Biliary Disease Flashcards
1
Q
What is bile made of
A
Water, bile salts, lecithin/traces of phospholipids, bilirubin & cholesterol
2
Q
Function of bile
A
digest/absorb fat
vehicle for excretion of bilirubin, excess cholesterol and metabolic byproducts
3
Q
cholelithiasis
A
stones in GB
4
Q
Cholecystitis
A
inflammation of GB
5
Q
Choledocholithiasis
A
stones in CBD
6
Q
Cholangitis
A
inflammation of the bile ducts
7
Q
Cholestasis
A
disruption of bile flow
8
Q
Risk factors for cholelithiasis
A
(female, fluffy, forty, fertile) females 40 YO obesity pregnancy estrogen (OCP, HRT)
rapid weight loss
familiy hx/genetics
ethnicity (native am)
DM
9
Q
Types of gallbladder stones
A
cholesterol (80%)
Pigment (20%) - black vs. brown
10
Q
Presentation of cholelithiasis
A
most asymptomatic
uncomplicated disease (biliary colic) - in the absence of gallstone-related complications
Complicated gallstone disease: gallstone-related complications
11
Q
Gall stone related complications
A
acute cholcystitis
Choledocholithiasis w/ or w/out acute cholangitis
Gallstone pancreatitis
12
Q
Test of choice for cholelithiasis
A
US
13
Q
Additional dx for cholelithiasis
A
US - test of choice Abdominal plain film (rare finding) CT abdomen (less sensitive than US)
14
Q
Tx fo asymptomatic (incidental) gallstones
A
no tx
refer for cholecystectomy if symptoms develop
Exceptions (Treat):
- increased risk of gallbladder CA
- hemolytic disorders
15
Q
When to treat asymptomatic gallstones
A
increased risk of gallbladder CA hemolytic disorders (Black stones)
16
Q
Etiology of pain with biliary colic (non-inflammatory)
A
gallbladder contracts, stone forces against outlet –> increased intra-gallbladder pressure –> increase in pressure results in pain –> as gallbladder relaxes, obstruction is relieved (pain subsides)
17
Q
Biliary colic sx
A
- Intense RUQ (or epigastric) pain that may radiate to the R shoulder blade
- Constant and steady (not colicky)
- Pain lasting at lease 30 min, plateauing within 1 hour • Usually lasting < 5-6 hours
- Postprandial pain, commonly after eating fatty or greasy foods
- Assoc. nausea, vomiting, diaphoresis
- Not exacerbated by movement
- Not relieved by squatting, bowel movements, or flatus
- Nocturnal pain—awakening patient is common
- Recurrence is variable (not daily)
18
Q
PE for biliary colic
A
VSS NAD no jaundice Anicteric Ab exam: possible RUQ/epigastric tenderness, no peritoneal signs, NEGATIVE MURPHY'S SIGN
19
Q
Dx for biliary colic
A
All normal: CBC, LFT, Amylase/lipase
US - show gallstones or sludge
20
Q
Tx for symptomatic uncomplicated biliary colic
A
cholecystectomy
21
Q
What is functional gallbladder disorder
A
Characterized by biliary-type pain in the absence of gallstones, sludge, microlithiasis, or microcrystal disease
22
Q
Cause of functional gallbladder disorder pain
A
gall bladder dysmotility
23
Q
Dx of functional gallbladder disorder
A
Normal labs (CBC, LFT, amylase/lipase) normal imagine/EGD
diagnosis of exclusion
Order HIDA (CCK-stimulated cholescintigraphy) after your r/o everything else: EF <35-40% support diagnosis
24
Q
EF in functional gallbladder disorder
A
<35-40%
25
Rome IV criteria for functional gallbladder disorder
biliary pain
absence of gallstones/other patholgy
Supportive:
- Low EF
- Normal LFT, bilirubin, amylase/lipase
26
Tx of functional gallbladder disorder
educate/reassure
refer
Cholecystectomy recommended w/ biliary type pain and EF <40%
27
Types of complicated gallstone disease
* Acute (calculous) cholecystitis
* Choledocholithiasis
* Acute cholangitis
28
What is acute (calculous) cholecystitis
acute inflammation of gall bladder due to complication of those w/ gallstones (cystic duct obstruction and gallbladder inflammation)
29
Presentation of acute cholecystitis
biliary pain that progressively worsens (most have had past episodes of biliary pain)
Prolong >4-6 hours, stead, RUQ/epigastric pain
Radiate to right shoulder or back
FEVER, N/V, anorexia
hx of fatty food ingestion
30
PE for cholecystitis
```
VS: fever, tachycardic
Gen: ill appearing, may be lying still
NO JAUNDICE
Abd exam: RUQ tenderness, +/- guarding
POSITIVE MURPHY'S SIGN
```
31
labs for acute cholecystitis
Leukocytosis w/ left shift!!!
