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
treatment when calculi within bile duct and symptomatic?
ERCP!
endoscopy
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
natural history of gallstones in symptomatic
more aggressive
if episode of biliary pain, much more likely to have it
risk of complications
cholecystectomy offered only after biliary symptoms dvelop
lab findings of acute cholecystitis
leukocytosis w bands
bili, aminotransferase, alk phos all high (suspect stone of bili >4)
cholesterol stones
most common type of gallstones
pure/mostly cholesterol
large and yellowish
indications for ercp in adults
obstructive jaundice
cholangitis
recurrent pancreatitis
pancreatic duct obstructions
