Biliary Tract Disease Flashcards
Presentation of gallstones?
Most are asymptomatic, with impacted gallstones presenting: Biliary colic Cholecystitis Jaundice Pancreatitis Bowel obstruction
Causes of gallstones?
Abnormal bile composition
Bile stasis
Infection
Excess cholesterol or bilirubin
Types of gallstones?
Mixed (80%)
Cholesterol (10%)
Pigment (black - 10%)
Primary bile duct stones (rare)
Risk factors for gallstones?
Age >40 Female High fat diet Obesity Pregnancy Hyperlipidaemia
Bile salt loss, e.g: in Crohn's Diabetes Dysmotility of GB Prolonged fasting TPN
What are the five Fs?
Female, fair, fat, fertile, forty
Why does biliary colic occur and describe the pain?
Stone impacts in cystic duct and spasm occurs; there is gradual build-up pain in the RUQ that radiates to the back or shoulder
This may last for 2-6 hours; it is associated with indigestion/nausea
Causes of acute severe epigastric pain?
Biliary colic Peptic ulcer disease Oesophageal spasm MI Acute pancreatitis
What is acute cholecystitis?
Inflammation in the gall bladder, usually due to obstruction of the cystic duct; this is initially sterile, then becomes infected
Presents with fever and positive Murphy’s sign
Diagnosis of gallstones?
Ultrasound CT scan MRCP (diagnosis) / ERCP (remove gallstones) HIDA EUS
Treatment of acute cholecystitis?
IV antibiotics and IV fluids
Urgent cholecystectomy
Sometimes, surgeon, will do an interval cholecystectomy (antibiotics and then, 6 months later, elective admission - allows inflammation to settle)
Complications of gallstones?
Stones may migrate into common bile duct, potentially causing: Jaundice Itching Anorexia Cholangitis Acute pancreatitis
Gallstone ileus - gallstones can enter small intestine and reach ileum, causing bowel obstruction
Diagnosis of common bile duct pathology?
MRCP is used
Abnormal LFTs
Treatment of gallstones?
Give patient pain killers; tell them to follow a low-fat diet and lose weight, if they are obese. Observe them for 3-6 months; if still symptomatic:
ERCP (ES + stone removal)
Symptomatic gallstones treated by removal of the gallbladder (laparascopic cholecystectomy)
For those who are unfit for surgery, ursodeoxycholic acid (10 mg/kg/day) to bind bile salts
Main causes of acute pancreatitis?
Alcohol
Gallstones
Mechanism of acute pancreatitis?
Auto-digestion of peri-pancreatic tissue by activated enzymes
How does a gallstones ileus occur?
Fistula from the gallbladder to the duodenum allows a large gallstone to pass into the small intestine
This moves down small bowel causing intermittent colic; presents with distal small bowel obstruction
Treatment of gallstone ileus?
Urgent laparotomy - small bowel enterotomy to remove stone (hole made in small bowel to squeeze gallstone out; hole is sealed up)
Interval cholecystectomy in 3 months
What is cholangiocarcinoma?
Malignancy of the cholangiocarcinoma; second most common hepatobiliary cancer
Presentation of cholangiocarcinoma?
Jaundice
Weight loss
Anorexia
Lethargy
Lymph node metastases
Peritoneal metastases at diagnosis
Methods of staging/assessing cholangiocarcinoma?
Duplex ultrasound
Spiral CT / ERCP / PTC
MRI / MRCP / MRA
Treatment of cholangiocarcinoma?
Surgical resection is the only
curative option
For palliation - a biliary stent can be placed
Describe Murphy’s sign
Patient breathes out and doctor gently places hand below the costal margin, on the right side at the mid-clavicular line (the approximate location of the gallbladder); patient is then instructed to inspire.
Normally, during inspiration, the abdominal contents are pushed downward, as the diaphragm moves down. If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner’s fingers) and winces with a ‘catch’ in breath, the test is considered positive
In order for the test to be considered positive, the same maneuver must not elicit pain when performed on the left side
