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LEARNING OBJECTIVES

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Learning Objectives

  • Learn the epidemiology, genetics, etiology, and pathogenesis of common biliary and pancreatic diseases in older adults.

  • Understand the common and atypical manifestations, and tests to diagnose common gallbladder and pancreatic diseases in older patients.

  • Learn state-of-the-art and emerging treatments for biliary and pancreatic disorders in older population.

  • Acquire knowledge about the symptoms, diagnosis, and treatment of gallbladder and pancreatic cancers in older adults.

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Key Clinical Points

  1. Age is a major risk factor for gallstones, which are more common among older adults, especially women.

  2. Acute cholecystitis may present atypically in older patients without fever, nausea, vomiting, or severe abdominal pain.

  3. Ultrasound is the initial diagnostic test of choice, and incidental discovery of gallstones is not an indication for treatment. When appropriate, early laparoscopic cholecystectomy is the treatment of choice in older patients.

  4. In the absence of gallstones and alcohol abuse, the most common cause of acute pancreatitis in older adults is malignancy.

  5. Alcohol abuse is the most common cause of chronic pancreatitis in older patients.

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BILIARY DISEASE

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Cholelithiasis

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Table 92-1 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 symptomatic gallstones each year.

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TABLE 92-1RISK FACTORS FOR GALLSTONE FORMATION
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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.

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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. ...

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