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Y4 Gastrointestinal > Biliary tract disease > Flashcards

Biliary tract disease Flashcards

1
Q

Where is bile stored and released through ?

A

Stored and concentrated in GB, released by CCK (Cholecystokinin) into 2nd part duodenum through common bile duct and Ampulla of Vater

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2
Q

What causes gallstone formation ?

A
  • Abnormal bile composition
  • Bile stasis
  • Infection
  • Excess Cholesterol
  • Excess Bilirubin
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3
Q

What are the risk factors for gallstones development ?

A
  • Think the ‘4 F’s’:
    • Fat: obesity is thought to be a risk factor due to enhanced cholesterol synthesis and secretion
    • Female: gallstones are 2-3 times more common in women. Oestrogen increases activity of HMG-CoA reductase
    • Fertile: pregnancy is a risk factor
    • Forty
  • other notable risk factors include:
    • diabetes mellitus
    • Crohn’s disease
    • rapid weight loss e.g. weight reduction surgery
    • drugs: fibrates, combined oral contraceptive pill
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4
Q

What are the 3 different types of gallstones?

A
  • Mixed (80%) – calcium salts, pigment & cholesterol
  • Cholesterol (10%)
  • Pigment (10%)
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5
Q

What are the complications which can develop due to gallstone formation ?

A

In gallbladder & cystic duct

  • Biliary colic
  • Acute cholecystitis: the most common complication
  • Gallbladder cancer

In the bile ducts:

  • Obstructive jaundice
  • Ascending cholangitis
  • Acute pancreatitis

In the gut:

  • Gallstone ileus
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6
Q

Describe what is meant by biliary colic ?

A
  • This is where gallstones are symptomatic due to causing obstruction of the cystic duct (sometimes can cause obstruction of the CBD in these causes obstructive jaundice seen)
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7
Q

What are the clinical features of biliary colic?

A
  • Colicky RUQ abdo pain (lasts 2-6hrs) (sometimes epigastric)
  • Pain is worse postprandially, worse after fatty foods
  • the pain may radiate to the right shoulder/interscapular region
  • · Nausea and vomiting are common
  • 15% of patients have gallstones in the CBD (choledocholithiasis) which can cause obstructive jaundice

Note - there is not fever/raised WCC or jaundice typically

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8
Q

How are gallstones diagnosed ?

A
  • 1st line = Abdo U/S + LFT’s
  • 2nd line = MRCP if US has not diagnosed but clinical suspicion still high
  • 3rd line = endoscopic US (EUS) if MRCP does not allow a diagnosis to be made
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9
Q

What is the treatment of biliary colic?

A

1st line:

  • Laproscopic cholecystectomy
  • If unfit for surgery – Ursodeoxycholic acid

anaglesia (NSAIDs) + reduce dietary fat + increase fluids

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10
Q

What is acute cholecystitis ?

A

This is inflammation of the gallbladder most commonly secondary to gallstones

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11
Q

Other than gallstones what is acute cholecystitis sometimes due to ?

A

Acalculous cholecystitis typically seen in hospitalised and severely ill patients (e.g. diabetes, organ failure)

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12
Q

What are the clinical features of acute cholescystitis ?

A
  • RUQ pain (sometimes epigastric) which may be referred to the R shoulder - pain is usually continuous and not colicky
  • Fever & signs of systemic upset (increased WCC & inflam markers)
  • Local peritonism - RUQ
  • Murphys sign +ve

In bold are the main things differentiating it from biliary colic

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13
Q

Describe murphys test

A

This is where you lay 2 fingers over the RUQ and have the patient breath in, this causes pain & arrest of inspiration as the inflammed gallbladder impinges on your fingers

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14
Q

How is acute cholecystitis diagnosed ?

A
  • 1st line to diagnose = Ultrasound
  • if the diagnosis remains unclear then cholescintigraphy (HIDA scan) may be used
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15
Q

What is the treatment of acute cholecystitis ?

A

IV antibiotics and IV fluids + early laparoscopic cholecystectomy, within 1 week of diagnosis.

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16
Q

What is chronic cholecystitis ?

A
  • Characterized by repeated attacks of pain (biliary colic) that occur when gallstones periodically block the cystic duct.
  • It almost always results from gallstones and from prior attacks of acute cholecystitis.
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17
Q

What are the clinical features of chronic cholecystitis ?

