2 - pathoph of GB and Biliary tree [3] Flashcards
Pathophys of gallstone formation
too much cholesterol in bile, too little water, or both
- usually dev in GB, but can spill to bile duct → obstruction of bile duct or pancreatitis
- most asymptomatic
factors contributing to GS
best way to dx?
- lithogenic bile
- stasis
- nucleation (mucin plug)
- US
Cholesterol GS
most common
soft, yellow/white, greasy
due to cholesterol supersaturation or
bile acid deficiency/phospholipid def
Pigment GS
black, hard, brittle, and associated with bile stasis
Mainly consists of calcium bilirubinate
risks: biliary obstruction, excess bilirubin excretion (hemolysis), asian, can be in GB or bile duct
Brown GS
least common
associated w/ bacterial infxn
GS risk factors
5F’s
Fat, Female, Forties (>30), Fam hx, Fertile
also rapid weight loss
Biliary colic
- what
- presentation
caused by MOVEMENT of stone into cystic duct or gallbladder neck
presentation: intermittent epigastrium or RUQ pain after meals (esp fatty foods) for about 1 hour (remits 3-8 hrs later)
Acute (calculous) cholecystitis
- what
- presentation
stone in the cystic duct or gallbladder neck →
bacteria colonization (GNRs, enterococci) →
transmural inflammation.
Perforation, sepsis, or death can result if not tx.
Presentation: severe pain in RUQ, nausea, fever + murphys sign
acalculous cholecystitis
happens from ischemia of GB in those with sepsis, recent surgery, trauma, burns, hypotension →
inflammation/necrosis
presentation: (like calculous) severe pain in RUQ, nausea, fever + murphys
Choledocholithiasis
stones in the bile duct - usually from the GB
presentation: jaundice, dark urine, abdominal pain, can lead to acute pancreatitis!
- cause elevated LFTs, cholangitis, or pancreatitis
Ascending cholangitis
life threatening
bacterial infxn of bile duct most likely due to choledocholithiassis complication
sx: Charcots triad/Reynolds pentad
Reynolds pentad
Charcots triad: fever, RUQ, jaundice
+
Hypotension, altered mental status/confusion
tx for: biliary colic Calculous (acute) cholecystitis Acalculous cholecystitis Choledocholithiasis Ascending cholangitis
biliary colic
- cholecystectomy, non-litogenic bile (↓ size)
Calculous (acute) cholecystitis
- NPO, IV hydrate, IV ab, cholecystectomy if stable, percutaneous draining if unstable
Acalculous cholecystitis
- cholecystectomy or drain GB
Choledocholithiasis
- ERCP with extraction or lithotripsy or surgery to remove GB
Ascending cholangitis
- admit, NPO, broad spec IV ab, IV fluids
- Urgent ERCP
1 cause of pancreatitis in US
Gallstone (biliary) pancreatitis
Pt has 5 F’s, has no gallstones on imaging, have dilated bile ducts, elevated liver chem, no other risk factors for pancreatitis
GB adenocarcinoma
gland forming epithelial cancer from gallstones and chronic cholecystitis
Biliary stricture
fixed, narrowing or blockage of bile duct (caused by edema and fibrosis associated with choledocolith or acute panc) can be: intra or extra-hepatic intrinsic or extrinsic benign or malignant
sx are more chronic and persistent than stones
Presentation of biliary stricture
RUQ pain cholestasis (bild acid build up to get skin jaundice) dark urine (choluria) acholic stools pruritis (from bile acid retention) LFT elevated in cholestatic patter
dx and tx of biliary stricture
dx: US/CT dilated ducts, MRCP/ERCP to confirm, and biopsy (malignant vs benign)
tx: ERCP with dilation or stenting or surgery if refractory/malignant
Primary sclerosing cholangitis
assoc w/
presents with
associated with IBD (UC/Crohns)
presents with: RUQ pain, jaundice, fevers → cirrhosis of liver
increased risk for cholangiocarcinoma
Alkphos/GGT> AST/ALT
Sphincter of Oddi dysfxn (SOD) mimics: what who levels dx tx
spincter contracts when its not supposed to (when you eat so bile cannot exit)
choledocholithiasis
comm in females 20-55
dynamically elevated ALT/AST/Alk phos
dx: ERCP with Sphincter of Oddi manometry
tx: biliary sphincterotomy
What test is the best way to image the biliary tree and best for tx?
ERCP
