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19 Feb 24 Flashcards

1
Q

Biliary Cyst pathogenesis

A

Cystic dilation of biliary tree

Most common:
Single , Extra hepatic dilation of CBD (type 1)

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2
Q

Biliary Cyst CF

A

🧣Incidental finding

🧣Classic triad (children/adults)
Abd pain
RUQ mass
Jaundice

🧣Neonates : jaundice , acholic stools , dark urine , hepatomegaly

🧣N , V

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3
Q

DX of biliary Cyst

A

USG. Or CT or MRCp

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4
Q

Complications of biliary Cyst

A

Cholangiocarcinoma
Acute Cholangitis
Pancreatitis
Stone formation

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5
Q

Ttt of biliary Cyst

A

Cyst resection (to dec risk for malignancy)

Roux en Y hepaticojejunoatomy
(To allow for biliary drainage)

Pt with obstructive SS should be treated for acute condition first and cyst resection later.

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6
Q

Differnt prsentations of biliary Cysts

A

🥾A/S

🥾Symptomatic :
RUQ abd pain , jaundice and RUQ mass

🥾Acute complications:
Pancreatitis, cholangitis , stone formation.

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7
Q

Biliary cysts and pancreatitis

A

Biliary cysts inc the risk of pancreatitis due to association with
ANOMALOUS pancreaticobiliary junction
🏣 abnormally long common channel connecting pancreatic duct and CBD

This lengthy channel is predisposed to OBSTRUCTION from plugs and stones which can cause reflux of pancreatic fluid and CHOLESTASIS (conjugated hyperbili).

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8
Q

Common etiologies of Acute Cholangitis

A

👘Choledocholithiaisis
👘Malignancy
👘PSC
👘Biliary interventions causing incomplete bile drainage

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9
Q

Ttt of acute cholangitis

A

😉BS antibiotic
😉ERCP with sphincterotomy for biliary drainage in 24-48hrs
😉PTC (percutaneous trashepatic cholangiography) with drain placement
open surgical decompression

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10
Q

CO of acute cholangitis

A

🗻Charcot triad : fever RUQ pain jaundice
🗻Reynold pentad : AMS , hypotension
🗻Leukocytosis
🗻Cholestasis : inc ALP and direct hyperbili
🗻AGMA with Lactic acidosis (with severe sepsis)

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11
Q

Acute cholangitis def

A

Life threatening infection that develops due to biliary obstruction , which enables bacteria to enter ampulla and biliary tree.

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12
Q

How to approach neonatal cholestasis
(Dark urine ,acholic stools , conjugated hyperbili)

A

🥁 ABD ultrasound
⬇️

↪️If abnormal/absent GB ➡️ biliary atresia

↪️If cystic dilation of biliary tree ➡️ biliary Cyst

↪️Isolated hepatomegaly or Normal USG
1️⃣ infectious evaluation
CMV , Toxoplasma , HSV , UTI /sepsis

2️⃣ genetic/metabolic evaluation
AAT def
Dubin johnson
Galactosemia
Cystic Fibrosis

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13
Q

Gall stone pancreatitis complicated by Acute cholangitis

A

Gallstone pancreatitis develops when gallstone passes thru bikiary tree and obstructs ampulla or flow from pancreatic duct allowing bile to reflux into pancreas.

Pts have pancreatitis CF plus cholestasis.

If stone remains in biliary tract resultant bile stasis allows bacteria to ascend from duodenum ➡️ Acute cholangitis.

So CF combined are ;
Pancreatitis plus cholestasis plus reynolds pentad.

Ttt: IV fluids
AB
ERCP (to relieve biliary obs - stone extraction/sphincterotomy/stent placement)

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14
Q

Pathogenesis of PBC

A

Autoimmune destruction of Intrahepatic bile ducts.
(Leading to bile stasis and cirrhosis)

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15
Q

CF of PBC

A

❇️Affects middle aged women
❇️Insidious onset of fatigue and pruritis
❇️Progressive jaundice , hepatomegaly , Cirrhosis
❇️Cutaneous XANTHOMAS, XANTHELASMAS.

