Biliary Tract Disease: gallstones, cholecystitis and ascending cholangitis Flashcards
Where is bile made?
Liver
What is the journey of the bile from the liver to the intestine?
Intrahepatic bile ducts: ductules, right and left hepatic ducts
Common hepatic duct
Cystic duct branch from gallbladder joins
Now common bile duct
Passes through pancreas
In most people, fuses with pancreatic duct
Ampulla of Vater
Duodenum
What are the epithelial cells of the bile ducts called?
Cholangiocytes
What are gallstones made of?
Cholesterol
Pigment
Mixed
What are the risk factors for gallstones?
Fat, Female, Forty, Fertile, Fair
Family history
T2DM
NAFLD
Haemolytic conditions (increased breakdown of RBCs so more bilirubin in bile)
How are gallstones made?
Gallstones develop in the gallbladder when there is an imbalance in substances that make up bile (cholesterol and pigment).
Cholesterol stones are most common and form where there is an excess of cholesterol compared to bile salts. This means can’t keep cholesterol in solution so crystallises to solid particles. Grow and aggregate.
Pigment stones form when excess of bilirubin which can combine with calcium and other particles to form solid particles.
What are the symptoms of gallstones?
RUQ “biliary colic” but unlike typical colic it’s constant severe episodes of pain for 30+ mins
Worse after a fatty meal
How do you diagnose gallstones?
Abdominal USS (1st line)
How do you treat gallstones?
Elective laparoscopic cholecystectomy
Until this, give NSAIDS for mild pain
or
IM diclofenac for severe pain
Also change in lifestyle and decrease fatty foods
What is cholecystitis?
Inflamed gallbladder, most commonly caused by gallstones obstructing bile flow or causing irritation to gallbladder wall
What are symptoms of cholecystitis?
RUQ pain and fever
Nausea
Tender gallbladder
May have have referred pain to right shoulder (phrenic nerve)
Positive Murphy sign
What is the Murphy sign?
Press on gallbladder and ask patient to inhale. Patient will wince and stop inhaling due to pain if have cholecystitis
How do you diagnose cholecystitis?
FBC: leukocytosis (increased WBCs) and neutrophilia
LFT: normal
Abdominal USS: gallbladder wall thickened to at least 3mm
How do you treat cholecystitis?
Urgent surgery, within 1 week, typically within 72 hours
Laparoscopic cholecystectomy (remove whole gallbladder)
Until surgery give IV fluid (as not eating or drinking to reduce strain on gallbladder, prevent dehydration), analgesia and possibly antibiotics
What is ascending cholangitis?
Ascending bacterial infection of the biliary tree.
Can be caused by bacterial ascent from duodenum into the bile ducts. Bacteria can do this when there are gallstones present (choledocholithiasis) or strictures.
What are symptoms of ascending cholangitis?
Fever
Jaundice
RUQ pain
Nausea
How do you diagnose ascending cholangitis?
FBC: leukocytosis and neutrophilia
LFT: increase conjugated hyperbilirubinemia
Abdominal USS: Common bile duct dilation and gallstones
MRCP (magnetic resonance cholangio-pancreatography): diagnostic and best pre-intervention management -Gold standard
How is ascending cholangitis treated?
ERCP (endoscopic retrograde cholangic-pancreatography,imaging and can act like stent) for bile duct clearance
then
laparoscopic cholecystectomy once stable to prevent recurrence.
Consider risk of sepsis
Why is there a risk of sepsis with ascending cholangitis?
biliary obstruction causes more backflow of “biliary sludge”. Stasis is the basis!
Bacteria like E. coli can climb from intestines up through Ampulla of Vater to bile ducts where can access bloodstream triggering systemic inflammatory response
Inflammation of the cholangiocytes can lead to obstruction of bile flow. Reduced flow of bile is called c______
cholestasis
Cholestasis can lead to back-pressure of the bile and lead to…
liver fibrosis, cirrhosis and failure
Jaundice with pale stool and dark urine due to bilirubin not being excreted
Cholesterol deposits called xanthelasma
Malabsorption of fat and greasy stools
C_____ triad is a set of 3 classic symptoms associated with certain liver and biliary conditions, particularly used as a diagnostic tool for ascending cholangitis
Charcot’s
What are the 3 components of Charcot’s triad?
Fever
Jaundice
RUQ pain
In more severe cases of ascending cholangitis, another set of symptoms known as R______ p____ may be observed
Reynold’s pentad
What are the components of Reynold’s pentad?
Charcot’s triad (Fever, jaundice, RUQ pain)
Hypotension
Altered mental status
Indicates prompt medical attention is needed including antibiotics.
