B5-022 CBCL: Cholecystitis-lithiasis Flashcards
drugs that increase risk of cholelithiasis
2
- octreotide
- clofibrate
calcium bilirubinate polymer formed in gallbladder
black pigment stone
mixture of cholesterol/fatty soap/calciu bilirubinate formed in bile duct
brown pigment stone
[…] pigment stones are associated with chronic hemolysis and Crohn’s
black
deconjugates bilirubin causing insoluble calcium bilirubin salts
bacterial B-glucoronidase
> 80% of all gallstone cases are caused by
cholesterol stones
(cholesterol monohydrate crystal)
20% pigment stones
conditions favor gallstone formation
lithogenic stage
first stage
episodes of biliary colic after a fatty meal
symptomatic gallstones
third stage
- usually asymptomatic
- may be discovered on imaging performed for reasons other than gallbladder disease
cholelithiasis
- RUQ pain/tenderness
- fever
- positive murphy’s sign
acute cholecystitis
what laboratory findings would you expect in acute cholecystitis?
- increased WBC
- mildy elevated bili
- mildly elevated transaminase
best initial step for diagnosis of acute cholecystitis
RUQ ultrasound
what should you see on ultrasound for diagnosis of acute cholecystitis?
- gallstones
- anterior wall >3mm thick
- pericholecystic fluid
treatment of acute cholecystitis
- IV fluids
- antibiotics
- patient NPO
- monitor for 48 hours
if symptoms worsen, urgent cholecystectomy. if not, schedule in 6 weeks
- fever
- RUQ pain/tenderness
- positive murphy’s sign
- scleral icterus/jaundice
choledocholithiasis
what would you expect to see on US of choledocholithiasis?
- gallstones
- common bile duct >8 cm dilated
- obstruction of biliary tract at the level of common bile duct
treatment for choledocholithiasis
ERCP spinchterotomy and retrieval of stone
elective cholecystectomy may follow
- fever
- RUQ pain/tenderness
- positive Murphy’s sign
- scleral icterus/jaundice
- AMS
- hypotension
- sepsis
- Reynold’s pentad
acute ascending cholangitis
Reynold’s pentad
- fever
- RUQ pain
- jaundice
- AMS
- hypotension
acute ascending cholangitis
treatment of acute ascending cholangitis
- IV fluids, hemodynamic stabilization
- antibiotics
- urgent biliary drainage
- ERCP
elective cholecystectomy may follow
expected lab findings for choledocholithiasis?
elevated WBCs
mildy elevated bili/transaminases
same for cholecystitis
expected lab findings for acute ascending cholangitis?
- elevated WBCs
- mildly elevated bili/transaminases
- elevated alk phos
charcot triad
jaundice
fever
RUQ pain
cholangitis
infection of the biliary tree usually due to obstruction that leads to stasis/bacterial overgrowth
ascending cholangitis
presence of gallstone in common bile duct
choledocholithiasis
risk factors for cholelithiasis
- female
- fat (obesity)
- fertile (mulitparity)
- forty
- fair
5 Fs - First Aid
causes of cholelithasis
- elevated cholesterol/bilirubin
- decreased bile salts
- gallbladder stasis
which type of stones are radiolucent?
2
cholesterol stones
brown pigment
which type of stones are radiopaque?
black pigment stones
carries nutrient rich blood into the liver
portal vein
provides oxygenated blood to liver
hepatic artery
collect blood from liver and take it to IVC
hepatic veins
bile duct epithelial cells
cholangiocytes
liver resident macrophages
Kupffer cells
major storage site for vitamin A
stellate cells
form a heterodimer to transport cholesterol into the bile
ABCG5/ABCG8
major transporter for secretion of bile acids from hepatocytes into bile
BSEP
lipid translocator that moves phosphatidylcholine from the inner leaflet to outer leaflet of the canalicular membrane for extraction into the lumen by bile salts
MDR3
exports bilirubin from hepatocytes into bile
MRP2
mediates intestinal cholesterol absorption
NPC1L1
mediates hepatocytes apical cholesterol secretion into bile
ABCDG5
how do bile salts and phospholipids prevent cholesterol precipitation in the bile?
