Procedure Practice 07/15/98 - Coding Recommendations

Feature Article 07/15/98:

Gallbladder, Bile Ducts, and Pancreas

Disorders - Diagnostic and Surgical Procedures
    

Anatomy and Physiology

  
Gallbladder and Bile Ducts

The gallbladder is an accessory digestive organ. It is a pear-shaped sac located beneath the liver on the right side of the abdomen. The gallbladder stores and concentrates bile and then secretes it into the duodenum to aid in fat digestion. The gallbladder is connected to the liver and duodenum via a series of ducts that carry bile. Collectively, the gallbladder and ducts comprise the biliary system. The narrow neck of the gallbladder connects with the cystic duct. The cystic duct joins the common hepatic duct as it exits the liver to form the common bile duct. This duct then continues downward, joins with the pancreatic duct and then finally enters the duodenum.
   

Pancreas

The pancreas is located behind the peritoneum and beneath the stomach. The head of the pancreas is nestled in the curve of the duodenum, with the neck, body, and tail regions extending to the left. The pancreas is both an exocrine and an endocrine gland.

Its exocrine function is to produce the digestive enzymes amylase, protease, and lipase. These enzymes travel down the main pancreatic duct to the common bile duct, entering the duodenum at the papilla (ampulla) of Vater. The sphincter of Oddi is the muscular sphincter at the papilla that controls the flow of bile and pancreatic enzymes into the duodenum.

The endocrine function of the pancreas is regulation of the amount of sugar in the blood. The cells that control blood sugar levels are called islets of Langerhans. Over one million microscopic clumps of islet cells are scattered throughout the pancreatic tissue among the other pancreatic cells. There are two kinds of cells in the islets: alpha and beta. The alpha cells secrete a hormone called glucagon and the beta cells secrete insulin. Insulin and glucagon work as a check and balance system regulating the body's blood sugar level. Glucogon accelerates glycogenesis, the chemical process by which stored glucose in liver (glycogen) is converted to glucose and enters the blood. This process increases the concentration of glucose in the blood. Insulin is an antigen to glucagon. It decreases the amount of blood glucose concentration. Insulin decreases blood glucose by accelerating its movement out of the blood, through cell membranes, and into cells, where the glucose is used as fuel. As glucose enters the cells at a faster rate, the cells increase their metabolism of glucose. In this form every cell in the body can absorb the glucose.

Disorders

Biliary System

• Jaundice (Icterus)
  Jaundice is a symptom of biliary system disease. It is a discoloration of the skin and the sclera of the eyes. It can vary from a slight lemon-yellow tint to a pronounced olive green depending upon the severity and duration of the underlying disease. It is caused by the deposit of bilirubin just below the outer layers of the skin. Bilirubin is a breakdown product of hemoglobin that is normally released into the blood stream after the natural destruction of old red blood cells. It is removed from the blood stream by the liver, slightly changed in its chemical structure, and then excreted as one of the constituents of bile. Thus a small amount of bilirubin normally circulates in the blood, but not in sufficient concentration to be deposited in the skin.
    
  Jaundice occurs when certain conditions cause an increase in the concentration of circulating bilirubin. These disease conditions are classified into three categories: 1) obstructive, 2) hepatocellular, and 3) hemolytic.

Obstructive jaundice is the blockage of bile between the liver and the intestinal tract. The bilirubin is reabsorbed and concentrates excessively in the blood. It is a frequent complication of common duct stones. Obstructive jaundice is also a complication of carcinoma of the head of the pancreas. Because the common bile duct passes close to the head of the pancreas as it enters the duodenum, a pancreatic tumor often compresses and may even invade the common duct.

Hepatocellular jaundice is due to an infection or poison which injures the working cells of the liver, thereby preventing the removal of bilirubin from the blood. It occurs in diseases such as viral hepatitis and yellow fever.  

Hemolytic jaundice occurs when the liver is unable to remove excess bilirubin fast enough due to an accelerated destruction of red blood. Hemolytic jaundice is sometimes seen in adults with hemolytic anemia, but it is most often encountered in newborn infants with hemolytic disease due to blood group incompatibility between mother and infant.
  

