Biliary Tract Disease Flashcards
What is meant by ‘Biliary colic’ in regard to gallstones
Term used for pain associated with the temporary obstruction of the cystic or common bile duct by a stone migrating from the gall bladder.
Describe the pain of stone-induced ductular obstruction
Of sudden onset, severe but constant and has a crescendo characteristic
What is Cholecystitis
Gallbladder inflammation
What does bile contain?
Cholestrol
Bile pigments (broken down Hb)
Phospholipids
Epidemiology of gall stones
Unusual before age of 30
More common in females
More common ethnic groups include Scandinavians, South Africans, Native North Americans
Less common in Asian and African groups
Where do most gall stones form
Gallbladder
Main causes of gall stones
Obesity and rapid weight loss Diet high in animal fat and low in fibre Diabetes M Contraceptive pill Liver cirrhosis
Risk factors of gall stones
Female
Fat
Fertile (more kids increases risk)
Smoking
What are 2 types of gall stone
Cholesterol
(Bile) Pigment
Pathophysiology of Cholesterol gall stones
Cholesterol is held in solution by the detergent action of bile salts and phospholipids, with which it forms MICELLES and VESICLES.
When there is an excess of cholesterol (LITHOGENIC BILE), there is a relative lack of bile salts and phospholipids.
-> Formation of cholesterol crystals and gall stones.
This is further promoted by lack of gall bladder motility, as well as nucleation factors (Calcium and mucus)
What are 2 types of Pigment gall stones
Black pigment gallstones
Brown pigment stones
What are Black pigment gallstones
Calcium biliurbinate composition and a network of mucin glycoproteins that interlace with salts e.g. calcium bicarbonate
Grass-like cross-sectional surface
What are Brown pigment gallstones
Composed of calcium salts e.g. calcium bicarbonate, fatty acids and calcium bilirubinate
Muddy hue with an alternating brown and tan layer on cross-section
Which pigment gall stones would be seen in a lot of patients with haemolytic anaemias e.g. spherocytosis, sickle cell and thalassaemia - chronic excess of bilirubin
Black pigment gall stones
Which pigment gallstone is a common cause of recurrent bile duct stones following cholecystectomy
Brown pigment gall stones
Which pigment gall stone is almost always found in the presence of bile stasis and/or biliary infection
Brown
Pathophysiology of pigment gallstones
Bilirubin polymers and calcium bilirubinate
Caused by excess of bilirubin
What % of Gall stones are asymptomatic at the time of diagnosis
70%
Where is most common symptomatic gallstone and what symptoms would you see
Biliary Colic - right upper quadrant
Sudden, nausea and vomitting.
Caused by gallstone impacting on the cystic duct or the ampulla of vater
What is second most common symptomatic gallstone condition
Acute Cholecystitis
What is acute cholecystitis
Inflamed gallbladder leading to fever, peritonitis and raised WCC
Distension of the gall bladder leads to necrosis and ischaemia
Aetiology of Cholesterol gallstones
Multifactorial
Cholesterol super saturation, nucleation factors and reduced gallbladder motility
Aetiology of Pigment gallstones
Chronic haemolysis (sphereocytosis and sickle cell), in which bilirubin production is increased. Also cirrhosis. Possible as complication of cholecystectomy and with duct strictures.
What % of population are affected by gall-stones
10-20%
Epidemiology of gallstones
Most common in women
Preveleance increases with age
What % of Western world’s gallstones are cholesterol gallstone
80%
Diagnosis of gallstone
Ultrasound (Trans-abdominal)
Also blood tests e.g. Raised serum bilirubin, serum alkaline phosphatase, ESR and CRP
Treatment of gallstone
Non-surgical = Pain relief; IV antibiotics if necessary (e.g. Cefotaxime) Surgical = Laparoscopic cholecystectomy (gall bladder removal in symptomatic cases)
Stone dissolution for pure cholesterol stones - give oral Ursodeoxycholic acid
Complications of gallstones
Jaundice - if biliary obstruction
Acute cholecystitis - cystic duct impaction
Pancreatitis - blocks pancreatic duct
Gallstone ileus - occludes intestinal lumen
Empyema - obstructed gallbladder fills with pus
Cholangitis - Inflammation of the GB or bile duct as a result go bile duct blockage
What is a Cholangiocarcinoma?
Cancer of the biliary tree (in or out of the liver)
Cholangiocarcinoma clinical presentation
Fever, Malasie, Weight loss
Right Upper Quadrant pain, jaundice (early)
Hepatomegaly, ascites
Cholangiocarcinoma Pathophysiology
90% ductal adenocarcinoma
10% are squamous cell carcinoma
Cholangiocarcinoma aetiology
Caused by flukes, primary sclerosing cholangitis, HBV, HCV, DM, Caroli’s
Cholangiocarcinoma epidemiology
mostly >60
Cholangiocarcinoma diagnosis
Contrast MRI - optimal imaging for diagnosis
ERCP - can obtain samples for biopsy
Cholangiocarcinoma Treatment
Complete surgical resection
Stent (or surgical bypass) to relieve symptoms
Is CRP or ESR better
CRP as more sensitive and accurate reflection of acute phase of inflammation
What does ERCP stand for
endoscopic retrograde cholangiopancreatogram
