All things Gall Bladder

Question 1

What are the 3 diseases of the biliary tree (not including gallstones)?

Answer 1

Primary Sclerosing Choclangitis, Primary Biliary Cholangitis, Ascending Cholangitis

Question 2

Which ducts are of primary concern with gallstones?

Answer 2

Cholelithiasis is concerned with Cystic duct and CBD (Sphincter of Oddi)

Question 3

Describe the pathogenesis of PSC vs PBC.

Answer 3

PSC has layers of concentric onion ring fibrosis layers which create patches of stenosis with proximal dilation. This obstruction actually leads to Secondary Biliary Cholangitis and destruction of the entire tract, then liver. PBC does not have the obstruction to cause its intrinsic inflammation and is autoimmune in nature attacking itself and eventually causing fibrosis and destruction.

Question 4

Between PSC and PBC, which one affects women more and which one can lead to canaliculi rupture?

Which is worse or better about each?

Answer 4

IBD and PSC are more common in men and the bile backflow is irritating and the stenosis can lead to a rupture of the canuliculi.

Positive thing about PSC is if you remove the stenotic obstruction early, pt won’t progress to secondary biliary cholangitis.

Positive thing about PBC is that Ursodiol treatment can severely improve symptoms.

Question 5

Which antibody is increased in Biliary Tract diseases?

Answer 5

Increased IgM.

Question 6

Which cholangitis is p-ANCA+ and which is anti-mitochondrial +?

Answer 6

PSC is p-ANCA positive. PBC is anti-mitochondrial.

Question 7

What is Ursodiol and how is it used?

Answer 7

Ursodiol is pharmacology grade bile acid. It dissolves gall stones of cholesterol and also has an anti-inflammatory effect on the cells in specifically PBC.

Question 8

What is Charcot’s Triad of Cholangitis? What is it most commonly indicative of?

Answer 8

Fever, Jaundice, RUQ pain. Gallstone obstruction causing Cholangitis.

Question 9

Which biliary disease is more prone to Cholangiosarcoma? What is the gender of most of these pts?

Answer 9

Primary Sclerosing Cholangitis. Gender is male.

Question 10

What are the two types of gallstones?

Answer 10

Cholesterol and Pigment. During fasting state SoD is closed and cholesterol in bile refluxes back, increasing its saturation and potential precipitation.

Question 11

Fat Fertile, Female, Forty-plus is the typical pt with what and why?

Answer 11

Cholesterol Gallstones. Increased estrogen and pregnancy and even post pregnancy increase likelihood of cholelithiasis.

Also rapid weight loss is associated with these stones.

Question 12

Which ethnic group is most often getting cholelithiasis?

Answer 12

Weirdly Native Americans. Think earth stones - eee.

Question 13

What are the types of pigment stones?

Answer 13

Black: Ca-Bilirubinate. Brown - signifies chronic infection of biliary tree (bacterial metabolism).

Question 14

Which conditions predispose to the dark black Ca-Bilirubinate and stones and why?

Answer 14

Chronic hemolysis and Cirrhosis (but Cirrhosis also increases cholesterol stones by the increased estrogen). When there is an abundance of unconjugated bilirubin, it leaks and is not as water soluble as conjugated. This why.

And biliary or GI stasis leads to increased reabsorption of bilirubin from bile.

Question 15

Which stones are associated with Crohn disease?

Answer 15

In the kidney, Calcium oxalate. In the gallbladder both Cholesterol and Black Ca-Bilirubinate stones.

Question 16

What is the MCCx of Cholelithiasis?

Answer 16

Acute Cystitis - inflammation arises when stone is stuck in the cystic duct or beyond and can’t merely return to fall back into the gall bladder.

Question 17

Acute Cystitis differs from Biliary colic how?

Answer 17

Biliary colic arises when stone is in neck of gallbladder resulting in colicky pain and nausea when eating and I cells release Cholecystikinin to squeeze gallbladder.

Question 18

How does Acute Cystitis present in the pt?

