Biliary Disease Flashcards
What is cholesterol used to synthesize in the liver?
Primary bile acids, promoted by Vitamin C through hydroxylation
Promoted by Vitamin C through hydroxylation.
Which antibiotics should be used to treat biliary tract infection?
ciprofloxacin
->Alternatively gentamicin
->Alternatively cephalosporin
What are the two types of bile acids formed from primary bile acids?
Secondary bile acids formed by intestinal flora and tertiary bile acids
Secondary bile acids are formed in the intestine, while tertiary bile acids are formed by intestinal flora or hepatocytes.
What is the most common type of gallstone?
Cholesterol stones
What are black stones composed of?
Calcium bilirubinate result from the breakdown of hemoglobin. black stones occur in those with an inflammatory disease such as Crohndisease or who undergo hemolysis
They result from the breakdown of hemoglobin.
What conditions are associated with the formation of black stones?
Inflammatory diseases like Crohn disease and hemolysis.
What are brown stones formed from?
Calcium substrates including calcium bilirubinate, calcium phosphate, cholesterol, and bile. Brown-pigmented stones are observed in those with parasitic or bacterial infections and biliary strictures
What are risk factors for gallstone formation?
- Prolonged fasting/weight loss Increases saturation of bile with cholesterol
- High estrogen levels, greatest during fertile years or use of contraceptive pill
- Rapid weight loss
- High altitudes may increase gallstone formation due to hepatic hypoxia
How does estrogen affect gallstone formation?
Increases cholesterol secretion into bile, increasing saturation and reduces gall bladder contractility.
What effect does high intake of sugars like fructose have on gallstones?
Promotes gluconeogenesis and triglyceride synthesis, decreases gallbladder emptying and contraction due to sensitivity to cholecystokinin.
Which medications promote gall stone formation?
Medications such as ezetimide and a state of insulin resistance inhibit cholesterol transport into the intestine and intestinal cholesterol absorption while promoting cholesterol synthesis.
Which hormones promote gall bladder emptying?
Vasoactive intestinal peptide and human fibroblast growth factor promote gallbladder emptying and refilling post-prandial in response to bile acid into the duodenum
What is cholelithiasis?
A gallstone in the gallbladder which an crease the risk of acute cholecystitis.
What is the treatment of cholelithiasis?
Choelithiasis treatment is ursodeoxycholic acid toit is a bile acid analogue that dissolves bile stones. Alternatively, elective cholecystectomy can be done laparoscopically for preventing cholethiasis.
Ezetimibe can be given which is a statin that blocks hepatic cholesterol synthesis by blocking hMG coA reductase
What is acute cholecystitis?
Inflammation of the gallbladder due to gallstones. This will cause stasis of the bile, increase in back pressure of gall bladder and the release of inflammatory enzymes that convert lecithin to lysolecithin which causes secretion of fluid into the lumen and distention with prostaglandin release resulting in ischaemia, necrosis and perforation.
What symptoms are associated with acute cholecystitis?
- Biliary colic pain Radiating to right upper quadrant, worse after a fatty meal
- febrile
- Nausea and vomiting
- Fever
- Murphy’s sign
What is an indicator of perforation?
Perforation is indicated by sudden relief of pain transiently before sudden progression to intense pain.
What is the criteria for cholecystitis?
Criteria for cholecystitis is pain, elevated white blood cell (WBC) count, c-reactive protein, pericholecystic fluid (fluid surrounding gallbladder), and thickening of the gallbladder wall
What is a complication with acute cholecystitis?
There is a risk of fistula formation between gall bladder and duodenum, causing stones to travel directly into the intestine,, typically in the ileum and causing small bowel obstruction known as gallstone ileus.
Complication includes wall ischaemia from arterial compression, leading to gangrenous cholecystitis
What is Murphy’s sign?
Palpation of the right upper quadrant causes halting of inspiration.
When does jaundice occur in acute cholecystitis?
jaudnice is not common unless Mirrizi syndrome occurs, where Gallstone causes external block of the common bile duct.
There is risk of gallstone ileus where it blocks the Pylorum or duodenum, resulting in a formation of a cholecystokinin-enteric fistula with the gallstone bladder and gut, known as Bouvert’s syndrome which causes small bowel obstruction.I
What are the Diagnostic findings for acute cholecystitis?
Investigations include raised WBC
FBC and high LFTs, and increased CRP
Ultrasound of gallbladder while show oedema, stones and gall bladder distention
Hepatobiiliary iminidacetic acid scan uses radiotracers to image the gallbladder.
How is acute cholecystitis treated?
Treatment is laparoscopic cholecystectomy.
What is the main investigation for gallbladder issues?
Ultrasound.
What is choledocholithiasis?
A gallstone in the common bile duct and can cause distention of bile duct with non infective biliary fluid.
What are the features of choledocholithiasis?
There will be RUQ, jaundice and elevated ALP. Complications include acute cholangitis (inflammation fo the bile duct) ascending cholangitis and acute pancreatitis from obstruction of pancreatic duct
What is biliary colic pain?
