Biliary Conditions Flashcards
what are the risk factors for developing gallstones?
- female
- pregnancy
- obesity
- age >40
family history - diabetes
- Crohn’s disease
what are the symptoms of gallstones, when they are symptomatic?
- RUQ pain -> biliary colic that radiates to back
- jaundice (+/-)
what makes gallstones symptomatic?
if they migrate to the cystic duct or common bile duct and beyond
describe biliary colic
pain in the RUQ that tends to increase in intensity and lasts several hours before resolving
what is the management of symptomatic gallstones?
- Analgesia (morphine)
- fluid rehydration
- nil baby mouth
- elective laparoscopic cholecystectomy
what is acute cholecystitis?
- inflammation of the gallbladder
what is the most common cause of acute cholecystitis?
impaction in the neck of the gallbladder by sludge or a gallstone
what are the symptoms of acute cholecystitis?
- Constant epigastric or RUQ pain, referred to the shoulder tip
- vomiting
- fever
- rigors
- jaundice
- pale stools
what are the signs of acute cholecystitis?
- local peritoneum
- gallbladder mass
- Murphy’s sign +
how would you elicit Murphy’s sign?
lay 2 fingers on patient’s RUQ
ask patient to breathe in
causes pain and arrest of inspiration if positive - cholecystitis
Repeat in LUQ - Murphy’s sign only positive if negative in LUQ
how would you investigate acute cholecystitis?
- FBC (raised WCC)
- CRP (Raised)
- Serum amylase (slightly raised - very high suggests pancreatitis)
- Ultrasound (thick walled, shrunken gallbladder, may see gallstones)
how would you manage acute cholecystitis?
- Nil by mouth
- Pain relief (morphine)
- IV antibiotics (co-amoxiclav)
- laparoscopic cholecystectomy if no perforation
- laparaotomy if there is perforation of GB
what is chronic cholecystitis?
chronic inflammation of the gallbladder +/- biliary colic
what are the symptoms of chronic cholecystitis ?
vague abdominal discomfort distension nausea flatulence fat intolerance chronic diarrhoea
what are the investigations for chronic cholecystitis?
ultrasound - to look for gallstones
what is the management for chronic cholecystitis?
cholecystectomy
what is acute cholangitis?
infection in the bile duct
what is acute cholangitis usually caused by?
bacteria ascending from the junction between bile duct and the duodenum
it tends to occur if the bile duct is already partially obstructed by a gallstone
what are the symptoms of acute cholangitis?
Charcot's triad: - RUQ pain - Fever +/- rigors - jaundice Reynold's pentad: - above + - mental state changes - low blood pressure
where can the infection in acute cholangitis ascend and what does this cause?
infection can ascend to the liver, causing liver abscess and cirrhosis
what are the investigations carried out when suspecting acute cholangitis?
- FBC (increased WCC)
- Inflammatory markers (raised ESR and CRP)
- U&Es
- LFTs (raised ALP, gamma GT, AST and ALT)
- ABG (sepsis)
- Blood cultures
- Imaging - ultrasound, CT (biliary dilatation, stones, strictures)
what is the management for acute cholangitis?
- fluid resuscitation (if patient is septic)
- monitor fluid and electrolyte balance
- IV antibiotics (piperacillin with tazobactam)
- Endoscopic retrograde cholangiopancreatography (clears bile ducts)
what is primary biliary cholangitis?
chronic autoimmune granulomatous inflammation of the small interlobular bile ducts (part of portal triad) in the liver
what is the pathophysiology of primary biliary cholangitis?
autoimmune granulomatous inflammation of interlobular bile ducts causes cholestasis which damages bile duct cells and hepatocytes and leads to fibrosis, cirrhosis and portal hypertension
what are the symptoms of primary biliary cholangitis?
- asymptomatic in early disease
- lethargy -> most common
- pruritus (cholestasis)
what are the signs of primary biliary cholangitis?
- hepatomegaly
- hyperpigmentation (increased amounts of melanin)
- splenomegaly
- jaundice
- cirrhosis (ascites, spider naevi)
what are the investigations for primary biliary cholangitis?
- FBC (often normal)
- ESR (elevated)
- LFTs (alkaline phosphatase
and gamma GT elevated, AST and ALT can sometimes be mildly elevated) - bilirubin rises as disease progresses
- prothrombin time (increased)
- albumin (decreased- impaired liver function)
- abdominal US (to exclude obstructive lesion within bile ducts)
- serum immunoglobulin - IgM is raised
- antimitochondrial antibodies present
what are the risk factors for primary biliary cholangitis?