mild elevation of AST/ALT
Elevated bilirubin/ALP NOT COMMON (if present, should suspect cholangitis, choledocholithiasis)
Serum amylase = normal (unless pancreatitis)
32
Dx of acute cholecystitis
US - gallstones present, wall thickening (>4-5 mm) or edema, pericholecystic fluid, + sonographic murphy's sign
HIDA - if diagnosis is uncertain; + = failure to visualize gallbladder in setting of cystic duct obstruction (doesn't fill)
33
Complications of acute cholecystitis
```
Gangrene (most common)
Perforation (often after gangrene)
Cholecystoenteric fistula
Gallstone ileus
Emphysematous cholecystitis, empyema, hydrops
Mirizzi syndrome
```
34
Tx of acute cholecystitis
Admit
NPO, IVF
IV pain control (ketoroloac, morphine, meperidine)
IV abx (empiric)
Cholecystectomy !!!!
35
Chronic cholecystitis
chronic inflammation of gallbladder due to gallstones or repeated acute/subacute cholecystitis
36
Sx of chronic cholecystitis
minimal
asymptomatic for years, may progress to symptomatic gallbladder disease or to acute cholecystitis or present w/ complications
no evidence that increases morbidity
37
Acalculous cholecystitis
Acute necroinflammatory disease of the gallbladder (in the absence of gallstones) -- VERY SICK
high morbidity and mortality rates
38
Pathogenesis of acalculous cholecystitis
* Gallbladder stasis and ischemia-->local inflammatory response in the gallbladder wall
* Secondary bacterial infection is common; perforation in severe cases
39
Who gets acalculous cholecystitis
hospitalized and CRITICALLY ILL PATIENTS (trauma/burn, postpartum, ortho surgery)
40
Sx of acalculous cholecystitis
similar to acute (calculous) cholecystitis OR clinical picture of sepsis-related cholestasis and jaundice (sepsis w/o a clear source)
41
suspect acalculous cholecystitis
Critically ill patients with sepsis without a clear source or jaundice
42
Workout for acalculous cholcystitis
US (CT, HIDA)
| LFT, CBC, electrolytes, pancreatic enzymes, UA
43
Tx for acalculous cholecystitis
* Risk of gallbladder gangrene and perforation • Obtain blood cultures
* Initiate antibiotics
* Cholecystectomy vs. gallbladder drainage (if too ill)
44
What is choledocholithiasis
gallstones in common bile duct (usually from gallstone in gallbladder); increases w/ age
45
Presentation of choledocholithiasis
biliary type pain
prolonged than typical biliary colic
some are asymptomatic
JAUNDICE
46
PE for choledocholithiasis
VS: WNL
RUQ/epigastric tenderness
Jaundiced
Courvoisier sign (palpable gallbladder)
47
Labs for choledocholithiasis
CBC- no leukocytosis
Elevated liver test (cholestasis) - elevated ALT/AST (early in course); later, liver test elevated in cholestatic pattern (increased bilirubin, ALP and GGT; exceeding elevations of ALT and AST)
Normal amylase and lipase
48
Imaging for choledocholithiasis
US - cholelithiasis, CBD stone, CBD dilation (>6mm)
MRCP/EUS if unsure
49
Tx for choledocholithiasis
```
remove CBD stone
Treat complications (acute cholangitis, acute pancreatitis)
```
ERCP: therapeutic and diagnostic
Cholecystecotomy to follow (if appropriate: low vs. high risk)
50
Acute cholangitis
inflammation of biliary duct system caused by bacterial infection in person w/ biliary obstruction (choledocholithiasis, benign biliary stricture, s/p ERCP, malignancy)
51
main cause of acute cholagitis
choledocholithiasis
52
Bacterial origin in cholangitis
ASCEND from duodenum
53
Symptoms of acute cholangitis
Charcot's Triad: fever, abdominal pain, jaundice
Reynolds Pentad: above + AMS and hypotension (significant morbidity and mortality)
54
Labs for acute cholangitis
Leukocytosis w/ left shift
Elevated CRP/ESR
Liver tests: evidence of cholestasis
- inc. bilirubin, ALP, GGT
- may see inc. AST/ALT
amylase/lipase increased in pancreatitis
some have positive blood culture
55
Imaging in acute cholangitis
US (CT, MRCP, EUS)
| - CBD dilation, stone
56
Tx for acute cholangitis
admit
monitor/tx for sepsis (empiric abx)
Emergent consult w/ GI and surgery - establishing biliary drainage (typically w/ ERCP)
57
Biliary drainage
relief of biliary obstruction imperative;
Done w/ ERCP w/ sphincterotomy and stone extraction (and/or stent insertion)
F/u w/ cholecystectomy (if appropriate)
58
Primary biliary cholangitis (PBC): what is it?