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16
Q

Labs of PBC

A

🛞Cholestatic pattern of liver injury
🛞⬆️⬆️ALP
🛞⬆️aminotransferases
🛞Antimitichondrial Antibody
🛞Severe Hypercholesterolemia
(Hyperlipidemia has elevated of HDL out of proportion to LDL and doesnt increase the risk of atherosclerosis)

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17
Q

Ttt of PBC

A

Urosodeoxycholic acid (delays progression)

Liver transplant

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18
Q

Complications of PBC

A

🥁Malabsorption, Fat soluble Vitamin def
🥁Metabolic Bone disease (osteoporosis , osteomalacia)
🥁HCC

🥇osteomalacia (dec bone mineralization) is related to vitamin D def and fat malabsorption.

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19
Q

How to manage suspected PBC

A

🦷Do labs
ALP , cholesterol, LFTs , bilirubin

🦷RUQ USG (distinguishes intrahepatic cholestasis vs Extrahepatic cholestasis-gall stones causing biliary tract dilation)
If USG suggests intraheptic cholestasis

🦷Antimitochondrial antibody titres

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20
Q

How to evaluate a patient with high ALP

A

1️⃣ check GGT. If Normal then ALP is from bone

2️⃣ if GGT is high ➡️ ALP is biliary

3️⃣ do RUQ USG and AMA

↪️ positive AMA or Abnormal USG
Liver biopsy

↪️ dilated bile ducts on USG
ERCP

↪️ both normal
Liver biopsy or ERCP or observe

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21
Q

Benefits of Ursodeoxycholic acid UDCA in PBC

A

Drug of choice

Increases biliary secretion and has anti inf and immunomodulatory effects

UDCA delays histologic progression in PBC and may improve SS and survival.

Should be given as soon as dx is made even to A/S patients.

Less effective ttt for more advanced stage of Dx.

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22
Q

Acute cholangitis etiology

A

👗Occurs in any setting of Biliary Stasis
Gall stones
Malignancy
Strictures /stenosis

👗Elevated intrabiliary pressure allows for disruption of Bile -blood -barrier
And translocation of bacteria from hepatobiliary system into bloodstream.

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23
Q

USG / CT findings Of AC

A

Dilation of intrahepatic ducts and CBD

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24
Q

Malignant biliary obstruction causes

A

Cholangiocarcinoma
Pancreatic cA / HCC
Metastasis (colon , gastric)