- female gender
- positive family history
- age between 45-60
describe the management for primary biliary cholangitis
- ursodexycholic acid
- prednisolone (immunomodulatory)
- colestyramine (sequesters bile acids in the intestine, preventing their absorption)
- liver transplantation is the only cure but disease can recur in transplanted liver
what is primary sclerosis cholangitis?
progressive cholestasis with bile duct inflammation and strictures - both intrahepatic and extrahepatic bile ducts can be affected
what is the difference between primary biliary cholangitis and primary sclerosis cholangitis?
primary biliary - inflammation of interlobular bile ducts (more common in women)
primary sclerosing cholangitis - inflammation of both intrahepatic and extra hepatic bile ducts and stricture formation (more common in men)
what are the symptoms of primary sclerosing cholangitis?
- may be asymptomatic
- jaundice nd pruritos
- RUQ pain
- Fatigue
- Weight loss
- Fever
- Sweats
what are the signs of primary sclerosis cholangitis?
- hepatomegaly
- jaundice
- signs of cirrhosis and portal hypertension (caput medusa, oesophageal varices, ascites)
what are the investigations for primary sclerosing cholangitis?
- LFTs (ALP, Gamma GT usually raised, AST slightly raised, bilirubin raised, albumin decreased and PT time increased)
- FBC (normal or shows liver dysfunction such as thrombocytopenia)
- antimitochondrial antibody (negative in sclerosis, positive in biliary)
- Ultrasound (abnormal bile ducts, liver cirrhosis)
- MRCP (strictures and dilatations)
what is the management of primary sclerosis cholangitis?
- observation and lifestyle changes for asymptomatic patients
- bone mineral density scan at diagnosis and at 2-3 year intervals
- colestyramine for pruritus
- ergocalciferol and calcium carbonate (vitamin D and calcium supplements) if hepatic osteopenia
- ERCP with balloon +/- stent to treat strictures
- liver transplantation
what is cholangiocarcinoma?
cancers arising from bile duct epithelium
can bee intrahepatic or extrahepatic
what is the presentation of cholangiocarcinomas?
- painless jaundice - most common
- weight loss and abdominal pain are fairly uncommon
what are the risk factors for chlonagiocarcinoma?
- age>50
- cholangitis
- gallstones
- ulcerative colitis
- primary sclerosing cholangitis
- liver cirrhosis
- alcoholic liver disease
- HIV
- Hepatitis B and C
what investigations are done when suspecting cholangiocarcinoma?
- LFTs (serum bilirubin raised, alk phos raised, gamma GT raised, AST slightly raised, PT time increased)
- Cancer markers (CA-19-9 and CEA elevated)
- abdominal ultrasound (shows mass and dilated ducts)
- abdominal CT or MRI
what is the management for cholangiocarcinoma?
Resectable tumours: • Intrahepatic tumour: ◦ Partial liver resection ◦ Chemotherapy / radiotherapy • Extrahepatic tumour: ◦ Surgical excision ◦ Chemotherapy / radiotherapy
Unresectable tumours:
• Liver transplant if they are a candidate
• Chemotherapy / radiotherapy
what problems does liver failure lead to?
- increased susceptibility to infections
- increased susceptibility to toxins and drugs
- increased blood ammonia -> hepatic encephalopathy
what is acute liver failure?
rapid failure of the liver’s synthetic and metabolic function in the absence of a known pre-existing liver disease
how is acute liver failure classified?
based on the time interval between the initial onset of jaundice and the development of encephalopathy:
- hyper acute (0-7 days)
- acute (8-28 days)
- subacute (29 days - 12 weeks)
what is the most common cause for acute liver failure?
- paracetamol overdose (UK)
- acute viral hepatitis (worldwide)
what is the presentation of acute liver failure?
- jaundice
- evidence of risk factors such as overdose, hepatitis and hepatotoxic drugs
- signs of hepatic encephalopathy (lethargy, confusion, asterixis)
- abdominal pain
- nausea and vomiting
- hepatomegaly
how would you investigate acute liver failure?
- LFTs (high bilirubin, very high AST and ALT in paracetamol overdose)
- prothrombin time increased
- U&Es (metabolic derangements and elevated urea)
- FBC (leukocytosis, anaemia, thrombocytopenia)
- blood type and screen (in case transfusion needed)
- ABG (acidosis and raised lactate are prognostic factors)
- paracetamol level
- viral hepatitis serology
- autoimmune hepatitis markers (autoantibodies) to help diagnosis
- pregnancy test (can have liver disorders in pregnancy)
- abdominal ultrasound with doppler (for hepatic vessel thrombosis and hepatomegaly)
what is the management for acute liver failure?
- intensive care
- liver transplantation assessment + contact transplant centre
- neurological status monitoring for advanced encephalopathy
- monitor blood glucose, electrolytes and blood cultures
- acetylcysteine for paracetamol overdose
- acyclovir for herpes simplex virus
- methylprednisolone for autoimmune hepatitis
- fluid resuscitation