Biliary colic presentation is CONTINOUS right upper quadrant/epigastric pain, worse after a fatty meal, with anusea and vomiting.
What are the investigations for choledocholithiasis?
Investigations include raised WBC, CRP and LFTS and ultrasound of gallbladder
What are the complications of choledocholithiasis?
- Acute cholangitis
- Acute pancreatitis
How is choledocholithaisis treated?
ERCP to removegallstone
What is ascending cholangitis?
Ascending cholangitis is inflammation of the bile duct from infective bile fluid, which is a common complication of choledocholithiasis. There is retrograde flow into the over and risk of sepsis and multisystem organ dysfunction. It typically presents with Charcot’s triad.
What is Charcot’s triad?
Fever, RUQ pain, and jaundice. There will also be high WBC and risk of Reynd’s Pentad in ascending cholangitis.
What is Reynold’s pentad?
which is a combination of Charcot’s with hypotension and neurological changes
What is the treatment for ascending cholangitis?
IV fluid resuscitations, IV Antibiotics and ERCP to remove the stone. Endoscopic instrumentation with cholecystectomy.
What is lithotripsy?
A procedure to use shock waves to destroy gallstones.
What does high bilirubin and ALP without fever medicate?
choledochilithiasis
What does high bilirubin, AP and WCC indicate?
ascending cholangitis
What does gallstone with Murphy sign and thickening of gall bladder wall indicate?
acute cholecystitis
What does a stone in the common bile duct with dilation indicate?
Choledocholithaisis
Ascending cholangitis
What can be used to image the biliary tree?
HIDA scan for radioactive tracer
How is ascending cholangitis treated?
antibiotics and ERCP to remove the stone. For those critically unstable, antibiotics and Percutaneous cholecystectomy is given.
What are the 5Fs risk factors for gallstones?
- Female
- Family history
- Fertile
- Forty
- Fat
What is primary sclerosing cholangitis?
Progressive fibrosis of the bile ducts causing chronic obstruction and an narrow strictre, outflow, resulting in hepatitis and fibrosis with a prognosis of 10 years from diagnosis.
What is the pathology of primary sclerosing cholangitis?
Biliary scarring can cause portal hypertension and lead to venous compression in the portal triad, and primary sclerosing cholangitis increase the risk of developing cholangiocarcinoma, driven by bile. It has a strong link to ulcerative colitis. There is risk of bacterial translocation and cholangitis.
What are the types of primary sclerosising cholangitis?
classic primary slcoerising cholangitis affecting small and large bile ducts in the entire biliary treee and is the most common type
Small duct
Autoimmune hepatitis
What is the most common subtype of primary sclerosing cholangitis?
classic primary slcoerising cholangitis affecting small and large bile ducts in the entire biliary treee and is the most common type
What are the demographic characteristics of primary sclerosing cholangitis?
Typically affects males aged 30-40 with ulcerative colitis and they may have symptoms of advanced liver disease such as jaundice and GI bleeding. Physical examination may show hepatosplenomgealy, splenomegaly, jaundice and excoriation of the skin from pruiritus.
What is the clinical presentation of primary cleansing cholangitis?
Clinical presentation is fatigue, jaundice, pruritis, right upper quadrant pain. However many patients are asymptomatic
How do liver enzymes change with primary sclerosing chaolngitis?
Liver function test will show cholestasis pattern with high ALP and bilirubin at early stages. In later stage, where hepatitis occurs ALT and AST will rise
What are the diagnostic findings for primary sclerosing cholangitis?
Diagnostic criteria for primary sclerosing cholangitis is increased ALP for 6 months, imaging through MRCP or ERCP showing bile duct strictres and exclusion of causes of secondary sclerosing cholangitis. A key feature in histology is periductal or onion skin fibrosis.
Autoantibodies are typically raised in majority, most common in 4% being anti-neutrophil cyptoplasmic antibodies.ANA and anti cardio lipid antibodies may also be raised.
What is the gold standard for diagnosing primary sclerosing cholangitis?
MRCP which shows an MRI of the liver, bile ducts and pancreas.
What does primary sclerosing cholangitis increase the risk of?
Acute cholangitis
Cholangiocarcinoma
Liver cirrhosis
Portal hypertension
cholelithiasis, biliary strictres and colorectal cancers and fat malabsorption
What is the treatment of primary sclerosing cholangitis?
has no established therapy but includes
Ursodeoxycholic acid, which inhibits the absorption of cholesterol in intestine and secretion of cholesterol into bile. Bile acid sequestrants lie cholestyramine can reduce symptoms in patients with PSC and moderate pruiritis. Second line agents are rifampin and naltrexone.
What is the conservative management of primary sclerosing cholangitis?
Lifestyle changes like alcohol avoidance
Supplementation of fat soluble vitamins
Dilation of strictres with ERCP
Definitive liver transplant
What is primary biliary cholangitis?
