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GI Fellowship > Biliary Tract > Flashcards

Biliary Tract Flashcards

1
Q

which clinical syndrome is seen when the common bile duct
and pancreatic duct (PD) join each other outside the duodenal wall forming a long common channel?

A

Pancreaticobiliary maljunction AKA abnormal pancreaticobiliary junction

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2
Q

In 75% of cases of Pancreaticobiliary maljunction, what two abnormal features are present?

A
  1. biliary ductal dilation
  2. choledochal cysts.
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3
Q

What about Pancreaticobiliary maljunction can lead to increased risk of biliary malignancy?

A

Pancreaticobiliary maljunction is associated with reflux of pancreatic secretions into the bile duct leading to chronic inflammation and increase risk of biliary malignancy

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4
Q

What about Pancreaticobiliary maljunction can lead to increase the risk of pancreatitis?

A

The dilated common channel and reflux of bile into the pancreatic duct may increase the risk of pancreatitis.

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5
Q

In patients with Pancreaticobiliary maljunction, what type of cancer are they at increased risk for? and what should be done prophylactically?

A

In patients with PBM, there is an increased risk of gallbladder cancer; therefore, prophylactic cholecystectomy should be strongly considered. ‘

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6
Q

Which types of choledochal cysts, confer an increased risk of malignancy ?

A

There is an increased risk of malignancy in choledochal cysts type 1, 4, and 5.

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7
Q

In patients with CBD dilation without evidence of an obstructing stone or mass, what clinical syndrome should be considered?

A
  • Think of choledochal cysts in patients with CBD dilation without evidence of an obstructing stone or mass.
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8
Q

What is The most common cancer associated with choledochal cysts?

A

The most common cancer is cholangiocarcinoma.

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9
Q

Aside from the most common cancer associated with choledochal cysts (cholangiocarcinoma), what three other cancers can be seen in patients with ?

A

Other associated malignancies include anaplastic, undifferentiated, and squamous cell carcinoma.

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10
Q

Choledochal cysts are often associated with what GI anatomical abnormality?

A

Choledochal cysts are often associated with an abnormal Pancreaticobiliary junction

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11
Q

What are the most common type of gallstones in adults?

A

Cholesterol stones are the most common type in adult (composed of cholesterol monohydrate crystals)

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12
Q

Which type of gallstones are associated with chronic hemolytic anemia?

A

Black stones are associated with chronic hemolytic anemia.

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13
Q

Which type of gallstones are associated with biliary stasis and infection?

A

Brown stones are associated with biliary stasis and infection.

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14
Q

Which type of gallstones are composed of calcium bilirubinate crystals?

A

Pigment stones are composed of calcium bilirubinate crystals.

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15
Q

Which clinical syndrome refers to an impacted cystic duct stone obstructing the common hepatic duct?

A

Mirizzi’s syndrome refers to an impacted cystic duct stone obstructing the common hepatic duet.

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16
Q

Which clinical syndrome results from a large gallstone obstructing the terminal ileum?

A
  • Gallstone ileus results from a large gallstone obstructing the terminal ileum. The gallstone enters the small bowel through a gallbladder-enteric fistula associated with cholecystitis.
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17
Q

How does a gallstone ileus occur?

A

The gallstone enters the small bowel through a gallbladder-enteric fistula associated with cholecystitis.

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18
Q

Which clinical syndrome is
associated with gastric outlet obstruction due to impaction of a gallstone in the pylorus or duodenum?

A

Bouveret’s syndrome.

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19
Q

What is the sensitivity of US for choledocholithiasis?

A

Gallbladder (GB) ultrasound is highly sensitive and specific for gallstones, but only 50% sensitive for choledocholithiasis. Other tests include CT, MRI/MRCP, EUS, ERCP, HIDA.

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20
Q

Is Prophylactic cholecystectomy recommended for asymptomatic gallstones?

A
  1. Prophylactic cholecystectomy is not recommended for asymptomatic gallstones
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21
Q

There are 7 scenarios in which a patients should undergo prophylactic cholecystectomy. What are they?

A
  1. Patients with GB wall calcifications AKA “porcelain gallbladder
  2. Patients with an abnormal pancreatobiliary junction (due to increased risk of galibladder cancer)
  3. Pts with GB polyps > 10 mm.
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22
Q

What is the risk of coexisting gallbladder malignancy in patients with porcelain gallbladder?

A

The risk of coexisting GB malignancy is - 20%.

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23
Q

Patients with gallbladder polyps should have a prophylactic cholecystectomy, when the gallbladder polyps are LARGER than what size?

A

Patients with GB polyps > 10 mm.

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24
Q

when should astronauts with gallstones have a prophylactic cholecystectomy?

