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Gastrointestinal > Biliary Pathology > Flashcards

Biliary Pathology Flashcards

1
Q

What is primary biliary cholangitis?

A

Autoimmune inflammation and destruction of bile ducts, causing the build up of bile and other toxins in the liver

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2
Q

What sex is primary biliary cholangitis more common in?

A

F>M

90% of patients are female

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3
Q

What age is primary biliary cholangitis more likely to occur?

A

Middle aged

30-60

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4
Q

What conditions are associated with primary biliary cholangitis?

A

RA

Coeliac

Sjogren’s syndrome

Hypothyroidism

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5
Q

How does primary biliary cholangitis present?

A

Pruritis

Jaundice

Fatigue

Pale stools and dark urine

Xanthelasmata and xanthoma

Hepatomegaly and splenomegaly

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6
Q

What investigations are used in primary biliary cholangitis diagnosis?

A

Antimitochondrial auto-antibodies (AMA)

LFT

  • Increased ALP
  • Increased GGT
  • Increased bilirubin

IgM elevation

>ESR

Liver biopsy, for diagnosis

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7
Q

In what percentage of primary biliary cholangitis patients are AMA antibodies present?

A

+ in over 95%

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8
Q

How is primary biliary cholangitis managed?

A

Ursodeoxycholic Acid (UDCA)

  • Bile acid analogue

Cholestyramine

  • For pruritis

Steroids/immunosuppression is sometimes considered

Liver transplant if end stage liver disease

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9
Q

Give complications of primary biliary cholangitis

A

Liver cirrhosis

Osteoporosis

Hypothyroidism

Hepatocellular carcinoma

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10
Q

What is primary sclerosing cholangitis?

A

Chronic progressive inflammation and fibrosis of the intra and extrahepatic bile ducts, preventing bile draining from the liver/cholestasis

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11
Q

What sex is primary sclerosing cholangitis more common in?

A

M>F

70% of patients are men

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12
Q

What age is biliary sclerosing cholangitis more common in?

A

Middle age

3rd-5th decade

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13
Q

What conditions are associated with primary sclerosing cholangitis?

A

UC, 80% of patients with PSC have UC

Cholangiocarcinoma

HIV

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14
Q

How does primary sclerosing cholangitis present?

A

Pruritis

Fatigue

Weight loss

RUQ pain

Night sweats

Pyrexia

Hepatomegaly

Obstructive jaundice

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15
Q

What investigations are used in primary sclerosing cholangitis diagnosis?

A

MRCP/ERCP

  • Beaded appearance of ducts

LFTs

  • Increased ALP, most deranged
  • Increased bilirubin

pANCA+

Increased IgM

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16
Q

How is primary sclerosing cholangitis managed?

A

UDCA

ERCP and biliary stents

Liver transplant

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17
Q

Give complications of primary sclerosing cholangitis?

A

Cholangiocarcinoma

Liver cirrhosis

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18
Q

What are the types of gallstones?

A

Cholesterol

Bilirubin/pigmented

Mixed

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19
Q

What is the most common type of gallstone?

A

Mixed (80%)

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20
Q

What are the causes of gallstones?

A

4 F’s

  • Female
  • Fat
  • Forty
  • Fair

Associated conditions

  • Diabetes
  • Pigment conditions/sickle cell anaemia/liver cirrhosis
  • Chrons

Drugs

  • COCP
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21
Q

How does gallstones/biliary colic present?

A

Majority asymptomatic, symptoms occur due to biliary colic

Sudden severe epigastric/RUQ pain

  • Often triggered by meals
  • Radiates to interscapular region

N&V

Jaundice

22
Q

What investigations are used in gallstone diagnosis?

A

EUS, best initial investigation

LFTs

  • Increased ALP

MRCP

Amylase, to rule out pancreatitis

23
Q

What is first line investigation/most useful investigation in gall stones?

A

US

24
Q

How are gallstones managed?

A

For asymptomatic, do nothing

Dissolution, given for frail patients unsuitable for surgery

Cholecystostomy/implanting drain to drain gallbladder

Laparoscopoc cholecystectomy

25
Q

Name complications of gallstones

A

Acute pancreatitis

Ascending cholangitis

Cholecystitis

Ileus/small bowel obstruction

Obstructive jaundice

Biliary colic, in which stone blocks gallbladder

Mirrizi’s Syndrome

26
Q

Give side effects of ERCP/MCRP

A

Haemorrhage

Duodenal perforation

Cholangitis

Pancreatitis

27
Q

When is ERCP done over MRCP?