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25
CF of malignant biliary obs
🚨Jaundice, pruritis , acholic stools, dark urine 🚨Weight loss 🚨RUQ pain 🚨RUQ mass/hepatomegaly 🚨Inc Direct bili , ALP , GGT
26
Dx of Malignant biliary Obs
➡️Serum Tumor Markers (CEA, CA 19-9, AFP) ➡️Abd imaging (USG, CT scan) ➡️EUS, ERCP for tissue dx if unclear
27
Tumor markers of Cholangiocarcinoma vs HCC
Cholangiocarcinoma Inc CEA , inc CA19-9 , normal AFP HCC : Normal CEA and CA19-9 , ⬆️ AFP
28
Cholangiocarcinoma Vs pancreatic CA
Both cause Inc CA19-9 Pancreatic Ca causes distal obstruction of biliary tree ( CBD dilation ) Cholangiocarcinoma Intrahepatic or CBD dilation Can occur anywhere in biliary epithelium
29
Acalculous cholecystitis RF
Severe trauma or recent Surgery Prologed Fasting or TPN Critical illness (sepsis , ICU) These conditions cause GB stasis and ischemia leading to distension , ischemia and sec Bacterial infection. These conditions also cause ADynamic ileus -dec bowel sounds , retension of gastric contents , gaseous small and large bowel distension.
30
CF of Acalculous Cholecystitis
Critically ill patient from trauma or post op fever (gall bladder stasis and sec bacterial infection) leukocytosiis ^ LFTs RUQ pain Signs of Adynamic ileus ( dec bowel sounds , gas and distention in small and large bowel)
31
Dx of acalculous chole
👘Abd USG (GB distension ,wall thickening and pericholecystic fluid in the absence of gall stones) 👘HIDA or CT if needed Dx requires a high index of suspicion and pts are too ill to verbalize symptoms.
32
Ttt of acalculous cholecystitis
🗻Enteric AB coverage 🗻Cholecystostomy for initial drainage 🗻Consider cholecystectomy once clinically stable
33
Acute chole vs biliary colic
Biliary colic constant pain that lasts only 6 hours ( intermittent obs of cystic duct that goes away once the stone falls back in GB) no inflammation signs. Normal labs No murphys signs on exam acute chole pain that lasts longer signs of GB inflammation on USG Fever leukocytosis positive murphys
34
Acute calculous Chole def
Inflammatory condition of GB that occur when a gallstone obstructs the cystic duct.
35
Acute calculous chole presentation.
👗RUQ pain 👗Severe and persistent pain 👗Radiates to shoulder along with voluntary guarding on exam 👗Fever , tachycardia and leukocytosis With left shift
36
Biliary colic and then Acute cholecystitis
Pt with transient PP RUQ pain as stone was in the cystic duct. As stone fall back in the GB pain goes away. No fever or any sign of inflammation. Acute chole is when GB inflames as stone is in Cystic duct continuously.
37
How to treat Acute Cholecystitis
We give AB as bile stasis increases risk for Sec. Bacterial infection 🥇Empiric AB (Piperacillin-tazobactam) For coverage against Enterobacteriaceae family (Ecoli, klebsiella, enterobacter) 🥇Cholcystectomy
38
Post Cholecystectomy Syndrome def And etiology
Post op recurrence or persistence of precholecystectomy symptoms. Cause : Biliary cause : EARLY: Bile leak (bile duct injury) , retained CBD stone LATE : Biliary stricture , Recurrent CBD stone , SOD ExtraBiliary Cause: PUD , IBS, Pancreatitis , CAD
39
Common features of post cholecystectomy syndrome
➡️Perisstent Abd pain, dyspepsia ➡️Inc LFTs , CBD dilation suggests biliary cause
40
Dx of Post Cholecystectomy Syndrome
If pt has Biliary cause acc to labs Inc LFTs , Or CBD dilation on USG Its most likely CBD stone, biliary stricture , SOD. Evaluate : MRCP , EUS ERCP Ttt: Treat underlying cause.
41
How to manage gallstones
1️⃣Without S/S : No ttt (Do not advise prophylactic chole Advise about symptoms of biliary colic should prompt cholelecystectomy) 2️⃣Gallstones with typical biliary colic symptoms: Elective laparoscopic Cholecystectomy URSO in poor surgical candidates 3️⃣Complicated gall stone dx (Acute Chole, Choledocholithiasis, gallstone pancreatitis) Cholecystectomy in 72hrs
42
Pts who need to treat A/S gall stones treated (prophylactic chole )
Pts at risk of GB cancer Pts with sickle cell dx
43
Gall stone ileus SS
🛞Stone travels through small bowel ; Intermittent tumbling obstruction signs S/S: Episodic abd pain , NV , bloating 🛞Complete and fix obstruction; Eventually stones lodges in narrowest portion of intestine. Causing fix obstruction. S/s: Inc intraabd pain, distension , hyperactive bowels . 🥾 despite its name gall stone ileus is not a true ileus , but mechanical bowel obstruction( functional disruption of motility)