A

Astronauts with gallstones before long duration space missions (controversial)

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25
Q

In post bariatric surgery patients who do undergo cholecystectomy, what has been shown to decrease the risk of formation of gallstones?

A

Ursodiol was shown to decrease the risk of formation of gallstones post bariatric surgery in patients who did not undergo cholecystectomy.

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26
Q

Why should patients who undergo resection of small intestinal neuroendocrine tumors who are planned to undergo treatment with somatostatin analogues have a prophylactic cholecystectomy?

A

Patients who undergo resection of small intestinal neuroendocrine tumors who are planned to undergo treatment with somatostatin analogues should have a prophylactic cholecystectomy due to the increased risk of cholelithiasis and complications in patients on those medications.

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27
Q

In patients with cholecystitis who are too sick to undergo cholecystectomy, what are the options for gallbladder drainage?

A

In patients with cholecystitis who are too sick to undergo cholecystectomy, options for gallbladder drainage include
cholecystectomy, endoscopic ultrasound-guided gallbladder drainage, or endoscopic
include percutaneous transpapillary drainage.

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28
Q

What is the most common site of bile leak after following cholecystectomy?

A

The most common site of leakage is the cystic duct stump or the ducts of Luschka.

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29
Q

What are the 4 main ways to diagnose bile leak?

A
  1. US
  2. CT
  3. HIDA
  4. Increased bilirubin level in the peritoneal drain fluid.
30
Q

How is bile leak treated?

A

ERCP with stent placement, with or without a sphincterotomy.

31
Q

Which clinical condition is suspected in patients with biliary type pain after cholecystectomy?

A

Sphincter of Oddi dysfunction (SOD)

32
Q

How many different types of Sphincter of Oddi dysfunction are there?

A

3

33
Q

Which type of Sphincter of Oddi dysfunction is associated with ?

A
34
Q

Which type of Sphincter of Oddi dysfunction is associated with less clear obstruction at the Biliary Sphincter and may have spasm at the sphincter.

A

Type 2 Sphincter of Oddi dysfunction,

35
Q

Which type of Sphincter of Oddi dysfunction is associated with mechanical obstruction at the biliary sphincter?

A

Type 1 SOD is now referred to as “sphincter of Oddi stenosis”
because there is mechanical obstruction at the biliary sphincter. The treatment of choice is sphincterotomy.

36
Q

What is the utility of sphincterotomy for SOD type III ?

A

The EPISOD trial found no benefit of sphincterotomy for SOD type III (biliary pain with no duct dilation and no liver enzymes elevation) compared to sham intervention® Therefore, type 3 SOD has been abandoned and these patients are considered to have functional pain.

37
Q

What lab abnormalities are seen in patients with Type 2 SOD ?

A

Rome IV criteria for this disorder are: Biliary pain, dilated CBD or elevated liver enzymes, absence of choledocholithiasis,
or structural abnormalities.

38
Q

What are the 3 main HIGH predictors of choledocholithiasis in patients with symptomatic gallstones?

A
  • CBD stone on abdominal imaging
  • Clinical diagnosis of cholangitis
  • Both: Bilirubin > 4 and dilated CBD
39
Q

What are the 3 main intermediate predictors of choledocholithiasis in patients with symptomatic gallstones?

A

Abnormal liver enzymes
* Age > 55
* Dilated CBD (>6 mm if intact GB, >8 mm if history of cholecystectomy)
Intermediate

40
Q

Which clinical syndrome is associated with villous hyperplasia of the gallbladder mucosa associated with infiltration of the lamina propria with lipid laden foamy macrophages.?

A

Cholesterolosis

41
Q

What are the most common type of gallbladder polyps?

A

Non-neoplastic growths are the most common type.

42
Q

Which clinical syndrome is associated with thickened mucosa with invaginations into the muscularis propria of the gallbladder?

A

Adenomyomatosis

43
Q

The risk of gallbladder malignancy is significantly increased in patients with GB polyps greater than what size?

A

Greater than 10mm

44
Q

In patients with gallbladder polyps less than 10mm, what is recommended surveillance?

A

Follow up ultrasound every 6-12 months is recommended in poor surgical candidates and for polyps smaller than 10 mm.

45
Q

Which clinical syndrome refers to bacterial infection of an obstructed biliary tract?

A

Acute ascending cholangitis refers to bacterial infection of an obstructed biliary tract.

46
Q

What is the mainstay of treatment for patients with acute cholangitis?

A

-IV fluids
-Obtain blood cultures
-Give broad antibiotics.
-ERCP with biliary drainage is recommended within 48 hours of diagnosis.

47
Q

What are the most common risk factors for cholangiocarcinoma?