• Cholelithiasis
  This year, more than 1 million people in the United States will learn they have gallstones. Infection, metabolic disturbances, and stasis of the bile are the three most probable causes of gallstones. Stones (calculi) range in size from 2 to 3 inches (5-8 cm) in diameter to fine gravel. A single large calculus or thousands of tiny "gravel" type calculi may be. Stones that remain in the gallbladder generally do not cause symptoms.
    
• Choledocholithiasis
  Choledocholithiasis occurs if smaller stone/s are extruded into the cystic duct or the common bile duct and become impacted within the biliary duct. This event causes severe abdominal pain called biliary colic. The pain results from spasm of the smooth muscle in the ducts combined with contractions of the gallbladder that attempt to move the stone through the ducts. Sometimes a stone can be passed through the ducts into the duodenum, but often it becomes impacted. If the stone lodges in the cystic duct, bile can neither enter nor leave the gallbladder, but the flow of bile from the liver into the duodenum via the common duct is not disturbed. If a stone becomes lodged in the common duct, bile cannot reach the intestine. Common duct stones can also interfere with the flow of pancreatic enzymes into the small intestine, leading to pancreatitis.
    
• Cholecystitis
  Cholecystitis may occur in a gallbladder without stones (acalculous cholecystitis), but it is most often associated with stones. The infecting organisms in cholecystitis are often intestinal flora. In severe acute cases, the gallbladder may rupture and cause either a localized abscess or peritonitis. Individuals with chronic recurrent cholecystitis are predisposed to the development of gallstones. The recurrent infections cause the walls of the gallbladder to thicken and become fibrotic. The ability of the gallbladder to contract and move bile thus becomes impaired and the bile remains within the gallbladder, causing stone formation.
    
• Hydrops
  Hydrops of the gallbladder may also be called gallbladder mucocele. The condition refers to obstruction of the cystic duct (usually by calculi) with resultant accumulation of serous fluid within the gallbladder and gallbladder distention.
     

The Pancreas

• Acute Pancreatitis
  Most cases of acute pancreatitis are caused either by alcohol abuse or common duct stones. Acute pancreatitis is caused by escape of pancreatic enzymes from the ducts back into pancreatic tissues. These digestive enzymes cause widespread destruction of pancreatic tissues and severe hemorrhage.
    
  Alcohol is a strong stimulus to pancreatic secretions and can cause edema and spasm of the sphincter of Oddi. The combination of enzyme hypersecretion and sphincter spasm leads to high intraductal pressure, duct necrosis, and escape of pancreatic enzymes into the pancreas.
    
  Acute attacks caused by gallstones are called biliary pancreatitis. This condition usually occurs when a gallstone becomes lodged in the ampulla of Vater. The stone obstructs the pancreatic duct and pancreatitis results.
    
• Pseudocysts
  During attacks of acute pancreatitis enzyme secretions may break through the pancreatic tissues and accumulate in pools that require surgical or endoscopic drainage. These fluid accumulations are called pseudocysts because, unlike true cysts, they lack a lining membrane.
    
• Chronic Pancreatitis
  In more than 90% of adult patients, chronic pancreatitis follows many years of alcohol abuse. It may develop after only one acute attack, especially if there is damage to the ducts of the pancreas. In other cases, pancreatitis may be inherited. It is unclear why the inherited form occurs. Patients with chronic pancreatitis tend to have three kinds of problems: pain, nutritional malabsorption leading to weight loss, or diabetes. Weight loss occurs because the body does not secrete enough pancreatic enzymes to break down food, so nutrients are not absorbed normally. Poor digestion leads to loss of fat, protein, and sugar into the stool. Diabetes may also develop at this stage if the islet cells have been damaged.
    
• Cancer of the Pancreas
  Carcinoma of the pancreas is relatively common and occurs most often at the head of the pancreas. In this location, the tumor blocks the common bile duct, resulting in obstructive jaundice. Carcinoma elsewhere in the pancreas is usually far advanced when first detected and produces no specific symptoms.
    
• Diabetes Mellitus
  Each year, about 650,000 people are diagnosed with diabetes. Diabetes is the most common endocrine system disorder. It occurs when the pancreas fails to secrete enough insulin and so fails to regulate the glucose concentration in the blood. The normal glucose level for an average adult is 80 to 120 milligrams of glucose per 100 milliliters of blood. If the islets of Langerhans secrete too little insulin an excess of blood glucose develops and diabetes results.
    
