3. GI p278-287 (Biliary) Flashcards
Commonest cause of jaundice
Benign stricture (post traumatic from surgery or biliary intervention)
Bacterial cholangitis (2)
Hepatic abscess can develop due to cholangitis, usually due to stasis (stones).
Triad of Jaundice, Fever, RUQ pain.
Primary sclerosing cholangitis (7)
Chronic cholestatic liver disease of unknown aetiology.
Characterised by progressive inflammation, leading to multifocal strictures of the intra-and extrahepatic ducts.
Often results in cirrhosis.
Strongly associated with cholangiocarcinoma.
Buzzword for cirrhotic pattern is “central regenerative hypertrophy”.
Associated with inflammatoy bowel disease (UC 80%).
Indication for transplant, with post transplant recurrence of 20%.
AIDS cholangiopathy
Infection of the biliary epithelium (classically cryptosporidium) can cause distal disease in AIDS patients.
Mimics PSC with intra and extrahepatic multifocal strictures.
Associated with papillary stenosis in 60%
AIDS cholangiopathy vs PSC (3)
Focal strictures of the extra-hepatic duct >2cm vs extrahepatic strictures rarely >5mm
Absent saccular deformities of the ducts vs Saccular deformities of the ducts.
Associated papillary stenosis.
Oriental cholangitis (5)
aka recurrent pyogenic cholangitis.
Common in southeast asia (hence the name).
Dilated ducts, full of pigmented stones.
“Straight rigid intrahepatic ducts”
Cause unknown, may be associated with clonorchiasis, ascariasis and nutritional deficiency.
Don’t do well with endoscopic decompression, often need surgical decompression.
PBC (6)
Autoimmune disease resulting in destruction of small and medium intrahepatic ducts.
Mainly affects middle aged women, often asymptomatic.
Early stages, normal bile ducts help distinguish it from PSC.
Later stages, irregular dilatation of the intrahepatic ducts, with normal extrahepatic ducts.
Increased risk of HCC.
Excellent prognosis if caught early, responds to medical therapy with ursodeoxycholic acid.
Antimitochondrial antibodies positive in 95%.
Choledochal cysts/Caroli’s (7)
Congenital dilatation of bile ducts.
Type 1 is focal dilatation of CBD, by far most common (4 other types).
Type 2 is diverticulum of bile duct.
Type 3 is a choledococele.
Type 4 is both intra and extra.
Type 5 is Caroli’s and is intrahepatic only.
- AR disease, associated with polycystic kidney disease and medullary sponge kidney
- Intrahepatic duct dilatation, large and saccular.
- Central dot sign - portal vein surrounded by bile ducts.
Dilated bile ducts and hx of repeated cholangitis, think choledocal cyst.
Complication of Choledochal cysts (4)
Cholangiocarcinoma
Cirrhosis
Cholangitis
Intraductal stones
Normal gallbladder (4)
Inferior to interlobar fissure, between right and left lobe.
Size depends on recent eating, but should be <4x10cm.
Wall thickness should be <3mm.
Lumen should be anechoic
Phyringian cap
GB folds on itself. No clinical significance (anatomic variant).
Intrahepatic gallbladder.
Most found right above the interlobar fissure
Duplicated gallbladder
Can happen, not much clinical significance
Duct of Luschka (3)
Accessory cystic duct.
Can cause big problem (persistent bile leak) after cholecystectomy.
Several subtypes, not likely to be tested
Wall thickening (2)
Non-specific, can be due to biliary (cholecystitis, AIDS or PSC) or non-biliary (hepatitis, heart failure, cirrhosis)
Gallstones (3)
Found in 10% of asymptomatic patients.
Most (75%) cholesterol, other 25% are pigmented.
They cast shadows, unless <3mm in size
Wall Echo Shadow GB (3)
Can occur for 3 reasons.
1) GB full of stones (clean shadowing)
2) Porcelain gallbladder (variable shadowing)
3) Emphysematous cholecystitis (dirty shadowing)
Porcelain gallbladder (3)
Extensive wall calcification.
Increased risk of GB cancer.
Surgically removed.
GB polyps (6)
Cholesterol (most common) or non-cholesterol (adenomas/papillomas).
Cholesterol ones aren’t real polyps, but essentially enlarged papillary fronds full of lipid filled macrophages, attached to wall by stalk.
Non-cholesterol polyps are almost always solitary and usually larger.
Larger ones may have doppler flow. NOT mobile and NO shadow.
Surgically removed if >1cm.
Adenomyomatosis (6)
Due to hyperplasia of wall with formation of intramural diverticula (Rokitansky-Aschoff sinuses), which penetrate into the wall of the gallbladder.
These become filled with cholesterol crystals, which show as “comet tail artefact” - highly specific for adenomyomatosis.
3 types
- Generalised (diffuse)
- Segmental (annular)
- Fundal (localized or adenomyoma), cannot be differentiated from GB cancer.
GB adenomyomatosis vs cholesterolosis (4)
Both benign.
Gallbladder adenomyomatosis - hypertrophied mucosal and muscularis propria, with cholesterol crystals deposited in an intraluminal location (within Rokitansky-Aschoff sinuses)
Cholesterolosis - Cholesterol and triglyceride deposition within the substance of the lamina propria, associated with formation of cholesterol polyps
Gallbladder cancer (2)
Most GB cancers are associated with gallstones.
80% have direct tumour invasion of the liver or portal nodes at time of diagnosis.
Mirizzi syndrome (5)
Occurs when common hepatic duct is obstructed due to impacted cystic duct stone.
Stone can eventially erode into CHD ot GI tract.
Increased co-incidence of gallbladder Ca (5x risk) with Mirizzi.
Mirizzi occurs more in people with low cystic duct insertion (normal variant), allowing for more parallel course and closer proximity to the CHD.
Liver Doppler - terminology (2)
Duplex means colour
Spectral means colour with a waveform