mainly in women 30-64 YO; AUTOIMMUNE destruction of intrahepatic bile ducts which causes cholestasis -- may result in cirrhosis and liver failure
59
presentation of PBC
```
may be asymptomatic
fatigue, pruritis
jaundice
RUQ discomfort
skin hyperpigmentation
xanthelasmas
hepatomegaly
```
60
PBC associated w/
other autoimmune conditions (sjogren, thyroid disease)
61
Labs for PBC
Liver tests: cholestatic pattern (elevated ALP, GGT, 5-NT), +/- ALT/AST, increase bilirubin (later in disease)
Antimitochondrial antibodies (AMA) - serologica hallmark of PBC
ANA (70%)
HLD - strikingly elevated
62
Antibodies for PBC
AMA, ANA
63
Complications of PBC
```
• Cirrhosis
• Hepatocellular carcinoma
• Malabsorption (and steatorrhea)
- Fat-soluble vitamin deficiencies
• Metabolic bone disease
- Including osteopenia and osteoporosis
```
64
Dx of PBC
• No extrahepatic biliary obstruction
• No comorbidity affecting the liver
• At least 2 of the following are present:
- Elevated Alk. Phos (1.5 times the upper normal limit)
- + AMA
- Histologic evidence of PBC (liver bx, if needed)
65
Tx for PBC
refer to GI (meds and tx of complications)
66
Primary sclerosing cholangitis (PSC): what is it?
a sclerosing, inflammatory , and obliterative process involving the intrahepatic and/or extrahepatic biliary tree; chronic/progressive w/ unknown etiology
67
PSC most common in
MEN! (40 YO)
68
PBC most common in
women (30-64 YO)
69
PSC associated w/
IBD (UC>UD)
70
Complications of PSC
cholestasis
| end-stage liver disease
71
S/sx of PSC
asymptomatic
fatigue, pruritus
jaundice!
hepatomegaly
72
Labs for PSC
liver test- cholestatic pattern
Increased IgM levels, +P-ANCA, autoantibodies (ANA, ASMA)
NEGATIVE AMA!!!
73
Dx of PSC
Liver tests - especially in those w/ IBD
Cholangiography (MRCP or ERCP)
Liver bx (supports but rarely diagnostic)
74
Complications of PSC
* End-stage liver disease
* Fat-soluble vitamin deficiencies
* Metabolic bone disease
* Cholangitis and cholelithiasis
* Hepatobiliary cancer
* Colon cancer
* Patients with UC
75
Tx for PSC
refer to GI (meds/treatment of complications)
76
Gilbert's
inherited; inability to conjugate bilirubin (deficiency of enzyme for glucoronidation of bilirubin);
Unconjugated hyperbilirubinemia in ABSENCE OF HEMOLYSIS (normal CBC, blood smear, reticulocyte), remainder of liver tests normal
77
Presentation of Gilbert Syndrome
```
• Typically present during adolescence
(post-puberty)
• More common in males
• Mild intermittent episodes of jaundice
• Otherwise, most are asymptomatic with normal physical exam findings
```
78
Jaundice occurs when w/ Gilbert
dehydration
fasting
menstruation
stress
79
Most common cancer in biliary tract
Gallbladder CA (uncommon, but hightly fatal); W>M
80
Risk factors for gallbladder CA
```
Gallstone disease
Porcelain gallbladder***
Gallbladder polyps ***
PSC
Chronic infection (salmonella, Helicobacter)
Obesity
```
81
Presentation of gallbladder CA
asymptomatic
may mimic cholelithiasis or suggestive of malignancy (weight loss)
may see jaundice
82
Etiology of cholangiocarcinoma (bile duct cancer)
Arise from epithelial cells of the bile ducts (intrahepatic, perihilar, or distal extrahepatic biliary tree); rare; M>F
83
Cholangiocarcinoma associated w/
PSC
| choledochal cysts
84
Presentation of chlangiocarcionoma
```
jaundice
pruritus
abd pain
anorexia
weight loss
palpable gallbaldder (courvoisier sign)
```
85
Labs for cholangiocarcinoma
cholestasis pattern
| Increased CA 19-9 (in those w/ PSC)
86
Ampullary carcinoma
rare; arise w/i ampulla of vater (complex) - distal to the difurcation of distal CBD and pancreatic duct
87
Ampullary carcinoma associated w/
Familial Adenomatous Polyposis (FAP)
Hereditary Non-Polyposis Colon Cancer (HNPCC)
88
Presentation of ampullary carcinoma
jaundice
GI bleed w/ microcytic anemia
abdominal pain
89
women, pruritus, + AMA
PBC
90
men, IBD (UC), risk of cholangiocarcinoma
PSC
91
men, post-puberty, elevated unconjugated hyperbilirubinemia
Gilbert Syndrome
92
Initial test of choice in evaluation of biliary disease
US
93
Helpful for diagnosing stones/obstruction in the CBD when US non-diagnostic
MRCP
94
Uses CCK to measure EF for functional gallbladder disorder
HIDA
95
Used to relieve CBD obstruction; Choledocholithiasis, Cholangitis
ERCP
