3.15. Liver + Biliary Tree Disease - Cholestasis (Gallstones) Flashcards
What are the 2 Types of Cholestasis (Gallstones) which occur?
- Cholesterol Gallstones
2. Bile Pigmented Stones
Which if the 2 types of Gallstones are more common?
Cholesterol Gallstones - 80%
Bile Pigmented Stones - 20%
What are the Risk Factors for developing Cholesterol Gallstones?
- Increasing Age
- Being Female
- Rapid Weight Loss
- High Fat, Low Fibre Diet
- Alcoholism
- Predisposing Conditions
- Certain Medications
- Ileal Disease / Resection
At what age do Gallstones appear more frequently?
After the age of 30
How much more common are Gallstones in Females?
2-3 times, especially in those who have had many Children
Why can Rapid Weight Loss cause Cholesterol Gallstones?
Due to elevated Leptin levels, which are associated with the formation of Cholesterol Gallstones
What Predisposing Conditions are there?
- Diabetes Mellitus
- Obesity (+/- Metabolic Syndrome)
- Liver Cirrhosis
- Viral Hepatitis
- Acromegaly
What is an example of medication which can put you at risk of getting Cholesterol Gallstones?
The Oral Contraceptive Pill
Why can Ileal Disease or an Ileal Resection cause Cholesterol Gallstones?
Due to the resulting Bile Loss (Lack of Bile Reabsorption)
What are the Risk Factors for developing Bile Pigmented Stones?
- Haemolytic Conditions (e.g. Sickle Cell Anaemia, Hereditary Spherocytosis)
- Infection in the Biliary Tree
What forms the Cholesterol Gallstones?
The formation of Cholesterol Gallstones is due to Cholesterol Crystallization from Gallbladder Bile
What is the Cholesterol Crystallization from Gallbladder Bile (forming Cholesterol Gallstones) dependent on?
- Cholesterol Supersaturation in the Bile
- Crystallizing Promoting Factors within the Bile
- The Motility of the Gallbladder
How is Cholesterol Crystallization dependent on Cholesterol Supersaturation in the Bile?
- Cholesterol is formed and co-secreted with Phospholipids in the Biliary Canaliculus
- Supersaturation can occur due to:
a) Excess Cholesterol Secretion into the Bile
b) A decrease of Bile Salt Content, which can occur due to Bile Salt Loss (e.g. Ileal Resection, Crohn’s Disease)
Is everyone who has Cholesterol Supersaturation guaranteed to have Cholesterol Gallstones?
No, Many people who have this will never develop Gallstones
What are the Crystallizing Promoting Factors, within the Bile?
- There are a number of Lipoproteins which have been reported as Putative Crystallizing Factors
- There is Evidence to suggest a Genetic Factor is prevalent (After being ected on by an Environmental Factor)
How is Cholesterol Crystallization dependent on Gallbladder Motility?
A decrease in Gallbladder Motility, leads to Bile Stasis, which lead to Cholesterol Crystallization
What are the 2 Types of Bile Pigmented Stones?
- Black Pigmented Stones
2. Brown Pigmented Stones
What are Black Pigmented Stones comprised of?
- Calcium Bilirubinate
- A Network of Mucin Glycoproteins, which interlace with salts, such as:
a) Calcium Carbonate
b) Calcium Phosphate
What are Brown Pigmented Stones comprised of?
- Calcium Salts
- Fatty Acids
- Calcium Bilirubinate
What is the Pathology of Black Pigmented Gallstones?
- Bile Salt loss in the Colon (Due to Ileal Resection / Crohn’s) promotes Colic Reabsorption of Bilirubin
- This enhances the Enterohepatic Circulation of Bilirubin which leads to the formation of Gallstones
When are Brown Pigmented Gallstones found?
- In the presence of Bile Stasis / Biliary Infection
2. In the Intrahepatic Ducts in circumstances of Duct Disease (e.g. Primary Sclerosing Cholangitis)
What are Brown Pigmented Gallstones a common cause of?
Recurrent Bile Duct Stones following a Cholecystectomy
What are Black Pigmented Gallstones related to?
Bacterial Colonization of the Biliary Tree
What do All Types of Gallstones produce?
