Biliary Tract Flashcards
what are the boundaries of the triangle of Calot?
Three C’s
cystic duct
common hepatic duct
cystic artery
what is the source of alkaline phosphatase?
bile duct epithelium
- expect alkaline phosphatase to be elevated in bile duct obstruction
what is in bile
cholesterol, lecithin, bile acids, and bilirubin
what does bile do
emulsify fats
what is the enterohepatic circulation
circulation of bile acids from liver to gut and back to the liver
where are most of the bile acids absorbed
terminal ileum
what stimulates gallbladder emptying
cholecystokinin and vagal input
what is the source of CCK?
duodenal mucosal cells
at what level of serum total bilirubin does one start to get jaundiced
2.5
what are the signs and symptoms of obstructive jaundice
jaundice dark urine clay-colored stools (echoic stools) pruritus loss of appetite nausea
what causes the itching in obstructive jaundice
bile salts in the dermis
what is cholelithiasis
gallstones in gallbladder
what is choledocholithiasis
gallstone in the common bile duct
what is cholecystitis
inflammation of the gallbladder
what is cholangitis
infection of biliary tract
what is cholangiocarcinoma
adenocarcinoma of bile ducts
what is Klatskin’s tumor
cholangiocarcinoma of bile duct at the junction of the right and left hepatic ducts
what is biliary colic
pain from gallstones, usually from a stone in cystic duct
what is biloma
intraperitoneal bile fluid collection
what is the initial diagnostic study of choice for evaluation of the biliary tract/gallbladder/cholelithiasis
ultrasound
what is ERCP
endoscopic retrograde cholangiopancreatography
what is PTC
percutaneous trans-hepatic cholangiogram
what is HIDA scan
radioisotope study
- isotope concentrated in liver and secreted into bile
- will demonstrate cholecystitis, bile leak, or CBD obstruction
how does HIDA scan reveal cholecystitis
nonopacification of the gallbladder from obstruction of the cystic duct
what lab results are associated with obstructive jaundice
elevated alk phos, elevated bilirubin w/ or w/o elevated LFTs
what is cholelthiassi
formation of gallstones
what are the Big 4 risk factors for cholelithiasis
Female
Fat
Forty
Fertile
what are the five major complications of gallstones
- acute cholecystitis
- choledocholithiasis
- gallstone pancreatitis
- gallstone ileus
- cholangitis
how is cholelithiasis diagnosed
ultrasound
what are indications for cholecystectomy in asymptomatic patient
sickle-cell
calcified gallbladder
patient is child
what is the major feared complication of ERCP
pancreatitis
what is the pathogenesis of acute cholecystitis
obstruction of the bile duct leads to inflammation of the gallbladder
what are the risk factors foracute cholecystitis
gallstones
what are the signs and symptoms of acute cholecystitis
- unrelenting RUQ pain or tenderness
- fever
- nausea/vomiting
- painful palpable gallbladder
- positive Murphy’s sign
- right sub scapular pain
- epigastric discomfort
what are the complications of acute cholecystitis
abscess
perforation
choledocholithiasis
cholecystenteric fistula formation
what lab results are associated with acute cholecystitis
increased WBC
may have:
- slight elevation of alk phos, LFTs
- slight elevation in amylase, total bilirubin
what is the treatment of acute cholecystitis
IVFs, abx, and early cholecystectomy
what is acute acalculous cholecystitis
acute cholecystitis without evidence of stones
what is the pathogenesis of acute acalculous cholecystitis
sludge and gallbladder disuse and biliary stasis
what are the findings of acute acalculous cholecystitis on HIDA
non filling of the gallbladder
what is the management of acute acalculous cholecystitis
cholecystectomy
what is cholangitis
bacterial infection of the biliary tract from obstruction
what are the common causes of cholangitis
choledocholithiasis
what are the signs and symptoms of cholangitis
Charcot’s triad
- fever/chills
- RUQ pain
- jaundice
what is Reynold’s pentad
Charcot’s triad (fever/chills, RUQ pain, jaundice) +
- mental status changes
- shock
which organisms are most commonly isolated with cholangitis
gram negative organisms
- E. coli, Klebsiella, Psuedomonas, Enterobacter, Proteus, Serratia
what is suppurative cholangitis
severe infection with sepsis
- ‘pus under pressure’
what is the management of cholangitis
nonsuppurative:
- IVF and abx, definitive tx later
suppurative:
- IVF, abx, decompression
what is sclerosing cholangitis
multiple inflammatory fibrous thickenings of bile duct walls resulting in biliary strictures
what is the natural history of sclerosing cholangitis
progressive obstruction possibly leading to cirrhosis and liver failure
what is the major risk factor of sclerosing cholangitis
IBD
what type of IBD is the most common risk factor
ulcerative colitis
what are the signs and symptoms of sclerosing cholangitis
same as for obstructive jaundice:
- jaundice
- dark urine
- itching
- clay-colored stools
- loss of energy
- weight loss
how is sclerosing cholangitis diagnosed
elevated alk phos
PTC or ERCP revealing ‘beads on a string’
what are the management options for sclerosing cholangitis
hepatoenteric anastomosis and resection of extra hepatic bile ducts because of risk of cholangiocarcinoma
what is gallstone ileus
SBO from a large gallstone that has eroded through the gallbladder and into the duodenum/small bowel
what is the classic site of obstruction in gallstone ileus
ileocecal valve
what are the classic findings of gallstone ileus
air int he hepatic bile ducts
SBO with air fluid levels
gallstone in ileocecal valve
what are the signs/symptoms of gallstone ileus
symptoms of SBO:
- distention
- vomiting
- hypovolemia
- RUQ pain
what are the diagnostic test of choice
abdominal xray - air in biliary tract
abdominal CT scan
what is the management of gallstone ileus
surgery
what is carcinoma of the gallbladder
malignant neoplasm arising in the gallbladder
- majority are adenocarcinoma
what are the risk factors for carcinoma of the gallbladder
gallstones, porcelain gallbladder, cholecystenteric fistula
what is a porcelain gallbladder
calcified gallbladder
what are the symptoms of carcinoma of the gallbladder
biliary colic, weight loss, anorexia
- many are asymptomatic until late
- may present as acute cholecystitis
what are the signs of carcinoma of the gallbladder
jaundice (from invasion of the CBD or compression by involved pericholedochal lymph nodes) RUQ mass palpable gallbladder (advanced disease)
what is the route of spread in carcinoma of the gallbladder
contiguous spread to the liver
what is cholangiocarcinoma
malignancy of the extra hepatic or intrahepatic ducts
- primary bile duct cancer
what is the histology of cholangiocarcinoma
almost all are adenocarcinomas
what are the signs/symptoms of cholangiocarcinoma
those of biliary obstruction:
- jaundice, pruritus, dark urine, clay-colored stools, cholangitis
what is the most common location of cholangiocarcinoma
proximal bile duct
what is an MRCP
MRI with visualization of pancreatic and bile ducts
what is the management of a proximal bile duct cholangiocarcinoma
resection with Roux-en-Y
what is the management of distal common bile duct cholangiocarcinoma
Whipple procedure
