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Gen Med: GI > Biliary Tract Disorders > Flashcards

Biliary Tract Disorders Flashcards

1
Q

What are the biliary Tract Disorders?

A
  1. Cholelithiasis
  2. Cholangitis
  3. Acute Cholecystitis
  4. Chronic Cholecystitis
  5. Gallbladder Cancer
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2
Q

What is cholelithiasis?

A

1 or more calculi (gallstones) in the gallbladder

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3
Q

What are the risk factors for cholelithiasis?

A 
1. 4F’s
A. Female gender
B. Fat
C. Forty
D. Fertile: pre-menopausal women
2. Native American ethnicity
3. Western diet
4. (+) FH
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4
Q

What is the pathophys of cholelithiasis?

A
  1. Cholesterol stones account for 85% of gallstones
    A. Form from bile that’s supersaturated (sludge) w/cholesterol produced by liver
  2. Crystals or “microstones” are formed, then form into larger stones
  3. Stone may be “silent” or become lodged in cystic duct or CBD, causing pain & cholecystitis
  4. Stones can fill the entire gallbladder
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5
Q

What are the characteristics of black pigmented gall stones?

A
  1. Small & hard
    A. Ca bilirubinate & inorganic Ca salts
    B. Form w/alcoholic liver disease, chronic hemolysis, & older age
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6
Q

What are the characteristics of brown pigmented gall stones?

A
  1. Soft & greasy
    A. Bilirubinate & fatty acids
    B. Form during infection, inflammation, and parasitic infestation
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7
Q

What are the sxs of cholelithiasis?

A
  1. 80% asymptomatic
  2. +/- N/V
  3. Biliary colic
    A. Most common
    B. Not immediately after meal, but 1-2 hrs after fatty meal: Sudden onset RUQ pain w/radiation to back or right shoulder/arm, ↑ intensity w/in 15-60 min, steady intensity (not colicky) up to 12 h (usually < 6 h), then gradually disappears over 30-90 min, leaving dull ache
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8
Q

What are the dx studies for cholelithiasis?

A
  1. Ultrasonography
    A. Method of choice for detecting gallstones
    95% sensitivity & specificity
  2. Cholescintigraphy (HIDA scan w/Ejection Fraction)
    A. If needed
    B. May not pick up biliary sludge
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9
Q

What is the prognosis for cholelithiasis?

A
  1. Once biliary symptoms begin, they’re likely to recur
  2. Pain returns in 20-40% of patients/year
  3. 1-2% of patients/yr develop complications
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10
Q

What complications can result from cholelithiasis?

A
  1. Cholecystitis
  2. Choledocholithiasis
  3. Cholangitis
  4. Gallstone pancreatitis
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11
Q

What is the treatment for cholelithiasis?

A
  1. Cholecystectomy for symptomatic stones
    A. Laparoscopic or open laparotomy
  2. Stone dissolution
    A. Gallstones dissolved by oral bile acids over months
    B. Ursodeoxycholic acid (Ursodiol) 8-10 mg/kg/day po
    C. Dissolves 80% of tiny stones (< 0.5 cm) w/in 6 mo
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12
Q

What is included in Calot’s Triangle?

A

AKA: Hepatobiliary TriangleorHepatoCystic Triangle

  1. Cystic Duct
  2. Common Hepatic Duct
  3. Margin of Liver
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13
Q

What are the surgical landmarks for cholecystectomy?

A
  1. Calot’s Triangle

2. Mascagni (Lund’s) Lymph Node

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14
Q

What is Mascagni (Lund’s) Lymph Node?

A
  1. Sentinel lymph node of the gallbladder

2. ↑ in size incholecystitis& cholangitis

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15
Q

Who are candidates for stone dissolution?

A
  1. Pt who declines surgery
  2. High surgical risk
  3. Small, radiolucent stones (likely cholesterol)
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16
Q

What meds may be helpful for ppl with dumping syndrome?

A
  1. Bile Acid Sequestrants
    A. Bind bile acid in intestine preventing reabsorption
    B. Lower hepatic cholesterol
    C. Used w/ statin or nicotinic acid
    Synergistic effect
    Cholestyramine (Questran/Light), colestipol (Colestid), colesevelam (Welchol)
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17
Q

What is acute cholecystitis?

A
  1. Inflammation of gallbladder 2° to gallstone obstructing cystic duct
  2. Develops over hours
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18
Q

What is the most common complication of cholelithiasis?

A
  1. Acute cholecystitis

2/ 95% of patients w/acute cholecystitis have cholelithiasis

19
Q

What are the sxs of acute cholecystitis?

A
  1. Similar to biliary colic but lasts longer & more severe
  2. Vomiting is common
  3. Fever (low grade)
  4. Right subcostal tenderness
  5. (+) Murphy’s sign
    A Guarding
20
Q

How are the sxs of cholecystitis different in elderly?

A
  1. In elderly, sx’s may be systemic & nonspecific
A. Anorexia 
B. Vomiting 
C. Malaise 
D. Weakness 
E. +/- fever
21
Q

When do sxs resolve in acute cholecystitis?

A

Sx’s begin to subside in 2-3 days & resolve w/in 1 wk in 85% of patients

22
Q

What are the complications of acute cholecystitis?

A 
1. 10% perforate
A. Peritonitis 
2. ↑ pain, high fever, rigors, & rebound tenderness or ileus suggest: 
A. Empyema (pus in the gallbladder)
B. Gangrene
C. Perforation 
3. Mirizzi's syndrome
A. Rare
B. Gallstone impacted in cystic duct or Hartman's pouch, compresses & obstructs CBD → cholestasis (jaundice)
  1. Gallstone pancreatitis
    A. Gallstones pass from gallbladder into CBD block pancreatic duct
  2. Cholecystoenteric fistula
    A. Rare
    B. Large stone erodes thru gallbladder wall, creating a fistula into small bowel
23
Q

When should you suspect CBD obstruction in acute cholecystitis?