Chronic autoimmune destruction of bile ducts most common in middle aged women between 30 and 60. There is association with coeliac’s disease, sjogren syndrome and thyroiditis. Prognosis is 15-20 years form diagnosis and risk factors include being female, smoker, predisposition to author autoimmune conditions like Sjogren’s and Family history.
What is the pathophysiology of primary biliary cholangitis?
reduced immune tolerance causes damage to small interlobular bileud cats causing cholestasis and cirrhosis. It id driven by antimictochondrial antibodies against pyruvate dehydrogenase E2 on biliary epithelium and T cell mediated destruction. This eventually result in portal hypertension. Environmental triggers for PBC includes toxic waste, cigarette smoking, nail polish and hair dyes in genetically susceptible patients.
Complications include hepatocellular carcinoma and osteoporosis.
What is the clinical presentation of primary biliary cholangitis?
Clinical presentation is typically asymptomatic but fr those with symptoms, jaundice and cholestasis pattern of increased ALP and pruritus from the effect of retained bile salts which is worse at night, in hot and humid weather or when the skin is dry.
What are the diagnostic findings for primary biliary cholangitis?
ALP will be evaluate, Antibody testing for antimitochodniral testing for high specificity in 90% of all cases, histopatholohical evidence of primary biliary cirrhosis with destruction of interlobular bile ducts and absence of other liver disease or exttraheptic biliary obstruction.
Imaging can exclude primary sclerosing cholangitis.
What is the first-line investigation for primary biliary cholangitis?
Abdominal ultrasound and MRCP.
Liver biopsy is gold standard
What is the treatment of primary biliary cholangitis?
Treatment is to prevent disease progression with ursodeoxycholic acid to reduce gallstone formation and inhibits apoptosis and fibrosis of the bile ducts, best taken at an earlier stage but many patients are resistant.
Alternatively obetichoic acid can be given, which is a farsenoid receptor agonist that reduces bile acid synthesis.
Cholestyramine provides symptomatic relief from itching.
Definitie treatment is liver transplant
Bispohphaonte supplements to prevent osteoporosis
Hyperlipidaemia will occur as disease progresses so statin therapy
What is cholangiocarcinoma?
An adenocarcinoma of the bile ducts, most commonly occurs in the perihilar region where the left and right hepatic ducts join.
What are the risk factors for cholangiocarcinoma?
liver fluke infection and primary sclerosing cholangitis and ulcerative colitis.
What is the clinical presentation of cholangiocarcinoma?
Clinical presentation is typically painless obstructive jaundice with steatorrhoea, icterus sclerosis, dark urine, generalised pruritus and unexplained weight loss, right upper quadrant pain, palpable gallbladder and hepatomegaly.
What is Courvoisier’s sign?
Palpable gallbladder with jaundice indicates cholangiocarcinoma or pancreatic cancer
Which imaging is used for cholangiocarcinoma?
Diagnosis is with imaging and histology
MRCP imaging
ERCP to stent and obtain biopdyb
What is Meckel’s diverticulum?
A congenital abnormality of the small intestine caused by incomplete obliteration of the vitelline duct, with most patients being asymptomatic.
What is the role of the vitelline duct?
The vitelline duct provides nutrition until the placenta forms and is the most common congenital anomaly of the GI tract. Risk factors for being symptomatic include age younger than 50, male, diverticulum longer than 2cm.
What is the rule of 2s in relation to Meckel’s diverticulum?
- Occurs in 2% of population
- 2% are symptomatic
- Typically affects males twice as often as females
What is the typical clinical presentation of Meckel’s diverticulum in children?
Painless rectal bleeding described as currant jelly colored stool.
What is the location of Meckel’s diverticulum?
2 feet proximal to the ileocecal valve
What is the length of Meckel’s diverticulum?
2 inches long or less
How many types of mucosal lining can Meckel’s diverticulum have?
2 types
What does the vitelline duct provide until the placenta forms?
Nutrition
What is the most common congenital anomaly of the GI tract?
Vitelline duct anomaly
What are risk factors for being symptomatic with Meckel’s diverticulum?
Age younger than 50, male, diverticulum longer than 2cm
What is the clinical presentation of Meckel’s diverticulum in the first 10 years of life?
Painless rectal bleeding, currant jelly coloured stool
How do adults typically present with Meckel’s diverticulum?
Melena
What is the diagnostic method used to visualize Meckel’s diverticulum?
Meckel’s radionuclide scan To be absorbed by ectopic gastric mucosa
CT of abdomen and pelvis for inflammation or obstruction of diverticulm
What imaging technique can show inflammation or obstruction of Meckel’s diverticulum?
CT scan of abdomen and pelvis
What is included in the treatment for symptomatic Meckel’s diverticulum?
Volume resuscitation with blood transfusion, surgical excision via laparoscopy
Fill in the blank: The treatment for Meckel’s diverticulum includes _______.
[surgical excision via laparoscopy]
Blood transfusion
True or False: Meckel’s diverticulum is only symptomatic in children.
False
What type of stool is associated with Meckel’s diverticulum in children?
Currant jelly coloured stool
What complication can arise from Meckel’s diverticulum over time?
Effects of bleeding
