Biliary Pathology Flashcards
What is primary biliary cholangitis?
Autoimmune inflammation and destruction of bile ducts, causing the build up of bile and other toxins in the liver
What sex is primary biliary cholangitis more common in?
F>M
90% of patients are female
What age is primary biliary cholangitis more likely to occur?
Middle aged
30-60
What conditions are associated with primary biliary cholangitis?
RA
Coeliac
Sjogren’s syndrome
Hypothyroidism
How does primary biliary cholangitis present?
Pruritis
Jaundice
Fatigue
Pale stools and dark urine
Xanthelasmata and xanthoma
Hepatomegaly and splenomegaly
What investigations are used in primary biliary cholangitis diagnosis?
Antimitochondrial auto-antibodies (AMA)
LFT
- Increased ALP
- Increased GGT
- Increased bilirubin
IgM elevation
>ESR
Liver biopsy, for diagnosis
In what percentage of primary biliary cholangitis patients are AMA antibodies present?
+ in over 95%
How is primary biliary cholangitis managed?
Ursodeoxycholic Acid (UDCA)
- Bile acid analogue
Cholestyramine
- For pruritis
Steroids/immunosuppression is sometimes considered
Liver transplant if end stage liver disease
Give complications of primary biliary cholangitis
Liver cirrhosis
Osteoporosis
Hypothyroidism
Hepatocellular carcinoma
What is primary sclerosing cholangitis?
Chronic progressive inflammation and fibrosis of the intra and extrahepatic bile ducts, preventing bile draining from the liver/cholestasis
What sex is primary sclerosing cholangitis more common in?
M>F
70% of patients are men
What age is biliary sclerosing cholangitis more common in?
Middle age
3rd-5th decade
What conditions are associated with primary sclerosing cholangitis?
UC, 80% of patients with PSC have UC
Cholangiocarcinoma
HIV
How does primary sclerosing cholangitis present?
Pruritis
Fatigue
Weight loss
RUQ pain
Night sweats
Pyrexia
Hepatomegaly
Obstructive jaundice
What investigations are used in primary sclerosing cholangitis diagnosis?
MRCP/ERCP
- Beaded appearance of ducts
LFTs
- Increased ALP, most deranged
- Increased bilirubin
pANCA+
Increased IgM
How is primary sclerosing cholangitis managed?
UDCA
ERCP and biliary stents
Liver transplant
Give complications of primary sclerosing cholangitis?
Cholangiocarcinoma
Liver cirrhosis
What are the types of gallstones?
Cholesterol
Bilirubin/pigmented
Mixed
What is the most common type of gallstone?
Mixed (80%)
What are the causes of gallstones?
4 F’s
- Female
- Fat
- Forty
- Fair
Associated conditions
- Diabetes
- Pigment conditions/sickle cell anaemia/liver cirrhosis
- Chrons
Drugs
- COCP
How does gallstones/biliary colic present?
Majority asymptomatic, symptoms occur due to biliary colic
Sudden severe epigastric/RUQ pain
- Often triggered by meals
- Radiates to interscapular region
N&V
Jaundice
What investigations are used in gallstone diagnosis?
EUS, best initial investigation
LFTs
- Increased ALP
MRCP
Amylase, to rule out pancreatitis
What is first line investigation/most useful investigation in gall stones?
US
How are gallstones managed?
For asymptomatic, do nothing
Dissolution, given for frail patients unsuitable for surgery
Cholecystostomy/implanting drain to drain gallbladder
Laparoscopoc cholecystectomy
Name complications of gallstones
Acute pancreatitis
Ascending cholangitis
Cholecystitis
Ileus/small bowel obstruction
Obstructive jaundice
Biliary colic, in which stone blocks gallbladder
Mirrizi’s Syndrome
Give side effects of ERCP/MCRP
Haemorrhage
Duodenal perforation
Cholangitis
Pancreatitis
When is ERCP done over MRCP?
Only used if patient is unable to tolerate MRCP (ie metal implants), as ERCP is more invasive
Give complications of cholecystectomy
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
What is Mirrizi’s Syndrome?
Gallstone in cystic duct or neck of gallbladder, leading to obstruction of common hepatic duct
What is cholestasis?
Accumulation of bile within the hepatocytes due to blockage of flow
What causes cholestasis?
Viral hepatitis
Alcoholic hepatitis
Liver failure
Drugs
Obstetric cholestasis
What is cholecystitis?
Inflammation of the gallbladder, usually due to gallstone causing obstruction of gall bladder outlet
(think gallstones/biliary colic, but systemically unwell)
How does cholecystitis present?
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
What is Murphy’s sign?
Patient catches breath on inspiration when two fingers are placed in RUQ, yet not in the LUQ
What investigations are used in cholecystitis diagnosis?
FBC
- >WCC
LFTs are often normal
US, to assess gallstones
How is cholecystitis managed?
Supportive
- Analgesia
- IV fluids
IV antibiotics
- Cefuroxime and Metronidazole
Laparoscopic cholecystectomy
- Within 1 week of diagnosis
What is ascending cholangitis?
Infection of the biliary tree due to lesion/gall stone in the common bile duct which results in bacteria ascending from the duodenum
What organism is associated with ascending cholangitis?
E coli
How does ascending cholangitis present?
RUQ pain
Fever
Jaundice
Dark urine
Pale stools
Pruritis
Tachycardia
Hypotension
Confusion
What is Charcot’s triad?
Associatd with ascending cholangitis
Jaundice
Fever
RUQ pain
What is Reynolds pentad?
Associated with ascending cholangitis
Jaundice
RUQ pain
Fever
Shock/hypotension
Altered mental status
What investigations are used in ascending cholangitis diagnosis?
FBC
- >WCC
>CRP
LFTs
- >ALP
- >Bilirubin
ERCP
US
How is ascending cholangitis managed?
Supportive
- IV fluids
- Analgesia
- IV Antibiotics (Cefuroxime and Metronidazole)
Endoscopic/ERCP
- After 24-48 hours to relieve obstruction
- Stone removal
- Stent placement
Cholecystectomy
How do you differentiate between biliary colic, cholangitis and cholecystitis?
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
What is cholangiocarcinoma?
Malignancy of the biliary tree
What is the most common type of choliangocarcinoma?
Adenocarcinoma
Give risk factors for cholangiocarcinoma
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
How does cholangiocarcinoma present?
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
How is cholangiocarcinoma managed?
Surgery, only 10% are suitable for curative resection
Stenting
Chemo/radiotherapy
Give complications of laparoscopy
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