44
How to dx gall stone ileus
CT scan shows peumobilia gallbladder wall thickening obstructing stone Dilated bowel loops with air fluid levels
45
Ttt of gall stone ileus
Urgent cholecystectomy remove the fistula bowel resection
46
Gall stone ileus Etiology
Large stone >- 2.5cm passes into intestine by eroding through GB and adj bowel wall forming Biliary-enteric fistula. RF : 🚨Prev pericholecystic inflammation which causes adhesion formation 🚨Elderly women
47
Hemobilia Cause
Liver biopsy Cholecystectomy ERCP A consequence of hepatic or biliopancreatic interventions. Massive hemobilia causes hemodynamic instability and UGIBleed after the procedure. Intraductal hematoma formation results in delayed UGIB until after dissolution of clot (5 days post-procedure)
48
Hemobilia CF
RUQ pain Jaundice UGIBleed (melena , hematemesis) Direct hyperbili from bile duct obstruction Anemia Leukocytosis Reactive thrombosis (due to inflammation)
49
Dx of Hemobilia and ttt
Dx : CT , Abd USG Ttt: Self limited Conservative management (iv fluids , blood transfusions) Persistent bleed req angiography with embolization or surgery.
50
Emphysematous Cholecystitis RF and CF
🧣DM 🧣Vascular compromise (compromised cystic artery blood supply, atherosclerosis) 🧣Immunosuppression CF: Fever , RUQ pain, NV Crepitus in abd wall adjacent to GB Complications like gangrene and perforation (perforation may transiently relieve pain but subsequently results in peritoneal signs)
51
Dx of emphysematous chole
Do CT SCAN 👠Air Fluid levels in GB , gas in GB wall 👠Cultures with gas-forming Clostridioides,EColi 👠 unconjugated Hyperbili , mildly elevated transaminases 🥾USG is less sensitive due to poor visualization of air filled structures 🥾unconjugated bili is high as exotoxin frombacteria cause hemolysis.
52
Ttt of Emphysematous Chole
🧣Emergency Cholecystectomy 🧣BS antibiotics with clostridiodes coverage (Piperacillin-tazobactam)
53
Etiology of emphysematous chole
Damaged or ischemic GB tissue becomes a nidus for gas-forming bacteria (clostridium) and some EColi to proliferate. Gas formed within GB wall may then leak into gall bladder lumen and biliary tree(pneumobilia) or into the adj abd wall (occasionally detected as RUQ crepitus.
54
Porcelain GB complication dx and ttt
Gallbladder adenocarcinoma Ttt: Cholecystectomy (Esp for pts who are symptomatic or have incomplete mural cakcification) Dx: CT scan
55
What is biliary colic
GB contracts in response to diet esp fatty foods. When it contracts against blocked cystic duct the increased Intragallbladder pressure causes Pain. CF : 🧣Intense RUQ pain with NV 🧣Pain is constant (not colicky) 🧣Rapidly inc in intensity in 30-60 min Subsides in 4-6hrs. 🧣(GB then relaxes and stone falls back from the duct ) 🧣Abd exam is benign even during episodes Vs Acute chole : Pain stays longer than 6hrs Murphys signs positive Inflammatory
56
Pt with dull RUQ abd pain after meals and resolves in 60mins
Biliary Colic Do RUQ USG
57
Sphincter of Oddi dysfunction Causes
SO is muscular valve containing biliary and pancreatic sphincter that control bile and pancreatic juices into duodenum. Stenosis : 🥁Due to inflammation or scarring (Gallstone passage or pancreatitis) Dyskinesia: 🥁functional obstruction caused by intermittent smooth muscle dysmotility (eg spasm , impaired relaxation)
58
SOD dx and ttt
👠Mostly happens in post cholecystectomy pts. 👠Recurrent RUQ abd pain lasting 30mins to several hours (like biliary colic) without stones. 👠Opioid analgesics increase sphincter contraction and ppt or exacerbate pain. 👠depending on which component is involved biliary or pancreatic labs are see Aminotransferase , bilirubin , ALP (biliary Amylase , lipase (pancreatic. 👠 Abd USG : Dilated CBD without stones. 👠 gold standdard; sphincter of Oddi manometry 👠 ttt: Sphincterotomy.
59
When do we do ERCP
Uses fluoroscopy to visualise biliary tree 🛞Done when stone is in CBD (Elevated ALP , bilirubin, CBD dilation) 🛞Sphincterotomy is mostly done for passage of stones.
60
DXof acute calculous chole
USG : Thick GB , sludge , gallstones HIDA : non visualization of GB
61
Ttt of acute calculous chole
NPO , IV fluids Antibiotics Cholecystectomy <72hrs

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