Biliary Disease Flashcards
What are the presentations of gallstones?
1) Assymptomatic (incidental finding)
2) Biliary cholic
3) Cholecystitis
4) Jaundice
5) Pancreatitis
6) Bowel obstruction
What percentage of the general population have gall stones/
10-30% Most are asymptomatic
Is gallstones more prevalent in females or males?
Females- incidence increases with age
What are the causes of gallstones?
1) Abnormal bile composition (excess cholesterol or bilirubin)
2) Bile stasis
Where are most gall stones formed?
Gall bladder
Rarely they can be primary bile duct stones formed in the duct.
What are the 3 types of gall stones?
Mixed (80%)
Cholesterol (10%)
Pigment- bilirubin (10%)
What are the risk factors for gallstones?
(5 F’s) and others.
Forty Fat Female Fertile (pregnant) Fair (more common in the cuaction paopulation
Chron's disease Diabetes Dysmotility Prolonged fasting TPN
Why does Chron’s disease increase risk of gall stones?
Chron’s disease often effects the terminal ileum and this means less bile salt reabsorbtion => gallstones
What causes contraction for the gall bladder?
CCK release from the gland cells of the duodenum in the presence of food.
Prolonged fasting => increased risk of stasis in the gall bladder
What causes biliary cholic?
Large gall stone which intermittently obstructs the cyctic duct => distended gall bladder and some pain
How is biliary cholic treated?
Often with pain killers initially unless the symptoms cannot be controlled.
What causes cholcystitis?
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.
What is the presentation of biliary cholic?
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
What are the differential diagnosis for severe acute epigastric pain?
Biliary cholic PUD Oesophageal spasm MI Acute pancreatitis
Which gall stones can be seen on X ray?
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.
What is the gold standard imaging for gallstones?
USS: Cheap, accessible, safe, high diagnostic yeild. You can also measure the wall thickness of gallbladder and >3mm is pathological.
Why would you do a CT scan if you suspected gall stones?
If you suspect complications eg. rupture, compression of other structures.
Visuallise liver and pancreas well.
What is an MRCP?
Magnetic resonance cholangiopancreatography.
This will help you to visualise where the stone is within the biliary tree and if there is any obstruction
WHat does a HIDA nuclear scan show?
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.
What is EUS (endoscopic ultrasound) used for?
Most sensitive for detecting microstones (cause pancreatitis)
What is the treatment for acute cholecystitis?
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.
What is the triangle of calot?
Where the cyctic artery is found.
Between liver, CBD and cystic duct.
Laproscopic cystectomy: what is the risk of conversation to open operation?
2-3% and very low risk of bile duct injury
What are the complications fo gallstones if they move into the CBD?
Jaundice
Cholangitis
Acute Pancreatitis.
What is the difference between cholangitis and cholecystitis?
Cholangitis- inflammation of the bile ducts
Cholecystitis- inflammation of the gall bladder.
What are the common presenting symptoms of a patient with a gall stone in the bile duct?
Itch, nausea, anorexia,
Jaundice
Abnormal LFTs (Raised GGT and ALP)
How is a stone in the CBD diagnosed?
USS, LFTs and MRCP.
How is a gall stone in the common bile duct treated?
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
Should ERCP be used in diagnosis?
No- too many complications and many stones will pass on their own
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?
Because the bile drainage must be good to remove gall bladder- you don’t want it to be so full it bursts!
Acute pancreattis is a complication of gall stones if the stone impacts on the pancreatic duct or below. What is the treatment?
Hydration and ERCP to remove stone
What is gall stone ileus?
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.
What will X ray findings of gall stone ileus be?
Dilated bowel and air in biliary system suggesting fistula. Cannot normally see the stone. Need contrast CT for that.
How is gallstone ileus managed?
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
Where can cholangiocarcinoma occur?
Any point along the bile duct. Most common in upper 1/3rd.
What is the clinical presentation of cholangiocarcinoma?
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?
What is the assessment for cholangiocarcinoma?
USS,
CT/ERCP/PTC
MRI/MRCP/
Hyler choligiocarcinoma is very difficult to treat. Why?
You need to keep all the individual blood vessels intact for the gall bladder and the liver
Staged 1-4
Cholangiocarcinoma can be resected?
Yes if its just within the wall
If you cannot treat the cholangiocarcinoma by resection what are your oprtions?
Palliative treatment
Stenting using ERCP.
Radiological pericutainious drainage of bile into the duodenum or into a bag.
Palliative chemo