A
  1. When sx’s accompanied by jaundice, CBD obstruction is likely
    A. Due to stones or inflammation
24
Q

What dx studies are used in acute cholecystitis?

A
  1. Labs
    A. Leukocytosis w/ L shift
    B. Bilirubin up to 4 mg/dL & mildly elevated alkaline phos
  2. Ultrasonography
    A. Best test to detect gallstones
    B. Pericholecystic fluid or thickening of the GB wall → acute inflammation
  3. Cholescintigraphy (HIDA scan)
    A. If USN results are equivocal or (-) & ↑ suspicion
    B. Failure of the radionuclide to fill GB → obstructed cystic duct
    C. Low EF → GB dysfunction
25
Q

What is the tx for acute cholecystitis?

A
  1. Hospital admission, IV fluids, & analgesia w/ketorolac (Toradal) or opioid
  2. NPO
  3. NG tube to suction if vomiting or ileus present
  4. IV antibiotics for possible infection
    A. Empiric Tx [gram (-) enteric organisms]
    IV ceftriaxone (Rocephin) 2 g q 24h
    +
    IV Metronidazole (Flagyl) 500 mg q 8h
    OR
    IV piperacillin/tazobactam (Zosyn) 4 g q 6h alone
  5. Cholecystectomy
    A. Early cholecystectomy preferred
    B. In 1st 24-48 h IF:
    -Dx clear & low surgical risk
    -Elderly or diabetic & higher risk of infectious complications
    -Empyema, gangrene, perforation, or acalculous cholecystitis
26
Q

What is Cholangitis?

A
  1. CBD blocked & infection occurs backing up into the liver
    A. Can block the hepatic or common bile ducts & force bile into the circulation → jaundice
  2. MEDICAL EMERGENCY
27
Q

What is charcot’s Triad?

A

RUQ pain
Fever
Jaundice

28
Q

What is the pathophys of cholangitis?

A
  1. Choledocholithiasis
  2. Biliary tract manipulations/interventions & stents more common cause
  3. Hepatobiliary malignancies less common cause
29
Q

What is the most common causative agent/pathogen for cholangitis?

A

Most common anaerobic organism- Bacteroides fragilis

30
Q

What are the dx studies for cholangitis?

A
  1. Ultrasonography
  2. CBC w/diff
    A. Leukocytosis w/L shift
  3. LFT’s
    A. Hyperbilirubinemia
    B. ↑ alkaline phos
  4. Blood cultures
31
Q

What is the antbiotic rx for cholangitis?

A 
1. IV antibiotic therapy
A. IV  ceftriaxone (Rocephin) 2 g q 24h  Gm (-)
	\+ 
IV metronidazole (Flagyl) 500 mg q 8h anearobes
	\+
IV ampicillin 4 g q 6h Gm (+)
	OR 
IV Fluoroquinolone (Cipro or Levaquin)
32
Q

What is the tx for severe or toxic cholangitis?

A

May require emergency biliary drainage

33
Q

What is the non-abx tx for cholangitis?

A
  1. Diagnostic & therapeutic purposes (drainage)
  2. Endoscopic retrograde cholangiopancreatography (ERCP)
  3. Percutaneous transhepatic cholangiography (PTC)
    A. Needle inserted through skin at R subcostal area, guide-wire passed through liver & into the blockage in the bile duct
    B. Stent placed
  4. Eventual cholecystectomy if candidate
34
Q

What is chronic cholecystitis?

A
  1. Long-standing gallbladder inflammation almost always due to gallstones
  2. Damage ranges from modest chronic inflammatory cells to a fibrotic, shrunken gallbladder
35
Q

What is a porcelain gallbladder?

A

Extensive calcification due to fibrosis from chronic cholecystitis

36
Q

What are the sxs of chronic cholecystitis?

A
  1. Gallstones intermittently obstruct cystic duct causing recurrent biliary colic
  2. Generally mild sx’s
  3. RUQ tenderness may be present, but no fever
  4. Fever suggests acute cholecystitis
  5. Once episodes begin, they are likely to recur
37
Q

What are the dx studies for chronic cholecystitis?

A
  1. Ultrasonography
    A. Suspected in patients w/recurrent biliary colic + gallstones
    B. Shows gallstones and sometimes a shrunken, fibrotic gallbladder
  2. HIDA scan w/ EF is no stones seen on US
38
Q

What is the tx for chronic cholecystitis?

A
  1. Laparoscopic cholecystectomy

2. Low fat diet until surgery

39
Q

What are the epidemiological characteristics for gallbladder cancer?

A
  1. ↑ risk in 6th-7th decades
  2. Female > Male (3:1)
    95% associated w/ gallstones
  3. 6x more common in Native Americans
  4. 22% increased risk if “porcelain GB” or calcified wall is seen on U/S
40
Q

What type of gallblader cancer is most common?

A

> 90% are Adenocarcinoma

41
Q

What are the sxs of gall bladder cancer?

A
  1. Similar to biliary colic but lasts longer & more severe
  2. Vomiting is common
  3. Fever (low grade)
  4. Right subcostal tenderness
  5. (+/-) Murphy’s sign
    A. Guarding
42
Q

What is the treatment for gallbladder cancer?

A

Chemo has less than a 40% response rate

43
Q

What is the prognosis for gallbladder cancer?

A
  1. 5 years survival is 5%

2. Mean life expectancy 6-8 months

Gen Med: GI (16 decks)

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