A

Only used if patient is unable to tolerate MRCP (ie metal implants), as ERCP is more invasive

28
Q

Give complications of cholecystectomy

A

Bleeding, infection, pain and scars

Damage to the bile duct including leakage and strictures

Stones left in the bile duct

Damage bowel, blood vessels or other organs

Anaesthetic risks

DVT or PE

Post-cholecystectomy syndrome

29
Q

What is Mirrizi’s Syndrome?

A

Gallstone in cystic duct or neck of gallbladder, leading to obstruction of common hepatic duct

30
Q

What is cholestasis?

A

Accumulation of bile within the hepatocytes due to blockage of flow

31
Q

What causes cholestasis?

A

Viral hepatitis

Alcoholic hepatitis

Liver failure

Drugs

Obstetric cholestasis

32
Q

What is cholecystitis?

A

Inflammation of the gallbladder, usually due to gallstone causing obstruction of gall bladder outlet

(think gallstones/biliary colic, but systemically unwell)

33
Q

How does cholecystitis present?

A

Sudden sharp pain in right upper quadrant

  • Radiating to right shoulder
  • Pain worse when breathing deeply
  • Persistent pain

N&V

Sweating

Murphy’s Sign

Systemic upset

  • Pyrexia
  • Tachycardia
  • Tachypnoea
34
Q

What is Murphy’s sign?

A

Patient catches breath on inspiration when two fingers are placed in RUQ, yet not in the LUQ

35
Q

What investigations are used in cholecystitis diagnosis?

A

FBC

  • >WCC

LFTs are often normal

US, to assess gallstones

36
Q

How is cholecystitis managed?

A

Supportive

  • Analgesia
  • IV fluids

IV antibiotics

  • Cefuroxime and Metronidazole

Laparoscopic cholecystectomy

  • Within 1 week of diagnosis
37
Q

What is ascending cholangitis?

A

Infection of the biliary tree due to lesion/gall stone in the common bile duct which results in bacteria ascending from the duodenum

38
Q

What organism is associated with ascending cholangitis?

A

E coli

39
Q

How does ascending cholangitis present?

A

RUQ pain

Fever

Jaundice

Dark urine

Pale stools

Pruritis

Tachycardia

Hypotension

Confusion

40
Q

What is Charcot’s triad?

A

Associatd with ascending cholangitis

Jaundice

Fever

RUQ pain

41
Q

What is Reynolds pentad?

A

Associated with ascending cholangitis

Jaundice

RUQ pain

Fever

Shock/hypotension

Altered mental status

42
Q

What investigations are used in ascending cholangitis diagnosis?

A

FBC

  • >WCC

>CRP

LFTs

  • >ALP
  • >Bilirubin

ERCP

US

43
Q

How is ascending cholangitis managed?

A

Supportive

  • IV fluids
  • Analgesia
  • IV Antibiotics (Cefuroxime and Metronidazole)

Endoscopic/ERCP

  • After 24-48 hours to relieve obstruction
  • Stone removal
  • Stent placement

Cholecystectomy

44
Q

How do you differentiate between biliary colic, cholangitis and cholecystitis?

A

Biliary colic patient is usually systemically well and pain is chronic and intermittent/occurs after eating

Cholangitis patient will be systemically unwell and jaundiced, think charcot’s triad

Cholecystitis patient is systemically unwell, think charcot’s triad but murphy’s sign instead of jaundice

45
Q

What is cholangiocarcinoma?

A

Malignancy of the biliary tree

46
Q

What is the most common type of choliangocarcinoma?

A

Adenocarcinoma

47
Q

Give risk factors for cholangiocarcinoma

A

Primary sclerosing cholangitis, and hence IBD

Gallstones/history of gallstone disease

Porcelain/calcification of gallbladder due to cholecystitis

Gallbladder adenoma/polyps

Abnormal bile duct anatomy

Obesity

Infection causing chronic cholangitis

Smoking

48
Q

How does cholangiocarcinoma present?

A

Pruritis

Jaundice

Weight loss

Palpable gall bladder/Courvoisier sign

Hepatomegaly

Lymphadenopathy

  • Sister Mary Joseph node
  • Virchow’s node

Intermittent RUQ pain, associated with eating fatty foods

49
Q

How is cholangiocarcinoma managed?

A

Surgery, only 10% are suitable for curative resection

Stenting

Chemo/radiotherapy

50
Q

Give complications of laparoscopy

A

General risks of anaesthetic

Vasovagal reaction (e.g. bradycardia) in response to abdominal distension

Extra-peritoneal gas insufflation/surgical emphysema

Injury to gastro-intestinal tract

Injury to blood vessels e.g. common iliacs, deep inferior epigastric artery

Gastrointestinal (14 decks)

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