  The three types of diabetes mellitus are:
    
  Insulin-Dependent Diabetes Mellitus (IDDM) or Type I Diabetes is considered an autoimmune disease. The immune system attacks the insulin-producing beta cells in the pancreas and destroys them. The pancreas then produces little or no insulin. Daily injections of insulin are required for survival. IDDM accounts for about 5 to 10 percent of diagnosed diabetes cases in the United States.
    
  Noninsulin-Dependent Diabetes Mellitus (NIDDM) or Type II Diabetes is the most common form of the disease. About 90 to 95 percent of people with diabetes have NIDDM. This form of diabetes usually develops in adults over the age of 40. In NIDDM, the pancreas usually produces insulin, but the body cannot use it effectively. The end result is the same as for IDDM - an unhealthy buildup of glucose in the blood and an inability of the body to make efficient use of its main source of fuel.
     
  Gestational Diabetes develops or is discovered during pregnancy. This type usually disappears when the pregnancy is over, but women who have had gestational diabetes have a greater risk of developing NIDDM later in their lives.

Diagnostic and Surgical Procedures

• Cholangiography
  Cholangiography is a diagnostic imaging procedure that requires injection of dye into the bile ducts followed by x-ray. The contrast material is taken up quickly by the liver, and the biliary system is then sequentially visualized.

• Cholecystectomy
  Despite the development of nonsurgical techniques, gallbladder surgery, or cholecystectomy, is the most common method for treating gallstones. Each year more than 500,000 Americans have gallbladder surgery. Surgery options include open cholecystectomy and the less invasive laparoscopic cholecystectomy. Open cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 5- to 8-inch incision. Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through separate small incisions. The gallbladder is identified and separated from the liver and other structures. Finally, the cystic duct is cut and the gallbladder removed through one of the small incisions. Complications such as abdominal adhesions and other problems that obscure vision are discovered during about 5 percent of laparoscopic surgeries, forcing surgeons to switch to open cholecystectomy.

• Oral Dissolution Therapy
  In addition to surgery, nonsurgical approaches have been pursued, but are used only in special situations and only for gallstones that are predominantly cholesterol. Oral dissolution therapy with ursodiol (Actigall) and chenodiol (Chenix) works best for small, cholesterol gallstones. These medicines are made from the acid naturally found in bile. They most often are used in individuals who cannot tolerate surgery. Treatment may be required for months to years before gallstones are dissolved.

• Endoscopic Retrograde Cholangiopancreatography (ERCP)
  Endoscopic retrograde cholangiopancreatography (ERCP) may be done as either a diagnostic or therapeutic procedure. An endoscope is passed orally into the duodenum. The ampulla of Vater is cannulated and filled with contrast material. The pancreatic duct, common bile duct, and entire biliary tract including gallbladder are then visualized.

• Endoscopic Retrograde Sphincterotomy (ERS)
  Endoscopic retrograde sphincterotomy is a therapeutic application of ERCP in which soft tissues and muscle fibers at the sphincter of Oddi are divided with electrocautery to permit passage of ductal calculi into the duodenum. In a variation of this procedure, a balloon is used to dilate the ampulla of Vater.

• Endoscopic Transpapillary Catheterization of the Gallbladder (ETCG)
  This procedure is done to dissolve gallstones. The gallbladder is catheterized using an ERCP catheter. The catheter with a hydrophilic guidewire is passed through the nose and advanced via a retrograde approach through the common bile duct. The ERCP catheter is then exchanged for a radiopaque Teflon biliary dilating catheter that allows the guidewire to be inserted into the cystic duct and gallbladder. The following day the patient undergoes extracorporeal shock wave lithotripsy (ESWL) and infusion of a solvent through the catheter to dissolve the stones.

• Percutaneous Biliary Drainage
  In this procedure a catheter-needle assembly is passed through the abdomen percutaneously into the liver. The needle is then removed and the catheter advanced into the desired bile duct for external biliary drainage. The catheter may be replaced by insertion of a T-tube into the biliary duct. Left in situ, the T-tube creates a tract for biliary drainage.

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Anatomy and Physiology - Disorders - Diagnostic and Surgical Procedures

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