Biliary Pathophys Flashcards
ascending cholangitis
the most serious and lethal complication of galstones
85% of cases caused by stone in the bile duct causing bile stasis, bacterial superinfection of stagnant bile, bacteremia
obstruction is necessary but not sufficient
need a duct that contains bacteria
blood cultures are usually positive
treatment for choledocholithiasis
ERCP with stone extraction followed by laproscopic cholecystectomy
natural history of gallstones in asymptomatic
biliary pain in 2% per year, decreases over time
pain is the initial symptom in 90%
low complications
don’t need to remove gallbladder
What is the best test for acute cholecystitis
cholescintigrapy
assesses patency of the cystic duct
if it’s a normal scan, excludes acute cholecystitis
porcelain gallbladder
intramural calcification of the gallbladder wall - usually associated w stones
no symptoms but 20% carcinoma of the gallbladder
prophylactic cholecystectomy
emphysematous cholecystitis
infection of the gallbladder wall with a gas forming organism
mostly in old diabetic men
high morbidity and mortality!! treat with IV abx and cholecystectomy
choldedochal cysts
Choledochal cysts (aka bile duct cyst) are congenital conditions involving cystic dilatation of bile ducts.[1] They are uncommon in western countries[2] but not as rare in East Asian nations like Japan and China.
high incidence of biliary cancer - surgical excision - remove all cyst tissue
if involves liver, may require liver transplantation
acute cholecystitis
swelling and irritation of gallbladder
Acute cholecystitis occurs when bile becomes trapped in the gallbladder. This often happens because a gallstone blocks the cystic duct, the tube through which bile travels into and out of the gallbladder. When a stone blocks this duct, bile builds up, causing irritation and pressure in the gallbladder. This can lead to swelling and infection.
charcot’s triad
clinical manifestation of ascending cholangitis
fever
RUQ pain
jaundice
(can also have hypotension and metnal confusion)
suggests gram neg sepsis
What is the best test for choledocholithiasis
endoscopic ultrasound
highly accurate for excluding/confirming stones in the CBD
can be used instead of MRCP to exclude CBD stones - use for low to moderate clinical probablity of choledocholithiasis
What is the best test for choledocholithiasis?
Choledocholithiasis is the presence of gallstones in the common bile duct (thus choledocho- + lithiasis). This condition causes jaundice and liver cell damage
MRCP - rapid and non invasive - prvides bile duct and pancreatic duct images equal to ECRP
low to mod clinical porbabolity of choledocholithiasis
medical imaging technique that uses magnetic resonance imaging to visualize the biliary and pancreatic ducts in a non-invasive manner.
brown pigment stones
calcium salts of unconjugated bilirubin w varying amts of cholesterol and protein
usually associated w biliary infection
can form in galllbladder or within biliary tree
almost always associated w colonization of bile by enteric organisms and with ascending cholangitis
more likely than other stones to form de novo in bile ducts
treatment for biliary colic?
elective laparascopic cholecystectomy
ERCP
what is the most common type of cholangiocarcinoma
adenocarcinoma (90%) - nodular - intense desmoplastic with extensive fibrosis
do gallstones have a genetic predisposition?
yes, first degree relatives are 4.5x more likely to develop gallstone disease
What is the best test for complications of gallstones
CT scan
abscesses, perforation of gallbladder/CBD, pancreatitis
choledocholithiasis
Choledocholithiasis is the presence of gallstones in the common bile duct (thus choledocho- + lithiasis). This condition causes jaundice and liver cell damage
primary sclerosing cholangitis
all parts of biliary tree can be involved in chronic fibrosing inflammatory process resulting in obliteration of biliary tree and ultimately biliary cirrhosis
generalized beading and stenosis of the biliary tree on cholangiography
“onion skinning”
progressive - life expencance is 10-12 years
what is the most important determinant of crystal formation?
the extent of cholesterol saturation in gallbladder bile
cholesterol, phospholipds, biles acids
if CSI greater than 1 - bile is saturdated and cholesterol can precipitate out and form crystals
ECRP
best for choledocholithiasis and cholelithaisis (ultrasound is still better)
high sensitivity and specificity
used to extract stones (or drain infected bile)
life saving - reduces the need for CBD exploration at the time of cholecystectomy
with high clinical probability of choledocholithiasis
mirizzi’s syndrone
impacted stone in the gallbladder neck or cystic duct
extrinsic compression of the common hepatic duct
janudince and RUQ pain
cholecystonenteric fistula
erosion of a large stone through the gallbladder nto adjacent bowel (duodenum)
galstone ileus (terminal ileum)
cholecystectomy and bowel closure
what is the best test for choledocholithiasis w high clinical probability
ERCP
high sensitivity and specificity
used to extract stones (or drain infected bile)
life saving - reduces the need for CBD exploration at the time of cholecystectomy
with high clinical probability of choledocholithiasis
Mirizzi’s syndrome
stone in the cystic duct compressing or fistulizing into the common bile duct
pathogenesis of cholesterol stones
cholesterol crystals fom in and are trapped by mucin gel which accumulates as a result of gallbladder hypomotility and gallbladder hypersecretion
mucin glycoproteins act as an annealing agent in the agglomeration of crystals to form gallstones
vol of bile that resides in the gallbladder decreases by 80-90% because of active sodium transport and water absorption - promote more gallstone formation
intermittent bilary colic
stone intermitently obstructing cistic duct
RUQ pain 1-2 hours after eating, no pain when not eating
pathogenesis of brown pigment stones
enteric bacteria make beta-glucaronidase, phospholipase A, conjugated bile acid hydrolases
beta-glucoronidase activity results in the production of uncongjuaged bilirubin
phospholipase A liberates free fatty acids from phospholipids
unconjugated bile acid hydrolases make unconj bile acids
all complexes can complex w calcium to produce insoluble calcium salts and result in stone fprmation
dead bacteria/bacterial glycoproteins are annealing agents