A
  • Have recurring attacks of pain - less severe than the pain of acute cholecystitis and does not last as long.
  • The upper abdomen above the gallbladder is tender to the touch.
  • In contrast to acute cholecystitis, fever rarely occurs in people with chronic cholecystitis.
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18
Q

How is chronic cholecystitis diagnosed and managed?

A

Same as acute via U/S and tx with cholecystectomy

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19
Q

What is used to diagnose the CBD complications of gallstones:

  • Obstructive jaundice
  • Cholangitis
  • Acute Pancreatitis
A
  • 1st line = do abdo US
  • 2nd line = MRCP to diagnose

Note after US - Where pancreatic neoplasia is suspected the next test should be a pancreatic protocol CT scan (i.e. constitutional symptoms or its painless obstructive jaundice). With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option.

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20
Q

What are the features of obstruction of the CBD ?

A
  • Itch, nausea, anorexia
  • Jaundice
  • Abnormal LFTs
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21
Q

What is the treatment of obstructive jaundice caused by gallstones in the CBD ?

A

ERCP - endoscopic sphincterotomy + stone removal

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22
Q

What is ascending cholangitis ?

A

It is a bacterial infection of the biliary tree. The most common predisposing factor is gallstones.

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23
Q

What is the main causative organism of ascending cholangitis ?

A

Typically E. coli

24
Q

What are the typical presenting features of ascending cholangitis ?

A
  • Fever (+raised WCC & inflam markers)
  • RUQ pain
  • Jaundice
  • Hypotension and confusion are also common

In bold makes charcots triad = ascending cholangitis until proven otherwise

25
Q

What is the treatment of ascending cholangitis ?

A

IV Abx (GAM) + ERCP (24-48hrs after to remove any obstruction)

26
Q

What is acute pancreatitis ?

A

Acute pancreatitis is sudden inflammation of the pancreas that may be mild or life threatening but usually subsides.

27
Q

What are the 2 primary causes of acute pancreatitis ?

A

Alcohol abuse or gallstones.

28
Q

What are the clinical features of acute pancreatitis ?

A
  • Sudden onset severe epigastric or central abdo pain that may radiate through to the back
  • Nausea & vomiting is very common
  • Examination may reveal tenderness, ileus and low-grade fever, if severe may be in shock or have peritionitis (widespread guarding & absent BS)
  • Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare
29
Q

What investigation in particular if raised suggests acute pancreatitis ?

A

Raised serum amylase (>1000) (> 3 UNL is diagnostic)

30
Q

What is the mneumonic used to remember all the different causes of pancreatitis ?

A

Popular mnemonic is GET SMASHED

  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps (other viruses include Coxsackie B)
  • Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
  • Scorpion venom
  • Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
  • ERCP
  • Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
31
Q

How is acute pancreatitis diagnosed ?

A
  • 1st line = measure serum amylase or lipase (lipase more specific) for diagnosis.
  • 2nd line = US for all patients to exlcude gallstones (MRCP may then be needed)

Followed by this patients get a CT to assess the severity of pancreatitis & look for complications

32
Q

What scoring systems are used to assess the severity of acute pancreatitis ?

A
  • Glasgow, Ranson scoring systems and APACHE II
  • CRP > 150 used in NW to categorise as severe
33
Q

What is the intital treatment of acute pancreatitis ?

A
  • Resuscitation with intravenous fluids.
  • Supplemental oxygen (to maintain oxygenation of vital organs).
  • Pain relief.
  • Antibiotics for treatment of associated cholangitis or acute infections, such as chest infection or urinary tract infection.
  • Early nutritional support - enteral feeding usually
34
Q

What is the treatment of acute pancreatitis ?

A

​1st line = do cholecystectomy (reduces readmission rates)

OR 1st line = ERCP if its caused by gallstones in CBD (obstructive jaundice) or they are elderly/frail

2nd line = follow-up with cholecystectomy during same admission (unless elderly/frail then ERCP all they get)

35
Q

What are the main complications of acute pancreatitis ?

A
  • Peripancreatic fluid collections
  • Pseudocysts
  • Pancreatic abscess
  • Pancreatic necrosis
  • Haemorrhage
  • ARDS
36
Q

What is the management of peripancreatic fluid collections ?

