Biliary Tract Diseases Flashcards
what makes up the bile?
cholesterol, phospholipid, bile salts and bilirubin
what causes secretion of bile?
CCK by the small intestine
Gallbladder ___ and mucosal _______ may contribute to their formation - gallstones
Gallbladder pH and mucosal glycoproteins may contribute to their formation
Gallstones form when there is an imbalance between the ratio of cholesterol to bile salts
and you get free _____
crystalisation
cholesterol stones are ___
soft
with gallstones what happens to the wall of the gall bladder?
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
Excess ___- cannot be solubilised in bile salts so forms pigment stones
bilirubin
what could cause excess bilirubin
haemolytic anaemia or hereditary spherocytosis
most gallstones are a ____
mixture of the two
what are some complications of gallstones
Acute Cholecystitis Chronic Cholecystitis Mucocoele Empyema Carcinoma Ascending Cholangitis Obstructive Jaundice Gallstone Ileus Acute Pancreatitis Chronic Pancreatitis
what is gallstone ileus?
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
- 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
acute cholecytsitis
- Associated with gallstones
- May develop insidiously or after bouts of acute cholecystitis
- Gallbladder wall is thickened but not usually distended
chronic cholecystitis
this is rare and is an adenocaricnoma which can invade the liver lobe
it has a poor prognosis because of its incidious onset
carcinoma of the gallbladder
This is rare
It is associated with UC and PSC
Presents with obstructive jaundice
They are all adenocarcinomas
cholangiocarcinoma
why do we get gallstones?
Abnormal bile composition Bile stasis Infection Excess cholesterol or bilirubin Gallbladder pH and mucosal glycoproteins may contribute to their formation
what is the clinical presentation of gallstones?
Colic Cholecystitis Jaundice Pancreatitis Bowel obstruction
what are the risk factors for gallstones? the 5 Fs
- 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
how are gallstones diagnosed?
First do ultrasound and then MRCP
CT can be used but because the stones are not calcium they fail to show up easily
how are gallstones managed?
Pain killers
Low fat diet/ lose weight if obese
Observe 3-6 months
if people get recurrent episdodes of pain/coli with the gallstones what should be considered
total cholecytsectomy or ursodeoxycholic acid (if unfit for surgery)
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
in the cystic duct and causes pain which radiates to the back/shoulder and may last 2-6 hours
what are associated symptoms of biliary colic
nausea and indigestion
what are the symptoms of acute cholecytstitis?
The patient is tender and sore and may have murphy’s sign
Also may have anorexia, nausea, vomiting, jaundice and fever
what is the treatment of acute cholecystitis?
- IV antibiotics and IV fluids
- Nil by mouth in case they need surgery
- Ultrasound to confirm diagnosis
- URGENT CHOLECYSTECTOMY ASAP
what is the diff. diagnosis of acute epigastric pain?
Biliary colic Peptic ulcer spasm Oesophageal spasm MI Acute pancreatitis
gallstones may also migrate causing ____, ____ and acut ____
also more rare ___ ___
Jaundice, cholangitis, acute pancreatitis
rrare - gallstone ileus
what are the symptoms and signs of CBD pathology
Itch, nausea, anorexia
Jaundice
Abnormal LFTs
what should be done in the management of CBD pathology
- do MRCP - need to see how big the stone is
- could then do ERCP
Open or lap surgery
Small bowel obstruction caused by gallstone impacted in the terminal ileum
It is caused by fistula formation between the gallbladder and the duodenum
gallstone ileus
gallstone ileus Causes intermittent ____ and they can present with __ ___ obstruction
Causes intermittent colic and they can present with distal SB obstruction
how is gallstone ileus investigateD?
AXR
how is gallstone ileus treated?
Urgent laparotomy
Interval cholecytectomy in 3 months, if they are old and frail may just get laparotomy and no cholecystectomy
_____ is the commonest hepaobiliry cancer
cholangiocarcinoma
what is the common cholangiocarcinoma presentation?
Usually present late
Jaundice
Weight loss
Anorexia and lethergy
HOW IS cholangiocarcnimoa staged?
Duplex ultrasound
(Spiral CT/ERCP/PTC)
MRI/MRCP/MRA
what are the treatment options for cholangiocarcinoma?
Surgical resection is the only chance of a cure
Palliation - biliary stent ERC/PTC insertion
