Biliary Tract Flashcards
3 parts of gallbladder
fundus
body
neck
Most important part of gallbladder
neck because there is a groove that meets the cystic pouch (Hartmann’s pouch) where stones get stuck
common bile duct
cystic duct + hepatic duct
Function gallbladder
store bile
bile emulsifies fat- assisting with absorption of fates
Patho cholelithiasis
bile–>vesicles–>crystal–>stone
Most likely to get cholelithiasis
Native Americans
uncomplicated gallbladder disease
biliary colic in the absence of complications such as cholecystitis, cholangitis, or gallstone pancreatitis
RF cholelithiasis
Age women FHx Pregnant Obesity Rapid weight loss Diabetes HyperTG Medications- OCP, hormone replacement, ceftriaxone Gallbladder stasis Decrease physical activity
Prevent cholelithiasis
statins coffee vegetable protein and nuts Mediterranean diet- poly/monounsaturated fats exercise
Complications cholelithiasis
acute cholecystits
gallstone pancreatitis
bouvert syndrome (gallstone ileus)
Clinical cholelithiasis
asymptomatic biliary colic RUQ after fatty meal (voluntary guarding) non-specific abdominal pain mid epigastric pain chest pain full after meal abdominal distention N/V diaphoresis
Dx cholelithiasis
CBC with diff
LFT normal- ALT higher than AST if cholestatic pattern
RUQ/abdominal ultrasound
Tx cholelithiasis
- Asx/incidental finding= expentant management (signs/sx to look for)
- Sx= prophylactic cholecystectomy
Def cholecystitis
inflammation of the gallbladder
Acute cholecystitis
RUQ pain, fever, leukocytosis with gallbladder inflammation
Acalculous Cholecystitis
identical to acute but without gallstone
chronic cholecystitis
recurrent infection or chronic mechanical irritation of galllstones–> fibrosis and thickening of GB
Complications fo acute cholecystitis
gangrene of gallbladder
gallbladder perforation–> pericholecystic abscess
emphysematous cholesystitis
mirrizi syndrome- hepatic duct compresses–> jaundice
gallbladder rupture
chronic cholecystitis
Sequelae acute cholecystitis
- porcelain gallbladder- discolored brittel consistency due to Ca2+
- strawberry gallbladder- villi enlarged due to cholesterol and look like strawberry
- xanthogranulomatous cholecystitis- macrophage in gladder
- fistulization to the gallbladder
- carcinoma of the gallbladder
Clinical acute cholecystitis
- sudden onset RUQ pain/ epigastric after a fatty meal
- N/V
- Murphy sign
- Fever
- Jaundice
- Courvoisier’s sign
Dx acute cholecystitis
CBC with diff- leukocytosis with left shift
LFT increased, bilirubin increased is obstruction; ALT higher than AST
RUQ/Abdominal ultrasound
Tx acute cholecystitis
Admit to hospital (IVF, pain management, ABX)
cholecystectomy within 24hrs
Pre-op ABX- Cipro and Flagyl, 3rd gen ceph + flagyl, carbapenem
Percutaneous drainage indications for acute cholecystitis
pericholecystic abscess
CBD obstruction
significant edema and swelling
Def choledocholithiasis
gallstones in the bile duct
Complications choledocholithiasis
acute cholangitis
acute pancreatitis
hyrops gallbladder
acute cholecystitis
Clinical choledocholithiasis
- biliary type pain
- RUQ mid epigastric pain or shoulder pain
- afebrile
- N/V
- jaundice and/or fever if complicated
Dx choledocholithiasis
CBC with diff- normal
LFT will be cholestatic pattern if stone retained
RUQ ultrasound
MRCP- no confirmed stone but need to know if have
ERCP- confirmed stone that needs out
CT with contrast
Tx choledocholithiasis
- removal of common bile duct via endoscopically (ERCP) or surgical
- most ptn with choledocholithiasis operative repair will have cholecystectomy as well
Def acute cholangitis
bacterial infection with biliary obstruction
Cause acute cholangitis
biliary calculi
benign stenosis
malignancy
MC organism in acute cholangitis
e.coli
Clinical acute cholangitis
abdominal pain fever yellow skin wakness charcot triad reynolds pentad
charcot triad
fever, abdominal pain, jaundice
Reynold’s pentad
fever abdominal pain jaundice confusion hypotension
Dx acute cholangitis
CBC with diff- leukocytosis with left shift LFT- elevated cholestatic pattern Blood culture Abdominal ultrasound first MRCP or ERCP second
Tx acute cholangitis
admit to hospital
empiric ABX- Zosyn, Unasyn, Fluoro + Flagyl, Carbapenem
Establish biliary drainage
- ERCP- sphincterotomy with stone excision or stent placement
Patho Primary Sclerosing Cholangitis
chronic progressive disorder leading to complications of cholestasis and hepatic failure–> multifocal strictures, segmental dilations–> end stage liver disease
PSC leads to increased risk of what
cholangiocarcinoma, gallbladder cancer, HCC
Who gets PSC
men 20-25
Clinical PSC
asymptomatic jaundice splenomegaly fatigue pruritis
DX PSC
LFT with cholestatic pattern
MRCP
Tx PSC
liver transplant
symptomatic relief- UDCA, biliary stents
