Biliary Tract Diseases

Question 1

what makes up the bile?

Answer 1

cholesterol, phospholipid, bile salts and bilirubin

Question 2

what causes secretion of bile?

Answer 2

CCK by the small intestine

Question 3

Gallbladder ___ and mucosal _______ may contribute to their formation - gallstones

Answer 3

Gallbladder pH and mucosal glycoproteins may contribute to their formation

Question 4

Gallstones form when there is an imbalance between the ratio of cholesterol to bile salts
and you get free _____

Answer 4

crystalisation

Question 5

cholesterol stones are ___

Answer 5

soft

Question 6

with gallstones what happens to the wall of the gall bladder?

Answer 6

Get a thickened and fibrosed gall bladder which can cause inflammation and infection and pain as the stones get mixed about and rub against the epithelium

Question 7

Excess ___- cannot be solubilised in bile salts so forms pigment stones

Answer 7

bilirubin

Question 8

what could cause excess bilirubin

Answer 8

haemolytic anaemia or hereditary spherocytosis

Question 9

most gallstones are a ____

Answer 9

mixture of the two

Question 10

what are some complications of gallstones

Answer 10

Acute Cholecystitis
Chronic Cholecystitis 
Mucocoele
Empyema
Carcinoma
Ascending Cholangitis
Obstructive Jaundice
Gallstone Ileus 
Acute Pancreatitis
Chronic Pancreatitis

Question 11

what is gallstone ileus?

Answer 11

Gallstone ileus is a rare form of small bowel obstruction caused by an impaction of a gallstone within the lumen of the small intestine

its caused by a fistula between gallbladder and duodenum

Question 12

• Gallstones obstruct flow of bile
• Initially sterile and then gets infected
• May can empyema, rupture, peritonitis
• Causes intense adhesions within 2-3 days
• The gallbladder is very inflammed and full of neutrophils
• There will also be alot of haemorrhage

Answer 12

acute cholecytsitis

Question 13

• Associated with gallstones
• May develop insidiously or after bouts of acute cholecystitis
• Gallbladder wall is thickened but not usually distended

Answer 13

chronic cholecystitis

Question 14

this is rare and is an adenocaricnoma which can invade the liver lobe

it has a poor prognosis because of its incidious onset

Answer 14

carcinoma of the gallbladder

Question 15

This is rare
It is associated with UC and PSC
Presents with obstructive jaundice
They are all adenocarcinomas

Answer 15

cholangiocarcinoma

Question 16

why do we get gallstones?

Answer 16

Abnormal bile composition 
Bile stasis 
Infection 
Excess cholesterol or bilirubin
Gallbladder pH and mucosal glycoproteins may contribute to their formation

Question 17

what is the clinical presentation of gallstones?

Answer 17

Colic
Cholecystitis 
Jaundice 
Pancreatitis
Bowel obstruction

Question 18

what are the risk factors for gallstones? the 5 Fs

Answer 18

• age > 40, female, high fat diet, obesity, pregnancy and hyperlipidaemia
• Bile salt loss (crohn’s)
• Diabetes
• Dysmotility of the gallbladder
• Prolonged fasting
• Total parenteral nutrition

Question 19

how are gallstones diagnosed?

Answer 19

First do ultrasound and then MRCP

CT can be used but because the stones are not calcium they fail to show up easily

Question 20

how are gallstones managed?

Answer 20

Pain killers
Low fat diet/ lose weight if obese
Observe 3-6 months

Question 21

if people get recurrent episdodes of pain/coli with the gallstones what should be considered

Answer 21

total cholecytsectomy or ursodeoxycholic acid (if unfit for surgery)

Question 22

biliary colic Affects -% of people with gallstones and results from impacted stone in the ___ duct and causes pain which radiates to the back/shoulder and may last - hours

Answer 22

in the cystic duct and causes pain which radiates to the back/shoulder and may last 2-6 hours

Question 23

what are associated symptoms of biliary colic

Answer 23

nausea and indigestion

Question 24

what are the symptoms of acute cholecytstitis?

Answer 24

The patient is tender and sore and may have murphy’s sign

Also may have anorexia, nausea, vomiting, jaundice and fever

Question 25

what is the treatment of acute cholecystitis?

Answer 25

• IV antibiotics and IV fluids
• Nil by mouth in case they need surgery
• Ultrasound to confirm diagnosis
• URGENT CHOLECYSTECTOMY ASAP

Question 26

what is the diff. diagnosis of acute epigastric pain?

Answer 26

Biliary colic
Peptic ulcer spasm 
Oesophageal spasm 
MI 
Acute pancreatitis

Question 27

gallstones may also migrate causing ____, ____ and acut ____

also more rare ___ ___

Answer 27

Jaundice, cholangitis, acute pancreatitis

rrare - gallstone ileus

Question 28

what are the symptoms and signs of CBD pathology

Answer 28

Itch, nausea, anorexia
Jaundice
Abnormal LFTs

Question 29

what should be done in the management of CBD pathology

Answer 29

• do MRCP - need to see how big the stone is
• could then do ERCP

Open or lap surgery

Question 30

Small bowel obstruction caused by gallstone impacted in the terminal ileum

It is caused by fistula formation between the gallbladder and the duodenum

Answer 30

gallstone ileus

Question 31

gallstone ileus Causes intermittent ____ and they can present with __ ___ obstruction

Answer 31

Causes intermittent colic and they can present with distal SB obstruction

Question 32

how is gallstone ileus investigateD?

Answer 32

AXR

Question 33

how is gallstone ileus treated?

Answer 33

Urgent laparotomy

Interval cholecytectomy in 3 months, if they are old and frail may just get laparotomy and no cholecystectomy

Question 34

_____ is the commonest hepaobiliry cancer

Answer 34

cholangiocarcinoma

Question 35

what is the common cholangiocarcinoma presentation?

Answer 35

Usually present late
Jaundice
Weight loss
Anorexia and lethergy

Question 36

HOW IS cholangiocarcnimoa staged?

Answer 36

Duplex ultrasound
(Spiral CT/ERCP/PTC)
MRI/MRCP/MRA

Question 37

what are the treatment options for cholangiocarcinoma?

Answer 37

Surgical resection is the only chance of a cure

Palliation - biliary stent ERC/PTC insertion