Biliary tract diseases Flashcards

1
Q

What are the biliary tract diseases?

A

Diverse spectrum of diseases affecting the biliary system (gallbladder, bile ducts and liver).

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2
Q

Basic anatomy: the common hepatic duct.

A

The right hepatic duct and left hepatic duct leave the liver and join together to become the common hepatic duct.

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3
Q

Basic anatomy: the cystic duct.

A

The cystic duct from the gallbladder joins the common hepatic duct halfway along.

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4
Q

Basic anatomy: the pancreatic duct.

A

The pancreatic duct from the pancreas joins with the common hepatic duct further along.

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5
Q

Basic anatomy: the ampulla of Vater.

A

When the common bile duct and the pancreatic duct join, they become the ampulla of Vater, which then opens into the duodenum.

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6
Q

Basic anatomy: sphincter of Oddi.

A

The sphincter of Oddi is a ring of muscle surrounding the ampulla of Vater that controls the flow of bile and pancreatic secretions into the duodenum.

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7
Q

Describe the 3 types of gallstones and their causes.

A

Stones form from supersaturation of bile, meaning they are either made of:

  1. Cholesterol - large, often solitary; obesity and fatty diets, age, female sex
  2. Pigment - small, friable, irregular, seen in haemolytic anaemia
  3. Mixed - faceted (calcium salts, pigment + cholesterol) - made of both of the above
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8
Q

What is biliary colic?

A

Gallbladder attack:
Intermittent right upper quadrant (RUQ) pain caused by gallstones irritating/blocking the bile ducts and temporarily obstructing drainage of the gallbladder.

It is the name given to the pain experienced from gallstones, it is not a condition itself!!

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9
Q

Explain the pathophysiology of biliary colic.

A

Gallstones lodged in bile ducts -> temporary severe abdominal pain.
After meal, gallbladder contracts.
Gallstone ejected into cystic duct -> lodged -> gallbladder contract against lodged stone -> severe abdominal pain.
Pain subsides when gallstone dislodged.

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10
Q

Give 4 causes of biliary colic.

A
  1. Gallstones
  2. Narrow bile duct
  3. Pancreatitis
  4. Duodenitis
  5. Oesophageal spasms
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11
Q

What can trigger biliary colic?

A

Eating a heavy meal especially one that is high in fat.

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12
Q

Why do fatty foods trigger biliary colic?

A

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum.
CCK triggers contraction of the gallbladder, which leads to biliary colic.
Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.

Exams may test this mechanism, so it is worth remembering!!

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13
Q

Give the 5 risk factors for biliary colic.

A

The 5Fs:
1. Fat (obesity)
2. Fertile (- more kids = increased risk of gallstones)
3. Forty (age >40)
4. Female
5. FHx

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14
Q

Describe the pain of biliary colic.

Any other symptoms may occur?

A

Sudden onset, severe but constant, crescendo characteristic.

Severe, colicky epigastric or RUQ pain - increases.

Can radiate to right shoulder/scapula (epigastrium/back).

Other symptom:
- Nausea and vomiting

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15
Q

What exactly is meant by ‘colicky’ pain?

A

Colicky pain is pain that ‘comes and goes’.

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16
Q

Differential diagnoses of biliary colic.

A

Think of other causes of RUQ pain:
1. Cholecystitis and cholangitis (often progressions from untreated gallstones anyway).
2. IBD.
3. Pancreatitis.
4. GORD.
5. Peptic Ulcers.

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17
Q

Diagnosis of biliary colic - the diagnostic test?

A

Abdominal Ultrasound - most useful for gallstone disease diagnosis:

1.Stones
2.Gallbladder wall thickness (inflammation)
3.Duct dilation (suggests distal blockage)

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18
Q

More investigations for biliary colic.

A
  1. FBC and CRP → look for inflammatory response suggesting cholecystitis
  2. LFTs: Raised ALP → ALP is associated with biliary pathology.
  3. Bilirubin and ALT usually normal.
  4. Amylase → Check for pancreatitis as it can also give RUQ.

These tests are more to rule out the cholecystitis and cholangitis than to confirm gallstones. They alone are unlikely to derange many tests. Ultrasound is the diagnostic test.

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19
Q

Treatment of biliary colic.

A
  1. NSAIDs/Analgesia.
  2. Optional laparoscopic cholecystectomy (gallbladder removal): as gallstones often recur.
20
Q

How can gallstones be removed from the gall bladder?

A

Laproscopic cholecystectomy.

21
Q

Define acute cholecystitis.

A

Acute inflammation of the gallbladder - 95% of cases involve a gallstone.

22
Q

Explain the pathophysiology of cholecystitis.

A
  1. Stone is blocking the ducts - obstruction to gallbladder emptying.
  2. Bile builds up, distending the gallbladder.
  3. Vascular supply may be reduced from this distension.
  4. Inflammation follows these events secondary to the retained bile, inflaming the gallbladder.
23
Q

Describe the presentation of cholecystitis - give 2 symptoms.

A

Generalised epigastric pain migrating to severe RUQ pain.
Signs of inflammation like a fever or fatigue.
Pain associated with tenderness and guarding from inflamed gallbladder and local peritonitis.

Symptoms:
1. RUQ pain which may radiate to right shoulder
2. Fatigue - inflammation

Signs:
Fever - inflammation
Positive Murphy’s Sign → Severe pain on deep inhalation with examiners hand pressed into the RUQ
Tenderness and guarding

24
Q

Describe the presentation of cholecystitis - give 3 signs.

A

Signs:
1. Fever - inflammation

  1. Positive Murphy’s Sign → Severe pain on deep inhalation with examiners hand pressed into the RUQ
  2. Tenderness and guarding
25
Q

Investigations for acute cholecystitis.