Answer 18

Unremitting epigastric pain is constant with nausea and vomiting. Inflammation may irritate the diaphragm leading to referred pain to the shoulder.

Fever and leukocytosis but no labs are specific.

Question 19

What is Murphy’s Sign and how is it different than RUQ tenderness?

Answer 19

Murphy is sensitive for cholelithiasis. Cup/Hook fingers under right ribs + have patient inspire deeply causing diaphragm to drop and by default the liver and gall bladder toward your hand putting them in so much pain!! But the pain is not the Murphy sign.

Murphy sign is actually that the pt’s inspiration involuntarily stops secondary to pain.

Question 20

Liver enzymes are not elevated in Acute Cholecystitis why?

Answer 20

Alk Phos and GGT are actually related to hepatocytes of the bile canuliculi surrounding the biliary system - not the actual gall bladder. If they are elevated, suspect a more distal blockage or damage.

Question 21

How is Acute Cholecystitis diagnosed?

What is the most expensive best test for this?

Answer 21

Abdominal US will show me wall thickening and surrounding fluid with the stones you’d see in Biliary Colic.

HIDA scan radiotracer; uses contrast specifically secreted in bile; administered by IV taken up by liver. You watch tracer fill the Hepatic duct into CBD and back into the cystic duct and gallbladder but when there’s a stone, it won’t pass it and you can determine its location.

Question 22

What is Acalculous Cholecytitis?

Answer 22

No stone; only occurs in very ill pts. Wall thickening on U/S.

Question 23

Treatment of Acute Cholecystitis.

Answer 23

Urgent cholecystectomy within 24 hours.

Question 24

Cxs of Acute Cholecystitis.

Answer 24

Infection can occur but not necessarily. Potential perforation and a resultant fistula may or may not occur. If fistula with the bowel occurs, stone may end up lodged into the intestine.

Question 25

What is Gallstone Ileus?

Answer 25

Gallstone ileus is fistula with stone blocking ileocecal valve - leading to gut paralysis.

Question 26

What do you need to know about Chronic Cholecystitis?

Answer 26

More associated with enteric fistulas + eggshell thin layer of calcium turning it into porcelain gallbladder.

Porcelain Gallbladder leads to very high risk of cholangiocarcinoma.

Question 27

Why does movement of stone from Cystic Duct to CBD have such a difference in pathology?

Answer 27

GB is just a repository for bile. If CBD is obstructed, we have much bigger problems and bile can’t reach duodenum + reflux back into systemic circulation.

Question 28

Describe the labs of an Obstructive or Cholestatic pattern aka Choledocholithiasis.

Answer 28

Increased conjugated bilirubin with huge increase in Alk Phos, GGT, increased AST and ALT. Less RUQ pain.

Question 29

What is the treatment for Choledocholithiasis?`

Answer 29

Remove stone with ERCP. Easier than going all the way up to the GB. Find stone, drag wire past stone, inflate balloon + drag stone out!

Question 30

What are the 2 very nasty complications that may occur with Choledocholithiasis?

Answer 30

If stone lodges in Ampulla of Vater…uh oh. Pancreatic system does not like to be obstructed – Acute Pancreatitis (aka gallstone pancreatitis - always from choloedocholithiasis).

Second one is Ascending Cholangitis which is an infection. This should be obvious bc any obstruction (including from PSC or PBC) can lead to this. Also pressure can rupture the fragile bile canuliculi. And the bacteria travel to liver also making the whole thing a hot mess.

Question 31

What are the horrible things which occur with Ascending Cholangitis?

Answer 31

The high pressure can lead to rupture - with the infectious bacteria present leading to sepsis. And bacteria travel back up to liver and liver gets too much reflux causing it to deposit this crap into systemic circulation - again, bacteria and aggressive septic shock.

Question 32

What is Charcot Triad? What is Reynold Pentad?

Answer 32

RUQ pain, Fever, Jaundice (choledocholithiasis); add shock and altered mental status and then you have full blown Sxs of ascending cholangitis with resultant shock.