cases, near total pancreatectomy is needed with or without islet cell transplantation.
Pancreatic Cancer
Approximately 34,000 new cases of pancreatic cancer will be diagnosed, and 33,000 patients will die secondary to pancreatic cancer each year.
Approximately 87% of patients will be older than age 55 at diagnosis with the median age being 72. The overall 5year survival is 5%. Unfortunately,
little progress has been made to change the mortality from this disease over the last several decades. The genetics have now been further elucidated
showing that 85% of adenocarcinomas of the pancreas have an activating point mutation in the Kras oncogene. In addition, 95% have an inactivated
p16 tumorsuppressor gene. Genetic changes and new knowledge about the cytokine milieu are current areas of active research.
More than 70% of adenocarcinomas arise in the head of the pancreas, which leads to common presentations including jaundice, gastric outlet
obstruction, and pain. Approximately 15% of lesions do not have vasculature invasion or metastatic disease on presentation making surgical resection
possible, with curative intent. The 5year survival in this population is approximately 20%. Staging with CT scans and EUS to evaluate for metastatic
disease and vascular invasion is thus important. In addition, tissue diagnosis can be made with EUS and fine needle aspiration (FNA). Autoimmune
pancreatitis (sclerosing pancreatitis) can present as a pancreatic head mass and obstructive jaundice, making this diagnosis important to consider
prior to surgical or medical therapy for presumed pancreatic cancer. Autoimmune pancreatitis has elevated ANA as well as IgG4 autoantibodies in the
majority of cases and responds to prednisone.
Other tumors exist in the pancreas including neuroendocrine tumors and many types of cystic lesions of the pancreas. Neuroendocrine tumors of the
pancreas are typically solid tumors. Evaluation by EUS with or without FNA and surgical resection are often performed except in multiple endocrine
neoplasia (MEN) 1, where the pancreatic lesions are often multifocal in nature.
Pancreatic Cysts
Cystic lesions of the pancreas are becoming increasingly recognized because of more widespread abdominal imaging (Table 925). Incidental
pancreatic cysts are noted on 1% of abdominal CT scans obtained for any reason. These lesions include pseudocysts, congenital cysts (also known as
simple cysts), and cystic neoplasms including serous cystadenomas (SCN), mucinous cystadenomas (MCN), cystadenocarcinomas, and intraductal
papillary mucinous neoplasm (IPMN). According to guidelines from the American Society of Gastrointestinal Endoscopy, cystic lesions of the pancreas,
even when found incidentally, may represent malignant or premalignant neoplasms and require diagnostic evaluation regardless of size. Pancreatic
pseudocysts and congenital cysts have no malignant potential. Serous cystadenomas represent nearly 30% of pancreatic cystic neoplasms and are
most commonly found in women over 70 years of age. Malignant transformation is extremely rare and serous cystadenomas are often managed
nonoperatively. Over 95% of mucinous cystic neoplasms occur in women with a peak incidence in the fifth decade of life. MCNs account for 10% to 45%
of all cystic pancreatic neoplasms and have risk of malignant transformation near 20%. Intraductal papillary mucinous neoplasms occur most
commonly in males with peak incidence in the seventh decade. Unlike MCNs, IPMNs communicate with the main pancreatic duct (main duct IPMN) or
side branches of pancreatic duct (branch duct IPMN). The distinction between main duct and branch duct IPMN is significant since carcinoma is a
feature of approximately 50% of main duct IPMN lesions and about 10% of branch duct IPMNs. After a lesion is identified on imaging studies, EUS with
FNA is used to obtain fluid for cytologic evaluation and for tumor markers and amylase in order to classify pancreatic cystic lesions (see Table 925
and Figure 923). Given the high malignant potential, MCNs and main duct IPMNs are managed with surgical resection in geriatric patients who are
healthy enough to tolerate surgery. Branch duct IPMNs may be surgically resected as well, though serial imaging is often appropriate based on current
guidelines.
FIGURE 923.
Endoscopic ultrasound with FNA needle in pancreatic cyst. This cyst proved to be a serous cystadenoma. (Image courtesy of Deepak Gopal, MD,
University of Wisconsin, Madison, WI.)
FIGURE 923.
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Endoscopic ultrasound with FNA needle in pancreatic cyst. This cyst proved to be a serous cystadenoma. (Image courtesy of Deepak Gopal, MD,
University of Wisconsin, Madison, WI.)
TABLE 925
IMAGING FEATURES OF PANCREATIC CYSTS AND CYST FLUID ANALYSIS
PSEUDOCYST SCN MCN IPMN
Imaging features A menudo ocurre en el Quistes hipodensos Calcificación periférica, sin Irregular, poliquístico, se comunica

contexto de una con cicatriz central comunicación con el conducto con el conducto pancreático.
pancreatitis. pancreático
Riesgo de Ninguno Extremadamente Hasta 20% Conducto principal IPMN 50%;

malignidad bajo conducto de derivación IPMN 10%
Características Células inflamatorias Células que Células productoras de mucina, Células productoras de mucina,

