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GI > Biliary Disease > Flashcards

Biliary Disease Flashcards

1
Q

What are the presentations of gallstones?

A

1) Assymptomatic (incidental finding)
2) Biliary cholic
3) Cholecystitis
4) Jaundice
5) Pancreatitis
6) Bowel obstruction

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2
Q

What percentage of the general population have gall stones/

A

10-30% Most are asymptomatic

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3
Q

Is gallstones more prevalent in females or males?

A

Females- incidence increases with age

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4
Q

What are the causes of gallstones?

A

1) Abnormal bile composition (excess cholesterol or bilirubin)
2) Bile stasis

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5
Q

Where are most gall stones formed?

A

Gall bladder

Rarely they can be primary bile duct stones formed in the duct.

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6
Q

What are the 3 types of gall stones?

A

Mixed (80%)
Cholesterol (10%)
Pigment- bilirubin (10%)

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7
Q

What are the risk factors for gallstones?

(5 F’s) and others.

A 
Forty
Fat
Female
Fertile (pregnant)
Fair (more common in the cuaction paopulation
Chron's disease
Diabetes
Dysmotility 
Prolonged fasting 
TPN
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8
Q

Why does Chron’s disease increase risk of gall stones?

A

Chron’s disease often effects the terminal ileum and this means less bile salt reabsorbtion => gallstones

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9
Q

What causes contraction for the gall bladder?

A

CCK release from the gland cells of the duodenum in the presence of food.
Prolonged fasting => increased risk of stasis in the gall bladder

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10
Q

What causes biliary cholic?

A

Large gall stone which intermittently obstructs the cyctic duct => distended gall bladder and some pain

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11
Q

How is biliary cholic treated?

A

Often with pain killers initially unless the symptoms cannot be controlled.

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12
Q

What causes cholcystitis?

A

Small stones passing from the gall bladder and getting stuck in the cystic duct causing obstruction and dilation of the gall bladder => infection and inflammation .
Fluid is initially sterile but will become infected.

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13
Q

What is the presentation of biliary cholic?

A

Grandual build up of pain in RUQ which may radiate to back or shoulder.
May last 2-6 hours in the post prandrum period.
Associated with indigestion and nausea

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14
Q

What are the differential diagnosis for severe acute epigastric pain?

A 
Biliary cholic
PUD
Oesophageal spasm
MI
Acute pancreatitis
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15
Q

Which gall stones can be seen on X ray?

A

Only radio opaque gall stones- 10%.

You may also see air in the biliary system (abnormal) which implies a fistula between the gall bladder and duodenum.

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16
Q

What is the gold standard imaging for gallstones?

A

USS: Cheap, accessible, safe, high diagnostic yeild. You can also measure the wall thickness of gallbladder and >3mm is pathological.

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17
Q

Why would you do a CT scan if you suspected gall stones?

A

If you suspect complications eg. rupture, compression of other structures.
Visuallise liver and pancreas well.

18
Q

What is an MRCP?

A

Magnetic resonance cholangiopancreatography.

This will help you to visualise where the stone is within the biliary tree and if there is any obstruction

19
Q

WHat does a HIDA nuclear scan show?

A

Motility of the gall bladder. GIve a radioactive tracer to the patient which is excreted in the bile and measure how much passed through the biliary system within a given time. Looking for gall bladder filling and then contraction on stimulation with a drug. Ejection fraction <35% is pathological (common in diabetics) Also looks at the sphincter of Oddi.

20
Q

What is EUS (endoscopic ultrasound) used for?

A

Most sensitive for detecting microstones (cause pancreatitis)

21
Q

What is the treatment for acute cholecystitis?

A

IV antibiotics and IV fluids
Nil by mouth if vomiting
USS to confirm diagnosis.
Symptoms for less than 5 days: Urgent cholecystectomy. Surrounding tissues have not yet stuck to the gall bladder so laproscopic is safe.
Symptoms >5 days: IV antibiotics and fluid and interval cholecystectomy in 2-3 months when inflammation reduced.

22
Q

What is the triangle of calot?

A

Where the cyctic artery is found.

Between liver, CBD and cystic duct.

23
Q

Laproscopic cystectomy: what is the risk of conversation to open operation?

A

2-3% and very low risk of bile duct injury

24
Q

What are the complications fo gallstones if they move into the CBD?

A

Jaundice
Cholangitis
Acute Pancreatitis.

25
Q

What is the difference between cholangitis and cholecystitis?

A

Cholangitis- inflammation of the bile ducts

Cholecystitis- inflammation of the gall bladder.

26
Q

What are the common presenting symptoms of a patient with a gall stone in the bile duct?

A

Itch, nausea, anorexia,
Jaundice
Abnormal LFTs (Raised GGT and ALP)

27
Q

How is a stone in the CBD diagnosed?

A

USS, LFTs and MRCP.

28
Q

How is a gall stone in the common bile duct treated?

A

ERCP- endoscopic retrograde cholangiopancretography.
Pass a wire into the CBD to try to remove the stones.
Complications include bowel perforation and pancreatitis.
Alternatively Open or laproscopic surgery

29
Q

Should ERCP be used in diagnosis?

A

No- too many complications and many stones will pass on their own

30
Q

In order to remove the gall bladder you may need to insert a stent around gall stones in the CDB and then return later why?

A

Because the bile drainage must be good to remove gall bladder- you don’t want it to be so full it bursts!

31
Q

Acute pancreattis is a complication of gall stones if the stone impacts on the pancreatic duct or below. What is the treatment?

A

Hydration and ERCP to remove stone

32
Q

What is gall stone ileus?

A

Where a large gall stone enters the bowel via a gall bladder duodenal fistula and impacts on the ileocecal valve causing bowel obstruction.
Usually stone >3cm. Causes intermittent cholic as it moves and the patient presents with small bowel obstruction.

33
Q

What will X ray findings of gall stone ileus be?

A

Dilated bowel and air in biliary system suggesting fistula. Cannot normally see the stone. Need contrast CT for that.

34
Q

How is gallstone ileus managed?

A

Resuscitation with fluid and painkillers and monitor urine output.
Urgent laparotomy to remove the obstructing stone .
Interval cholecystectomy in 3 months to remove gall bladder if necessary

35
Q

Where can cholangiocarcinoma occur?

A

Any point along the bile duct. Most common in upper 1/3rd.

36
Q

What is the clinical presentation of cholangiocarcinoma?

A

Present usually late
Painless jaundice as tumour has occluded the duct.
Anorexia, lethargy.
50% already have lymph node mets and 20-30% have peritoneal mets at diagnosis?

37
Q

What is the assessment for cholangiocarcinoma?

A

USS,
CT/ERCP/PTC
MRI/MRCP/

38
Q

Hyler choligiocarcinoma is very difficult to treat. Why?

A

You need to keep all the individual blood vessels intact for the gall bladder and the liver
Staged 1-4

39
Q

Cholangiocarcinoma can be resected?

A

Yes if its just within the wall

40
Q

If you cannot treat the cholangiocarcinoma by resection what are your oprtions?

A

Palliative treatment
Stenting using ERCP.
Radiological pericutainious drainage of bile into the duodenum or into a bag.
Palliative chemo

GI (48 decks)

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