Biliary tract diseases Flashcards
What are the broad categories of cholelithiasis? (5)
Asymptomatic gallstones Chronic cholecystitis Acute cholecystitis Choledocolithiasis Gallstone pancreatitis
What is the prevalence of cholelithiasis?
How many are symptomatic?
10% Adult population
Only 10-20% are symptomatic
Describe the epidemiology of gallstones: prevalence, sex, age
10% Adult population
F>M
Increases with age (at 75yo 35% women and 20% men)
What are the different types of gallstones?
Cholesterol (70%)
Pigment==>Very hard, difficult to manage
Mixed
What factors are associated with cholesterol gallstone formation? (6)
Increased cholesterol secretion Decreased bile acid secretion Increased age Estrogen production/therapy Decreased HDL increased TG Ethnic groups=>Native Americans/Pima
What is biliary sludge?
Name some risk factors (4)
Mucoprotein and cholesterol crystals that can cause symptoms (acalculus cholecystitis)
RFs include pregnancy, total parenteral nutrition, starvation, weight loss
In which patients are asymptomatic gallstones a concern? (4)
Children
Sickle cell
Porcelain gallbladder (at risk for adenocarcinoma)
Pima indians
Describe biliary pain
RUQ/epigastric pain that radiates to R shoulder or scapula
Duration greater than 15 min; frequency from weeks to years
Nocturnal predominance not relieved by position change or antacids
Fatty food intolerance
What is recommendation for symptomatic cholelithiasis?
Delay surgery until symptoms recur unless other comorbidities
What is acute cholecystitis? What is treatment?
Complication of cholelithiasis (1-3%)
Requires supportive care followed by cholecystectomy or cholecystotomy
What is choledocolithiasis? What are observations?
A stone that obstructs the common bile duct and can lead to cholangitis
Results in increased AST, alkaline phosphatase and Bilirubin
What is treatment technique for choledocolithiasis?
What happens in gallbladder left in situ?
ERCP (successful in 95%) and cholecystectomy
If leave in situ symptoms recur in 30% cases
What is pathophysiology of gallstone pancreatitis?
Gallstone obstructs pancreatic duct causing inflammation and pancreatitis
What are observations of gallstone pancreatitis?
Lab values and imaging
Elevated liver associated enzymes
Dilated pancreatic duct
What is treatment for gallstone pancreatitis?
Supportive care usually
Urgent ERCP for severe acute pancreatitis or cholangitis/biliary abstructio
What are most common causes of malignant biliary strictures? (6)
Pancreatic head carcinoma Cholangiocarcinoma Ampullary tumor Gallbladder carcinoma Nodal compression Lymphoma
Common presentation of malignant biliary strictures?
Jaundice
What is the sign of a pancreatic head carcinoma on ERCP?
Double duct sign
What is treatment for biliary strictures due to malignancy?
What is major complication?
Treatment is to use fixed-diameter plastic stents
Major complication is occlusion leading to cholangitis and recurrent jaundice– most occur within 6 months (20-25% pts)
What are contents of clogged stents? (5)
Bacteria Bacterial glycocalix Calicum bilirubinate Ca palmitate Dietary fiber
What is alternative to fixed diameter plastic stents?
self-expanding metal stents==>reduce complications of occlusion but more expensive
Hilar strictures==> how do you treat them? (2)
Single segment drainage (less favorable response to stenting)
Selective guide wire cannulation
What are causes of benign biliary strictures? (4)
Bile duct injury: trauma, post op, post liver transplant, bile duct leaks
Chronic pancreatitis
Mirritz’s Syndrome
Primary sclerosing cholangitis
What are the three major etiologies of bile duct injuries?
Trauma: projectile, sharp, decceleration
Operative: liver tx, cholecystectomy, hepatobiliary surgery
Percutaneous intervention: biopsy/ablation
What is treatment for bile duct leaks?
Stent and/or sphincterectomy
What is primary sclerosing cholangitis?
What are possible long-term consequences? (4)
A frequently progressive chronic cholestatic hepatobiliary disease that leads to inflammation, fibrosis and structuring
Can result in cholestasis, cholangitis, liver failure, cholangiocarcinoma
What is the epidemiology of primary sclerosing cholangitis?
M>F
IBD: particularly ulcerative colitis
Describe the immunology (3) and genetic (1) observations of primary sclerosing cholangitis?
Immunology: IgM (50%), IgG (30%), P-ANCA (30-80%)
Genetics: HLA-B8
What is presentation of primary sclerosing cholangitis?
What are diagnostic signs? (2)
Abnormal LAE
Fatigue, pruritis, fever RUQ pain
Onion skinning of liver (concentric fibrosis)
Cholangiography reveals multifocal stricturing and dilation of intrahepatic/extrahepatic ducts
What is treatment strategy for PSC?
Goal to slow progression and manage complications until liver tx
Drugs: UDCA, antimicrobials
Endoscopic: dilation/stenting of dominant strictures
Liver tx
What is risk of cholangiocarcinoma in PSC?
What are diagnostic tools for cholangiocarcinoma?
10-15% lifetime risk– cholangiocarcinoma has very poor prognosis because it is subclinical until advanced stage
Dx with bush, biopsy, needle, serologic markers, imaging (US, cholangioscopy)
What are types of infections that occur in biliary tract? (3)
Cholangitis
AIDS associated
Parasitic– ascariasis, fasciola
