2 - pathoph of GB and Biliary tree [3]

Question 1

Pathophys of gallstone formation

Answer 1

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

Question 2

factors contributing to GS

best way to dx?

Answer 2

1. lithogenic bile
2. stasis
3. nucleation (mucin plug)

• US

Question 3

Cholesterol GS

Answer 3

most common
soft, yellow/white, greasy
due to cholesterol supersaturation or
bile acid deficiency/phospholipid def

Question 4

Pigment GS

Answer 4

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

Question 5

Brown GS

Answer 5

least common

associated w/ bacterial infxn

Question 6

GS risk factors

Answer 6

5F’s

Fat, Female, Forties (>30), Fam hx, Fertile
also rapid weight loss

Question 7

Biliary colic

• what
• presentation

Answer 7

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)

Question 8

Acute (calculous) cholecystitis

• what
• presentation

Answer 8

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

Question 9

acalculous cholecystitis

Answer 9

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

Question 10

Choledocholithiasis

Answer 10

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

Question 11

Ascending cholangitis

Answer 11

life threatening
bacterial infxn of bile duct most likely due to choledocholithiassis complication

sx: Charcots triad/Reynolds pentad

Question 12

Reynolds pentad

Answer 12

Charcots triad: fever, RUQ, jaundice
+
Hypotension, altered mental status/confusion

Question 13

tx for:
biliary colic
Calculous (acute) cholecystitis
Acalculous cholecystitis
Choledocholithiasis
Ascending cholangitis

Answer 13

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

Question 14

1 cause of pancreatitis in US

Answer 14

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

Question 15

GB adenocarcinoma

Answer 15

gland forming epithelial cancer from gallstones and chronic cholecystitis

Question 16

Biliary stricture

Answer 16

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

Question 17

Presentation of biliary stricture

Answer 17

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

Question 18

dx and tx of biliary stricture

Answer 18

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

Question 19

Primary sclerosing cholangitis
assoc w/
presents with

Answer 19

associated with IBD (UC/Crohns)
presents with: RUQ pain, jaundice, fevers → cirrhosis of liver

increased risk for cholangiocarcinoma
Alkphos/GGT> AST/ALT

Question 20

Sphincter of Oddi dysfxn (SOD) mimics:
what
who
levels
dx
tx

Answer 20

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

Question 21

What test is the best way to image the biliary tree and best for tx?

Answer 21

ERCP