A

Most resolve so conservative

37
Q

What are pancreatic pseudocysts ?

A
  • In acute pancreatitis result from organisation of peripancreatic fluid collection. They may or may not communicate with the ductal system.
  • The collection is walled by fibrous or granulation tissue and typically occurs 4 weeks or more after an attack of acute pancreatitis
38
Q

What are the clinical features of pancreatic pseudocysts ?

A
  • Pain
  • Nausea & vomiting
  • Jaundice
  • Weight loss
  • Usually 4 weeks or more after having acute pancreatitis
39
Q

What is the treatment of pancreatic pseudocysts ?

A

Endoscopic or surgical drainage

40
Q

What is the treatment of pancreatic necrosis ?

A
  • Conservative of sterile necrosis initially
  • Necrosectomy & lavage associated with high mortality but may be done
41
Q

What is a pancreactic abscess?

A

Intraabdominal collection of pus associated with pancreas but in the absence of necrosis

42
Q

What is the treatment of pancreatic abscess

A

CT/US guided retroperioneal or transperitoneal drainage

43
Q

What is chronic pancreatitis ?

A

It is an inflammatory condition which can ultimately affect both the exocrine and endocrine functions of the pancreas.

44
Q

What are the causes of chronic pancreatitis ?

A

Alcohol excess - the vast majority (80+%)

Others:

  • genetic: cystic fibrosis, haemochromatosis
  • Pancreatic ductal obstruction due to tumours or stones
  • Congenital - structural abnormalities including pancreas divisum and annular pancreas
45
Q

What are the clinical features of chronic pancreatitis ?

A
  • Very similar to acute pancreatitis - pain is typically worse 15 to 30 minutes following a meal & relieved by sitting forward
  • Alcohol Hx; smokers; medications etc
  • Masses/ascites/jaundice on examination
  • Pancreatic insufficiency - steatorrhoea, bloating weight loss etc
46
Q

How is chronic pancreatitis diagnosed ?

A
  • 1st = AXR
  • 2nd = US or CT (CT best) - diagnostic
47
Q

What is the treatment of chronic pancreatitis ?

A
  • 1st line = Pancreatic enzyme supplements (creon) if insufficency & analgesia
  • 2nd line = surgery (pancreatectomy or pacnreaticojejunostomy)
48
Q

What is a gallstone ileus ?

A

This is where a gallstone erodes through the gallbladder into the duodenum and then it obstructs the terminal ileum

49
Q

What are the clinical features of a gallstone ileus ?

A

Riglers traid:

  1. Pneumobilia = air in the CBD
  2. Small bowel obstruction
  3. A radiolucent gallstone seen
50
Q

How is a gallstone ileus diagnosed ?

A

Riglers triad seen on AXR/CT

51
Q

How is a gallstone ileus treated ?

A

1st line = Urgent Laparotomy – SB enterotomy to remove stone. Followed by cholecystectomy in 3 months.

52
Q

What are the main types of pancreatic cancer ?

A
  • 95% are adenocarcinomas
  • Others include - gastrinoma, insulinoma & glucagonomas
53
Q

What are the risk factors for the development of pancreatic cancer ?

A
  • increasing age
  • smoking
  • diabetes
  • chronic pancreatitis (alcohol does not appear an independent risk factor though)
  • hereditary non-polyposis colorectal carcinoma (HNPCC)
  • multiple endocrine neoplasia (MEN)
  • BRCA2 gene
54
Q

What are the clinical features of pancreatic cancer ?

A
  • Painless obstructive jaundice - steathorrea & dark urine
  • Weight loss, anorexia
  • Back pain
  • diabetes mellitus
55
Q

What is Courvoisier’s law

A

It states that in the presence of painless obstructive jaundice & a palpable gallbladder it is unlikely to be due to gallstones so think either cholangiocarcinoma or head of pancreas cancer

56
Q

How is pancreatic cancer diagnosed ?

A
  • 1st line = US
  • 2nd line = CT this is the gold standard (dave says if likely pancreatic cancer from the clinical picture then do a CT first often)
57
Q

What is the treatment of pancreatic cancer ?

A
  • Less than 20% are suitable for surgery at diagnosisif operable = Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. + adjuvant chemo
  • Inoperable = ERCP with stenting is often used for palliation

Y4 Gastrointestinal (28 decks)

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