forming mixed micelles
stimulates gallbladder contraction after a meal
CCK
- produced in the ileum in response to bile acid absorption
- regulates bile acid synthesis
FGF19
[…] pigment stones are formed in the gallbladder due to hypersecretion of bilirubin
black
chronic hemolytic anemia is associated with […] pigment stones
black
usually formed in the biliary tract and associated with chronic biliary tract infection
brown pigment stone
deconjugates bilirubin and contributes to brown stone formation in the biliary tract
bacterial B-glucoronidase
acute cholecystitis is most often to result of gallstone blockage of the
cystic duct
blockages of the ampulla of Vater leads to
jaundice
pro-nucleating agent in supersaturated bile
mucin
high molecular weight glycoprotein secreted by the gallbladder with the ability to bind lipids and bile pigment
mucin
anti-nucleating agent
apolipoprotein AII
bile stasis and decreased function of the spinchter of Oddi cause bacteria to migrate into the biliary tract causing
acute ascending cholangitis
ascending cholangitis caused by choledocholithiasis is often a result of
bacteria entering the biliary tree through the ampulla of Vater
which serum markers indicate biliary tract injury?
ALP
GGT
major basolateral conjugated bile acid uptake transporter
NTCP
mutation of […] results in decreased hepatic uptake of bile acids from the portal blood
NTCP
mutation of […] results in impaired canilicular bile acid secretion into the bile results in intrahepatic bile acid accumulation
BSEP
- canalicular phospholipid transporter
- mutation associated with intrahepatic cholestasis PFIC-3
ABCB4 (MDR3)
mutation of […] is associated with PFIC-1
ATP8B1
mutation of […] is associated with hypercholesterolemia and premature atherosclerosis due to reduced cholesterol conversion to bile acids
CYP7A1
best initial method for evaluating gallbladder pathology
US
characteristic features of ascending cholangitis
fever
jaundice
RUQ pain
result of bacterial infection-mediated release of beta-glucuronidase
brown pigment stones
increased unconjugated bilirubin precipitates as […], resulting in brown pigment stones
calcium salts
range in color from yellow to dark green and are due to the supersaturation of bile with cholesterol
cholesterol stones
[…] stones are associated with infected bile and can often be found outside the gallbladder in the intrahepatic or extrahepatic ducts
brown stones
- biliary colic
- hx of cholecystectomy
- common bile duct dilation
spinchter of Oddi dysfunction
treatment for spinchter of Oddi dysfunction
sphincterotomy via ERCP
best diagnotic modality for spinchter of Oddi malfunction
manometry via ERCP
measures pressures
often confused with cholelithiasis until the patient’s symptoms persist post cholecystectomy
spinchter of Oddi malfunction
thin layer of mineralization outling the gallbladder wall on US
porcelain gallbladder
calcified gallbladder due to chronic cholecystitis
porcelain gallbladder
often asymptomatic and found on incidental imaging
most common cause of porcelain gallbladder
recurrent biliary colic
gallbladder wall thickening on US is characteristic of
cholecystitis
distended gallbladder with clear fluid accumulation as a result of long standing cystic duct blockage
hydrops of gallbladder
gallbladder distention and stones pressing the gallbladder wall cause ischemia and necrosis
gangrenous cholecystitis
gallbladder calcification increases the risk for
gallbladder carcinoma
do asymptomatic patients generally require cholecystectomy?
no
exception: porcelain gallbladder and Native Americans
patients at risk for gallbladder cancer should have a cholecystectomy. what populations would this include?
