Biliary Diseases Flashcards by Danielle Dilday

What is the anatomy of the biliary tree?

Cystic duct, Common hepatic duct, Common bile duct, Liver, Gallbladder

Refer to Sabiston Textbook of Surgery, 20th edition for detailed anatomy.

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What causes cholesterol stones?

Supersaturation of bile

Usually occurs in middle-aged women who are overweight and fair-skinned.

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What causes pigment stones?

Hemolytic anemia

Pigment stones are primarily composed of bilirubin.

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What is the most common clinical manifestation of biliary disease?

Most patients are asymptomatic

Symptomatic patients may experience intermittent RUQ pain related to fatty food intake.

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What is the best initial test for gallstones?

RUQ ultrasound

It typically shows the presence of gallstones.

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When is elective cholecystectomy indicated?

Only treat symptomatic patients

Elective cholecystectomy should be performed when convenient.

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What is the treatment if a patient cannot undergo surgery for gallstones?

Ursodeoxycolic acid (UDCA or ursodiol)

This is used when surgery is not an option.

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What is cholecystitis?

Inflammation of the gallbladder due to obstruction of the cystic duct

Clinical manifestations include persistent RUQ pain, fever, leukocytosis, and a positive Murphy sign.

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What are the best initial tests for cholecystitis?

RUQ ultrasound and HIDA scan

RUQ ultrasound shows gallstones and pericholecystic fluid.

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What is the treatment for cholecystitis?

Urgent cholecystectomy within 72 hours

If surgery is not possible, a cholecystostomy tube may be inserted.

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What does a non-filling gallbladder on a HIDA scan indicate?

Confirms the diagnosis of acute cholecystitis

This occurs when a stone obstructs the cystic duct.

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What is emphysematous cholecystitis?

Inflammation of the gallbladder in the absence of a gallstone

Typically seen in very sick patients or those with severe trauma.

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What are the risk factors for emphysematous cholecystitis?

Severe trauma, extensive burns, recent surgery, prolonged fasting, critical illness, AIDS

These conditions may lead to gallbladder stasis.

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What is the best initial test for choledocholithiasis?

RUQ ultrasound

It may show a dilated CBD and gallstones.

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What is the treatment for choledocholithiasis?

ERCP to remove stones and open sphincter of Oddi

Cholecystectomy is also performed to remove the source of stones.

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What is ascending cholangitis?

Infection of backed up bile due to stone obstruction

Clinical manifestations include RUQ pain, fever, jaundice, and hypotension.

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What is Charcot’s triad?

Fever, jaundice, RUQ pain

This triad is indicative of ascending cholangitis.

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What does the term ‘chol’ in medical terminology refer to?

Bile

This prefix is used in various terms related to bile.

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What does ‘-lithiasis’ mean?

Stone

This suffix is used in terms like cholelithiasis.

What is the pathology of gallstone ileus?

Cholecystoduodenal fistula causing small bowel obstruction

It most commonly occurs at the ileocecal valve.

What is Rigler’s triad?

Small bowel obstruction, pneumobilia, and gallstone

This triad is indicative of gallstone ileus.

What is biliary dyskinesia?

Failure of gallbladder to fully contract and eject bile

Often referred to as “heart failure” of the gallbladder.

What are the clinical manifestations of biliary dyskinesia?

Biliary pain without stones, sludge or inflammation

History of biliary pain or disease without diagnosis. Comorbidities may include ischemic heart disease and PUD.

How is biliary dyskinesia diagnosed?

Diagnosis of exclusion with CCK-stimulated HIDA scan

A GBEF <40% is diagnostic and indicates surgery.

What is the treatment for biliary dyskinesia?

Elective laparoscopic cholecystectomy

What type of cancer is associated with chronic inflammation of the gallbladder?

Adenocarcinoma of the glandular epithelium ## Footnote Major risk factors include porcelain gallbladder and large gallstones.

What are the clinical manifestations of gallbladder cancer?

Cholecystitis in older women, weight loss, fatigue, jaundice, abdominal mass

What imaging is used to diagnose gallbladder cancer?

RUQ US shows irregular mass or polyp >1 cm; CT to visualize tumor involvement and assess resectability

What is the treatment for gallbladder cancer?

Often unresectable at presentation; non-invasive tumors may require open cholecystectomy, invasive tumors require radical cholecystectomy

What is primary biliary cholangitis (PBC)?

T-cell mediated autoimmune attack on intrahepatic bile ducts leading to granulomatous inflammation, cholestasis, cirrhosis, and liver failure

What is a common presenting symptom of primary biliary cholangitis (PBC)?

Intense pruritus ## Footnote Most common in middle-aged women.

What laboratory findings are associated with primary biliary cholangitis (PBC)?

Elevated alkaline phosphatase 1.5x normal, antimitochondrial antibody (AMA), biopsy showing damage to bile ducts

What is the first line therapy for primary biliary cholangitis (PBC)?

Ursodeoxycolic acid (UDCA)

What is primary sclerosing cholangitis (PSC)?

Inflammation, fibrosis, and stricturing of medium and large intra- and extrahepatic bile ducts leading to cirrhosis

What clinical manifestations are associated with primary sclerosing cholangitis (PSC)?

Pruritus, jaundice, fatigue, hepatomegaly ## Footnote Associated with ulcerative colitis.

What laboratory findings support a diagnosis of primary sclerosing cholangitis (PSC)?

↑ ALP, p-ANCA, Hyper-IgM (AMA always negative)

What imaging findings are characteristic of primary sclerosing cholangitis (PSC)?

MRCP or ERCP showing 'string of beads' pattern

What is cholangiocarcinoma?

Cancer of the bile duct epithelium ## Footnote Major risk factors include primary sclerosing cholangitis, cystic liver disease, Clonorchis, HCV, and gallstone disease.

What are the clinical manifestations of cholangiocarcinoma?

Painless obstructive jaundice, clay-colored stools, dark urine, vague RUQ pain, fatigue, weight loss

What is the best imaging study to visualize cholangiocarcinoma?

CT and/or MRCP

What is the typical treatment for cholangiocarcinoma?

Often unresectable; drain/decompress biliary tree if bilirubin >10 mg/dL, Whipple procedure for potential cure

What is the pathophysiology of cholecystitis?

Cystic duct obstruction leading to inflammation of the gallbladder

What are the complications of biliary disorders?

* Cholelithiasis * Cholecystitis * Choledocolithiasis * Cholangitis * Gallstone Ileus * Biliary dyskinesia * Gallbladder cancer

In a clinical scenario, what is the best next step for a patient with severe RUQ pain and elevated WBC count?

Emergent ERCP for biliary decompression

What is the most likely diagnosis for a young male with abdominal pain, jaundice, and a history of bloody diarrhea?

Primary sclerosing cholangitis

What laboratory finding would most likely be present in a patient with primary sclerosing cholangitis?

Positive p-ANCA antibody

What is the next best step in management for a patient with suspected ascending cholangitis?

Start antibiotics, IV fluids, and perform emergent ERCP