Biliary Diseases Flashcards
What are some of the consequences of disruption of the flow of bile
Pain Inflammation colonisation by micro-organisms infection loss of essential digestive functions of bile
Why does disruption of bile flow most commonly occur
Because of a mechanical blockage caused by biliary stones
What is bile composed of
Water electrolytes bile salts bilirubin phospholipds and cholesterol proteins that regulate GI function Drugs and drug metabolites
How does the gallbladder concentrate the bile
By absorbing 90% of the water content
Where do bile salts circulate
Through the entero-hepatic circulation
What is the difference between cholecystitis and cholangitis
Infection of gallbladder = cholecystitis
infection of the bile ducts = cholangitis
What are the most common organisms involved in biilary microbiology
Gram negatives (Escheria coli, Klebsiella, Enterobacter
What should patients with symptomatic gallstones ave
A cholecystectomy
What are gallstones made up of
Poorly soluble components of bile precipitated on a three dimensional matrix of mucins and proteins
What are the three main types of gallstones
Cholesterol
Black pigment
Brown pigment
What are the vast majority of gallstones in Western countries
Cholesterol or mixed type
What are some of the risk factors for cholesterol gallstones
FHx Age Female Pregnancy Obesity Rapid weight loss Prolonged fasting Diabetes mellitus Crohn's disease TPN
What are some of the possible preventative factors
High fibre diet
Low consumption of saturated fatty acids
high relative amount of trans-fatty acids
nut consumption
moderate physical activity
What are the clincal features of gallstones
Pain (right hypochondrial or epigastric)
Radiates to the upper back or right shoulder
Steady and intense - occurs more than an hour after meals
Often associated with an urge to walk
Each episode lasts 1-24 hours
Murphy’s sign positive
Fever
What are some routine investigations
Liver tests
MRCP
US
What are some routine investigations
Liver tests
MRCP
US
What is the treatment of choice for gall stones
Laparoscopic cholecystectomy
What might be a sufficient treatment for patients with gallstones who are not suitable for surgery
ERCP and sphincterotomy
How does acute cholangitis develop
When bacterial infection complicates obstruction within the biliary tract
What are some causes of acute bacterial cholangitis
Choledocholithiasis or sludge Biliary strictures Choledochal cysts Stenosis of the papilla of Vater Parasitic infection Iatrogenic (post ERCP)
What is the classical presentation of acute cholangitis
Fever
RUP pain
Jaundice
What are the investigations for acute cholangitis
Bloods: Serum biochemistry, FBC, clotting screen
Transabdominal US: first step in detecting bile duct stones
MRCP
ERCP - gold standard
Endoscopic US
What causes cholecystitis
An obstruction of the cystic duct usually by a gallstone
What are the clincal features of cholecystitis
Unremitting RUQ pain anorexia nausea vomiting fever
What is gangrenous cholecystitis
Severe acute cholecystitis can lead to necrosis of the gall bladder wall
What are some of the complications of cholecystitis
Perforation of the gallbladder
Pericholecystic abscess
fistula
What is the treatment of choice for cholecystitis
Open or laparoscopic cholecystemoctomy EARLY
What is meant by Acualculous biliary pain
Recurrent biliary type abdominal pain in patients with no evidence of cholelithiasis
What are some of the causes of acalculous biliary pain
Altered gallbladder motility
Impairment of gallbladder filling
Gallbladder hyperalgesia
What is the management for patients with Acalculous biliary pain
Usually conservative - treatments target chronic visceral pain
What are the three major adult manigestations of cholestasis
Primary biliary cirrhosis (PBC)
primary sclerosing cholangitis (PSC)
cholangiocarcinoma
What are the three major adult manigestations of cholestasis
Primary biliary cirrhosis (PBC)
primary sclerosing cholangitis (PSC)
cholangiocarcinoma
Primary sclerosing cholangitis has which sex prodominance
Male
What does primary sclerosing cholagitis have a strong associateion with
IBD - especially UC
What occurs in PSC
Progressive liver disease that causes inflammation, fibrosis and strictures in the intra-hepatic and extrahepatic bile ducts
WHat are the clinical features of PSC
Jaundice steatorrhoea pruritus weight loss failure or proper absoroption of calcium and fat soluble vitamins
What might be found on examination of suspected PSC
Xanthomas of the eyes, neck, chest and back
What do the lab tests show in PSC
Elevated conjugated bilirubin
An extremely high ALP (more than 3 times the upper limit of normal)
Elevated GGT
What is the management for PSC
Symptom management
What is the only life-extending therapy for PSC
Liver transplantation
Why do patients with PSC complicating IBD require more frequent colonic surveillance than those with iBD alone
Because of the increased risk of colon cancer
What is Primary Biliary cirrhosis
An autoimmune cholestatic liver disease in which the epithelial cells linign the intrahepatic bile ducts are damaged by the immune system
Who does Primary biliary cirrhosis predominantly affect
Women ages 30-65
What is the male to female ratio of PBC
1:10
What are the clincal features of PBC
Fatigue intense pruritus cutaneous hyperpigmentation xanthelasmas hepatosplenomegaly
What is PBC often associated with
Autoimmune diseases such as scleroderma
thyroiditis and Sjogren’s syndrome
What is the management for PBC
UDCA ist eh first line treatment in early disease
What prolong life in PBC
Liver transplant
What is cholangiocarcinoma
A slow growing malignancy of the bile duct
How are at risk of cholangiocarcinoma
Parasitic diseases of the biliary tract Congenital choledochal cysts IBD PSC Hisotry of other malignancy Previous surgery for choledochal cyst or biliary atresia Alpha 1 antitripsin deficiency Autosomall dominant polycycsti ckidneyy disease Gallstones Papillomatosis of the bile ducts thorotrast exposure chronic typohoid carrier status
What are the clincal features of cholangiocarcinoma
Abdominal pain palpable masses weight loss progressive obstructive jaundice Hepatomegaly
What investigations should be carried out for cholangiocarcinoma
US
Abdominal CT
MRCP
ERCP
What is the management of cholangiocarcinoma
Complete surgical resection
Palliation
Orthotopic liver transplantation