- porcelain gallbladder
- Native Americans
the presence of […] suggests the patient has a high risk for developing ascending cholangitis
jaundice
the presence of […] in the stool gives it its brown color
bilirubin
choledocholithiasis, biliary atresia, and hepatitis can decrease […], causing stool to appear pale in color
bilirubin release into intestine
conjugated bilirubin is exported across the […] of the hepatocytes into systemic circulation
basolateral side
[…] causes black stones in the gallbladder
hemolytic anemia
risk factors for cholesterol stones
- female
- fat
- fertile
- fair
- fourty
which type of pigment stone is more frequently formed in bile ducts?
brown
composed of calcium salts of unconjugated bilirubin and cholesterol
brown pigment stones
which type of stone is associated with chronic bacterial or parasitic infection of the bile duct?
brown pigment
what happens to unconjugated bilirubin in the presence of calcium?
forms highly insoluble calcium salts and complexes with other liquids to form pigmented stones
formed in the gallbladder and consist of crosslinked unconjugated bilirubin polymer and calcium salts
black pigment
bile acid sequestrants
2
- cholestipol
- cholestyramine
2 drug classes used to treat hypercholesterolemia
- bile acid sequestrants
- statins
2 drug classes used to treat hypertriglyceridemia
PPARa agonists fibrates (gemfibrozil)
niacin
activates PPARa to increase biliary cholesterol secretion and decrease bile acid synthesis
gemfibrozil
contributes to cholesterol supersaturation in bile
thought to decrease lipids by inhibiting adipose lipid release
niacin
how does rapid weight loss contribute to the development of gallstones?
- causes adipose to release a large amount of cholesterol via lipolysis
- causes increased hepatic cholesterol uptake and biliary cholesterol hypersecretion
causes cholesterol superaturation in bile
do incidentally detected gallstone in patients without symptoms need treatment?
no
describe appropriate management of acute cholecystitis
- IV antibiotics and observe
- if improvement in 48 hrs -> schedule elective cholecsytectomy within 6 weeks
- if no improvement/worsening–> urgent cholecystectomy
contraindicated in pregnancy due to potential risk of miscarriage and effects on fetus
NSAIDs
what can be used in pregnant women for pain management?
acetaminophen
opioids
what does the Reynold’s pentad indicate?
ascending cholangitis progressing to septic shock
what lab findings indicate acute pancreatitis?
serum lipase 3x upper limit of normal
glucose of 190 ml/dl
- itching
- dark-colored urine
- light colored stool
indicates a problem with
indicates a problem with bile excretion
how do issues with bile excretion cause dark colored urine?
when bile cant be excreted by the intestine, it is excreted by kidneys
first line treatment for PBC
ursodiol
UCDA
promotes biliary secretion, decreases inflammation and cell death, reduces the hydrophobicity of bile acid pool
medication
ursodiol
characterized by pruritis, elevated serum bile acids and developing 2nd/3rd trimester
ICP
resolves quickly after delivery
treatment for ICP
ursodiol
UDCA
what is the cause of gallstone in Crohn’s disease?
- decreased bile acid reabsorption
- lower bile acids in bile
- increased bilirubin -> cholesterol supersaturation
acute necroinflammatory disease of the gallbladder without evidence of gallstones or duct obstruction
acalculous cholecystitis
due to gallstone impaction of the cystic duct resulting in inflammation and gallbladder wall thickening
calculous cholecystitis
- due to gallbladder stasis, hypoperfusion, or infection
- seen in critically ill patients
acalculous cholecystitis
results from gallbladder stasis and ischemia, which then cause a local inflammatory response in the gallbladder wall
acalculous cholecystitis
treatment of acalculous cholecystitis
- IV fluids
- pain control
- antibiotics
- cholecystectomy
- critically ill patients with sepsis without a clear source or jaundice
- fever, abdominal pain
acalculous cholecystitis
ischemia, sepsis, gallbladder stasis cause
acalculous cholecystitis
- direct hyperbilirubinemia
- scleral icterus for years
- hyperpigmentation of liver
Dubin Johnson
- indirect hyperbilirubinemia
- can remain asymptomatic until adulthood
Crigler-Najjar type II
most common inherited hyperbilirubinemia
Gilberts
presents with indirect hyperbilirubinemia in times of stress
Gilbert
jaundice and unconjugated hyperbilirubinemia between the 3rd and 8th day of life
physiologic neonatal jaundice
what causes physiologic neonatal jaundice?
- increased fetal RBC turnover
- immature newborn liver (decreased UDP)