A Blockage / Obstruction of the Biliary Pathway, leading to a Backlog of Bile within the Hepatocytes
What is the Clinical Presentation of Gallstones?
- Asymptomatic (commonly)
- Jaundice with Pruritus
- Dark Urine / Pale Stools
- Nausea + Vomiting
- Fever + Rigors
- Biliary (Gallstone) Colic (Pain)
- Acute Cholecystitis
- Empyema
Do Gallstones causes Vague Upper Abdominal Symptoms, such as Dyspepsia, Flatulence, GORD upon Fat ingestion?
No
What type of Jaundice is present?
Post-Hepatic Jaundice
What is Pruritus? And why is it associated with the Jaundice present?
The itching sensation is associated with the increased levels of Serum Bilirubin
Why do Dark Urine / Pale Stools occur?
Dark Urine - Due to the increased presence of Bilirubin in the Urine
Pale Stools - Due to the lack of Bilirubin in the Stool
Why does Nausea and Vomiting occur?
This is related to the Biliary (Gallstone) Colic (Pain)
What are Fevers and Rigors suggestive of?
Complications of a Gallstone, such as:
- Cholecystitis
- Cholangitis
- Gallstone related Pancreatitis
What are the Characteristics of the Biliary (Gallstone) Colic (Pain?
- Severe and Constant
- Its onset is related to the over-indulgence of Food (usually with a High Fat content)
- The Pain starts in Epigastric Region, then radiates to the Right Upper Quadrant, and then (potentially) to the Right Subscapular (Shoulder) Area
What is Acute Cholecystitis?
Progressive Distension of the Gallbladder which can occlude its vascular supply?
What causes the Gallbladder Distension?
- Obstruction of Gallbladder Emptying - this increases the Gallbladder Glandular secretion, worsening the Distension
- The Inflammatory response to the Retained Bile within the Gallbladder
What can occur as a Secondary Phenomenon following the Vascular Inflammatory Events of the Gallbladder?
Infection
What can infection lead to?
Empyema
What is Empyema of the Gallbladder?
The Gallbladder can become Distended with Puss
What are the Worries of Empyema of the Gallbladder?
- Perforation - causing Peritonitis
- Gangrene occurring due to the lack of vascular supply
- Further Distension of the Gallbladder
What is the presentation of the Pain of Acute Cholecystitis?
- Severe Right Upper Quadrant
2. Associated with Tenderness and Muscular Rigidity
What investigations are requires in Cholestasis?
- Liver Function Test (and Biochemistry)
- Abdominal Ultrasound
- MRCP / ERCP
What does a Liver Function Test (and Biochemistry) test for?
Liver Function Test:
- Serum Albumin
- Prothrombin Time (PT)
Liver Biochemistry:
- Serum Bilirubin
- Alkaline Phosphatase (ALP)
- Gamma-Glutamyl Transpeptidase (G-GT)
- Aminotransferases:
a) Aspartate Aminotransferase (AST)
b) Alanine Aminotransferase (ALT)
What would a Liver Function Test (and Biochemistry) find in a patient with Gallstones?
There is unlikely to be any major abnormality:
- Elevated Serum Bilirubin
- Elevated Alkaline Phosphatase
- Elevated Aminotransferases
What is the purpose of the Abdominal Ultrasound?
This is used to diagnose and locate the Gallstone
What does MRCP and ERCP stand for?
MRCP - Magentic Resonance Cholangio-Pancreatography
ERCP - Endoscopic Retrograde Cholangio-Pancreatography
Why would an MRCP / ERCP be useful as an investigation?
To view the inside of the Biliary Tree, to diagnose and locate the Gallstone
What are the Treatment Options for Gallstones?
- Treat the Underlying Cause
- Analgesics
- I.V. fluid and Nutrients whilst being Nil by Mouth
- ERCP
- Cholecystectomy
How can the underlying cause be treated?
- Change in Diet
- Alcohol Cessation
- Antivirals (if due to infection)
What is the purpose of giving Analgesics?
For the pain control
What is the function of an ERCP as a treatment option?
This can break up and remove the Gallstone
What is a Cholecystectomy? And what is it’s purpose?
The Surgical Removal of the Gallbladder - this is the last resort due to Acute Cholecystitis
