Biliary tract diseases

Question 1

What are the broad categories of cholelithiasis? (5)

Answer 1

Asymptomatic gallstones
Chronic cholecystitis 
Acute cholecystitis
Choledocolithiasis 
Gallstone pancreatitis

Question 2

What is the prevalence of cholelithiasis?

How many are symptomatic?

Answer 2

10% Adult population

Only 10-20% are symptomatic

Question 3

Describe the epidemiology of gallstones: prevalence, sex, age

Answer 3

10% Adult population
F>M
Increases with age (at 75yo 35% women and 20% men)

Question 4

What are the different types of gallstones?

Answer 4

Cholesterol (70%)
Pigment==>Very hard, difficult to manage
Mixed

Question 5

What factors are associated with cholesterol gallstone formation? (6)

Answer 5

Increased cholesterol secretion
Decreased bile acid secretion
Increased age
Estrogen production/therapy
Decreased HDL increased TG
Ethnic groups=>Native Americans/Pima

Question 6

What is biliary sludge?

Name some risk factors (4)

Answer 6

Mucoprotein and cholesterol crystals that can cause symptoms (acalculus cholecystitis)

RFs include pregnancy, total parenteral nutrition, starvation, weight loss

Question 7

In which patients are asymptomatic gallstones a concern? (4)

Answer 7

Children
Sickle cell
Porcelain gallbladder (at risk for adenocarcinoma)
Pima indians

Question 8

Describe biliary pain

Answer 8

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

Question 9

What is recommendation for symptomatic cholelithiasis?

Answer 9

Delay surgery until symptoms recur unless other comorbidities

Question 10

What is acute cholecystitis? What is treatment?

Answer 10

Complication of cholelithiasis (1-3%)

Requires supportive care followed by cholecystectomy or cholecystotomy

Question 11

What is choledocolithiasis? What are observations?

Answer 11

A stone that obstructs the common bile duct and can lead to cholangitis

Results in increased AST, alkaline phosphatase and Bilirubin

Question 12

What is treatment technique for choledocolithiasis?

What happens in gallbladder left in situ?

Answer 12

ERCP (successful in 95%) and cholecystectomy

If leave in situ symptoms recur in 30% cases

Question 13

What is pathophysiology of gallstone pancreatitis?

Answer 13

Gallstone obstructs pancreatic duct causing inflammation and pancreatitis

Question 14

What are observations of gallstone pancreatitis?

Lab values and imaging

Answer 14

Elevated liver associated enzymes

Dilated pancreatic duct

Question 15

What is treatment for gallstone pancreatitis?

Answer 15

Supportive care usually

Urgent ERCP for severe acute pancreatitis or cholangitis/biliary abstructio

Question 16

What are most common causes of malignant biliary strictures? (6)

Answer 16

Pancreatic head carcinoma
Cholangiocarcinoma
Ampullary tumor
Gallbladder carcinoma
Nodal compression
Lymphoma

Question 17

Common presentation of malignant biliary strictures?

Answer 17

Jaundice

Question 18

What is the sign of a pancreatic head carcinoma on ERCP?

Answer 18

Double duct sign

Question 19

What is treatment for biliary strictures due to malignancy?

What is major complication?

Answer 19

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)

Question 20

What are contents of clogged stents? (5)

Answer 20

Bacteria
Bacterial glycocalix
Calicum bilirubinate
Ca palmitate
Dietary fiber

Question 21

What is alternative to fixed diameter plastic stents?

Answer 21

self-expanding metal stents==>reduce complications of occlusion but more expensive

Question 22

Hilar strictures==> how do you treat them? (2)

Answer 22

Single segment drainage (less favorable response to stenting)
Selective guide wire cannulation

Question 23

What are causes of benign biliary strictures? (4)

Answer 23

Bile duct injury: trauma, post op, post liver transplant, bile duct leaks
Chronic pancreatitis
Mirritz’s Syndrome
Primary sclerosing cholangitis

Question 24

What are the three major etiologies of bile duct injuries?

Answer 24

Trauma: projectile, sharp, decceleration
Operative: liver tx, cholecystectomy, hepatobiliary surgery
Percutaneous intervention: biopsy/ablation

Question 25

What is treatment for bile duct leaks?

Answer 25

Stent and/or sphincterectomy

Question 26

What is primary sclerosing cholangitis?

What are possible long-term consequences? (4)

Answer 26

A frequently progressive chronic cholestatic hepatobiliary disease that leads to inflammation, fibrosis and structuring

Can result in cholestasis, cholangitis, liver failure, cholangiocarcinoma

Question 27

What is the epidemiology of primary sclerosing cholangitis?

Answer 27

M>F

IBD: particularly ulcerative colitis

Question 28

Describe the immunology (3) and genetic (1) observations of primary sclerosing cholangitis?

Answer 28

Immunology: IgM (50%), IgG (30%), P-ANCA (30-80%)

Genetics: HLA-B8

Question 29

What is presentation of primary sclerosing cholangitis?

What are diagnostic signs? (2)

Answer 29

Abnormal LAE
Fatigue, pruritis, fever RUQ pain

Onion skinning of liver (concentric fibrosis)
Cholangiography reveals multifocal stricturing and dilation of intrahepatic/extrahepatic ducts

Question 30

What is treatment strategy for PSC?

Answer 30

Goal to slow progression and manage complications until liver tx

Drugs: UDCA, antimicrobials
Endoscopic: dilation/stenting of dominant strictures
Liver tx

Question 31

What is risk of cholangiocarcinoma in PSC?

What are diagnostic tools for cholangiocarcinoma?

Answer 31

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)

Question 32

What are types of infections that occur in biliary tract? (3)

Answer 32

Cholangitis
AIDS associated
Parasitic– ascariasis, fasciola