del líquido contienen posible displasia posible displasia
quístico glucógeno
Quiste amilasa > 250 U / L <250 U / L <250 U / L <250 U / L
Quiste CEA <192 ng / ml <10 ng / ml > 192 ng / ml > 192 ng / ml
CEA, antígeno carcinoembrionario.
OTRAS LECTURAS
Agrusa A, Romano G, Frazetta G, et al. Papel y resultados de la colecistectomía laparoscópica en ancianos. Int J Surg . 2014; 12 (supl. 2): S37 – S39.
[PubMed: 25159549]
Chen CC. The efficacy of endoscopic ultrasound for the diagnosis of common bile duct stones as compared to CT, MRCP and ERCP. J Chin Med Assoc .
2012;75(7):301–302. [PubMed: 22824042]
Fritz E, Kirchgatterer A, Hubner D, et al. ERCP is safe and effective in patients 80 years of age and older compared with younger patients. Gastrointest
Endosc . 2006;64(6):899–905. [PubMed: 17140895]
Henson DE, AboresSaavedra J, Corle D. Carcinoma of the gallbladder: histologic types, stage of disease, grade and survival rates. Cancer .
1992;70:1493–1497. [PubMed: 1516000]
Chen CC. The efficacy of endoscopic ultrasound for the diagnosis of common bile duct stones as compared to CT, MRCP and ERCP. J Chin Med Assoc .
Access Provided by:
2012;75(7):301–302. [PubMed: 22824042]
Fritz E, Kirchgatterer A, Hubner D, et al. ERCP is safe and effective in patients 80 years of age and older compared with younger patients. Gastrointest
Endosc . 2006;64(6):899–905. [PubMed: 17140895]
Henson DE, AboresSaavedra J, Corle D. Carcinoma of the gallbladder: histologic types, stage of disease, grade and survival rates. Cancer .
1992;70:1493–1497. [PubMed: 1516000]
IlesShih L, Hilden K, Alder DG. Combined ERCP and EUS in one session is safe in elderly patients when compared to nonelderly patients: outcomes
in 206 combined procedures. Dig Dis Sci . 2012;57:1949–1953. [PubMed: 22453997]
Jacobson BC, Baron TH, Adler DG, et al. ASGE guideline: the role of endoscopy in the diagnosis and the management of cystic lesions and
inflammatory fluid collections of the pancreas. Gastrointest Endosc . 2005;61(3):363–370. [PubMed: 15758904]
Laugier R, Bernard JP, Berthezene P, Dupuy P. Changes in pancreatic exocrine secretion with age: pancreatic exocrine secretion does decrease in the
elderly. Digestion . 1991;50(3–4):202–211. [PubMed: 1812045]
Li D, Xie K, Wolff R, Abbruzzese JL. Pancreatic cancer. Lancet . 2004;363(9414):1049–1057. [PubMed: 15051286]
Maurea S, Caleo O, Mollica C, et al. Comparative diagnostic evaluation with MR cholangiopancreatography, ultrasonography and CT in patients with
pancreatobiliary disease. Radiol Med . 2009;114(3):390–402. [PubMed: 19266258]
Robinson SM, Scott J, Oppong KW, White SA. ¿Qué hacer con la lesión quística pancreática incidental? Surg Oncol . 2014; 23 (3): 117–125. [PubMed:

24846834]

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TEST SENSITIVITY SPECIFICITY ADVANTAGES DISADVANTAGES

Ultrasound 20%–38% 80%–100% Noninvasive, low cost Low sensitivity, nontherapeutic

CT 50%–88% 84%–98% Ease for patient Expensive, nontherapeutic

MRCP 57%–100% 93%–97% Highly sensitive Expensive, nontherapeutic, may cause claustrophobia

EUS 94% 95% High precision Expensive, nontherapeutic, sedation

ERCP 57%–100% 73%–100% Therapeutic Expensive, may cause pancreatitis

PTC Therapeutic Bleeding, pain (especially in the absence of dilated bile ducts)

TEST SENSITIVITY SPECIFICITY ADVANTAGES DISADVANTAGES

Ultrasound 20%–38% 80%–100% Noninvasive, low cost Low sensitivity, nontherapeutic

CT 50%–88% 84%–98% Ease for patient Expensive, nontherapeutic

MRCP 57%–100% 93%–97% Highly sensitive Expensive, nontherapeutic, may cause claustrophobia

EUS 94% 95% High precision Expensive, nontherapeutic, sedation

ERCP 57%–100% 73%–100% Therapeutic Expensive, may cause pancreatitis

PTC Therapeutic Bleeding, pain (especially in the absence of dilated bile ducts)

A–D. Multiple ERCP images. A . Normal ampulla with cannulation. B . Bulging, ulcerated ampulla found to be adenocarcinoma s/p sphincterotomy and

PSEUDOCYST SCN MCN IPMN

Imaging features A menudo ocurre en el Quistes hipodensos Calcificación periférica, sin Irregular, poliquístico, se comunica

Riesgo de Ninguno Extremadamente Hasta 20% Conducto principal IPMN 50%;

Características Células inflamatorias Células que Células productoras de mucina, Células productoras de mucina,

Quiste amilasa > 250 U / L <250 U / L <250 U / L <250 U / L

Quiste CEA <192 ng / ml <10 ng / ml > 192 ng / ml > 192 ng / ml

Li D, Xie K, Wolff R, Abbruzzese JL. Pancreatic cancer. Lancet . 2004;363(9414):1049–1057. [PubMed: 15051286]

Robinson SM, Scott J, Oppong KW, White SA. ¿Qué hacer con la lesión quística pancreática incidental? Surg Oncol . 2014; 23 (3): 117–125. [PubMed:

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