A
  1. Primary sclerosing cholangitis 2. Lynch syndrome
  2. Choledochal cysts
  3. Caroli disease
  4. Hepatolithiasis
  5. Hepatobiliary infections
48
Q

which tumor marker has a moderate specificity as a tumor marker for cholangiocarcinoma?

A

CA19-9 has a moderate specificity as a tumor marker for cholangiocarcinoma.

49
Q

what is the most common location for cholangiocarcinoma ?

A

Extrahepatic cholangiocarcinoma (80%) of which 30% are distal, and 70% are perihilar.
Intrahepatic cholangiocarcinoma (20%):

50
Q

The presence of what other TWO conditions lowers the sensitivity of CA19-9 as a tumor marker for cholangiocarcinoma ?

A

The presence of
1. cholestasis and
2. cholangitis
lowers specificity.

51
Q

What is the treatment of choice for cholangiocarcinoma ?

A

Biliary drainage with ERCP with stenting is the treatment of choice.

52
Q

If ERCP is unsuccessful in treatment of choice for cholangiocarcinoma, what else can be done?

A

Percutaneous transhepatic cholangiography can be performed if ERCP is unsuccessful.

53
Q

What is the surgical treatment
for distal cholangiocarcinoma vs proximal/perihilar tumors.?

A

Pancreaticoduodenectomy (Whipple) for distal cholangiocarcinoma and local bile duct resection and segmental hepatectomy for proximal or perihilar tumors.

54
Q

For patients with with positive margins or lymph node metastasis for cholangiocarcinoma ?

A

Adjuvant chemoradiation is given for patients with positive margins or lymph node metastasis.

55
Q

What treatment is recommended for patients who are not surgical candidates for cholangiocarcinoma ?

A

Patients who are not surgical candidates receive systemic chemotherapy with gemcitabine and cisplatin!

56
Q

what is the preferred type of anastomosis in patients with PSC who have liver transplant?

A

choledocojujenostomy

57
Q

What are the 3 most common biliary complications after liver transplant?

A
  1. Biliary strictures
  2. Bile leak
  3. Biliary stones and casts
58
Q

what are the two types of biliary anastomosis?

A
  1. Duct to duct anastomosis
  2. Roux-en-Y choledochojejunostomy
59
Q

Comparatively, which group has more complications with, right liver graft recipients or left liver graft recipients?

A

right liver graft recipients have higher complications

60
Q

In pts with suspected biliary stricture, what is the first step in work up?

A
  • Doppler ultrasound to rule out hepatic artery thrombosis. And also MRCP, ERCP, or PTC (for choledochojejunostomy strictures).
61
Q

Which type of account for MOST (80%) types of strictures?

A

Anastomotic strictures account for 80% of all strictures.

62
Q

what is the timeframe for when most strictures present after transplant?

A
  • Most strictures present in the first year after transplant.
63
Q

What is the treatment of choice for duct-to-duct anastomotic biliary strictures?

A

ERCP with balloon dilation to 6-8 mm followed by stenting is the treatment of choice for duct-to-duct anastomotic strictures. Repeat ERCP every 6-8 weeks maximum 3 months).

64
Q

How are choledochojejunostomy strictures treated
compared to duct-to-duct anastomotic strictures?

A
  1. Choledochojejunostomy strictures are treated with percutaneous dilation and stent placement.
  2. ERCP with balloon dilation to 6-8 mm followed by stenting is the treatment of choice for duct-to-duct anastomotic strictures.
65
Q

what is the most common risk factor for development of biliary ischemic stricture?

A

Ischemic strictures develop secondary to hepatic artery thrombosis.

66
Q

what is the treatment for development of Non-anastomotic biliary strictures

A

ERCP with balloon dilation and stenting is the treatment of choice. Due to the diffuse nature of these strictures, multiple plastic stents are usually needed. PTC can be used for refractory intrahepatic strictures

67
Q

Aside from hepatic artery thrombosis, what are the other two main causes of Non-anastomotic biliary strictures?

A

Immunogenic: ABO incompatibility, autoimmune hepatitis, PSC.

68
Q

For patients with bile leak, what is the treatment for refractory cases?

A

Surgery

69
Q

For patients with suspected bile leak, but HIDA and CT/MRI are equivocal, what testing/intervention can be done next?

A

ERCP with sphincterotomy for dx and treatment, keep stent for 2-3 months

70
Q

For patients with suspected bile leak with large biliary collections, what is the recommended treatment?

A

Percutaneous drainage

71
Q

In patients with bile leak after liver transplant, what are the most common sites of biliary leakage?

A
  1. The anastomosis
  2. Cystic duct remnant
  3. The cut surface of the liver in LDLT
72
Q
A

GI Fellowship (11 decks)

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