A
  1. Blood tests - inflammatory markers:
    - Raised WCC (due to inflammation) and CRP (c-reactive protein)
    - Raised serum bilirubin, alkaline phosphatase and
    aminotransferase levels
  2. Abdominal ultrasound:
    - Thick walled, shrunken gallbladder (due to inflammation)
    - Pericholecystic fluid
    - Stones
  3. Physical abdominal examination:
    - RUQ tenderness
    - Positive Murphy’s sign: severe pain on taking a deep breath when examiner places 2 fingers on RUQ (where gallbladder is)
26
Q

Treatment for acute cholecystitis.

A

Conservative management before surgery:
1. IV Antibiotics e.g. e.g. CEFUROXIME or CEFTRIAXONE
2. Heavy analgesia - opiates
3. IV fluids
4. Nil by mouth

  1. Cholecystectomy, if needed
27
Q

What 3 bacteria are associated with acute cholecystitis?

A
  1. Klebsiella
  2. Enterococcus
  3. Escheria coli (E.coli)

(Antibiotics as per trust guidelines but are likely to be ones that target the 3 main pathogens).

28
Q

What differentiates biliary colic from acute cholecystitis?

A

Acute cholecystitis: is an inflammatory response!
Biliary colic: no inflammation

29
Q

Define ascending/acute cholangitis.

A

Ascending/acute cholangitis is an infection of the biliary tree and most often occurs secondary to common billed duct obstruction by gallstones (choledocholithiasis).

Acute inflammation and infection of bile duct due to common bile duct obstruction.

30
Q

What structure is being obstructed by gallstones if a patient has developed acute cholangitis?

A

Common bile duct

31
Q

Describe the clinical presentation of acute cholangitis.

A

Charcot’s triad:
1. RUQ pain
2. Jaundice - common bile duct blocked, bilirubin builds up
3. Fever with rigors/chills

Septic presentation - Hypotension/altered mental state
Reynolds pentad → Charcot’s triad + confusion + septic shock

Patient may present as septic and/or have developed some level of pancreatitis.

Jaundice is cholestatic, thus there is dark urine, pale stools and skin may itch.

32
Q

What is the triad of symptoms for acute cholangitis?

A

Charcot’s triad - jaundice, fever, biliary colic.

33
Q

What is Charcot’s triad? And what condition is it related to?

A

Charcot’s Triad:
1. RUQ pain
2. Jaundice - common bile duct blocked, bilirubin builds up
3. Fever with rigors/chills

Acute cholangitis.

34
Q

What is Reynold’s pentad? And what condition is it related to?

A

Reynolds pentad → Charcot’s triad + confusion + septic shock

Acute cholangitis.

35
Q

How would you tell that a gallstone had moved to obstruct the common bile duct?

A

Obstructive jaundice and acute cholangitis.

36
Q

What special test would you do on examination to confirm acute cholecystitis?

A

Murphy’s sign - 2 fingers over RUQ + ask patient to breathe in - causes pain and arrest of inspiration as inflamed gallbladder hits your fingers

37
Q

What is the gold standard investigation in acute cholangitis?

A

Transabdominal ultrasound - measure CBD dilatation.

38
Q

Investigations for acute cholecystitis.

A

1.Blood tests
* Elevated neutrophil count
* Raised ESR and CRP
* Raised serum bilirubin - bile duct obstruction if very high
* Raised serum alkaline phospahtase
* Aminotransferase levels are elevated; ALTs are higher then ASTs
normally

  1. Blood cultures/MC&S
    - To work out what the pathogen is so you can use the trust’s advised antibiotics
  2. Transabdominal Ultrasound:
    - Initial imaging choice
    - Dilatation of common bile duct
    - May or may not show cause of obstruction
    - Distal common bile duct stones are easily missed
  3. ERCP
    - Endoscopic Retrograde Cholangiopancreatography
    - Basically a biliary tree contrast X-ray
    - Clearly shows biliary tree making detection of common bile duct
    stones and presence or dilated duct
    - Much more clearer to see
39
Q

describe the clinical features of chronic cholecystitis

A

chronic inflammation ± colic. flatulent dyspepsia - vague abdo discomfort, distension, nausea, flatulence and fat intolerance.

40
Q

how would you treat acute cholangitis?

A

laparoscopic cholecystectomy with IV abx - cefuroxime and metronidazole

41
Q

Describe the management of acute cholangitis.

A
  1. Treat sepsis
  2. IV fluid
  3. IV antibiotics e.g. cefotaxime and metronidazole
    - continued after biliary drainage until symptom resolution
  4. Urgent ERCP
    - Urgent biliary drainage using ERCP with sphincterotomy (cutting of biliary sphincter)
  5. Stenting
    - To mechanically clear the blockage, surgery/cholecystectomy possible
  6. Surgery/cholecystectomy is required for large stones
42
Q

What is the difference between ascending cholangitis and acute cholecystitis?

A

A patient with acute cholecystitis would not have signs of jaundice!

43
Q

Give 4 potential complications of gallstones in the bile duct.

A
  1. Biliary pain.
  2. Obstructive jaundice.
  3. Cholangitis (infection of the biliary tract).
  4. Pancreatitis.
44
Q

Give a complication of gallstones in the gut.

A

Gallstone ileus.

45
Q

Give 3 complications of gallstones in the gallbladder and the cystic duct.

A
  1. Biliary colic
  2. Acute cholecystitis
  3. Empyema - gallbladder fills with pus
  4. Carcinoma
  5. Mucocoele
  6. Mirizzi’s syndrome - stone in gallbladder presses on bile duct, causing jaundice
46
Q

Compare the presentation of biliary colic, acute cholecystitis and acute cholangitis.

A