Biliary Tract & Gallbladder Disease Flashcards
Define cholecystits
gallbladder inflammation
What are the symptoms of acute cholecystitis?
RUQ pain (prolongued/steady) +/- radiation to shoulder or back, fever, leukocytosis, gallbladder inflammation, gallstones, abdominal guarding
What is murphy’s sign?
increased discomfort when pt take a deep breath in while examiner palpates RUQ
What are the symptoms of chronic cholecystitis?
gallstones, no correlation with symptoms
How to dx acute cholecystitis?
abdominal ultrasound
HIDA scan
CT
What are some complications of acute cholecystitis?
gangrene
perforation
cholecystoenteric fistula
emphysematous cholecystitis
Where do cholecystoenteric fistulas usually open up?
duodenum or jejunum
What is gallstone ileus?
passage of gallstone through CE fistula, mechanical bowel obstruction, usually in termina ileum
What is emphysematous cholecystitis?
2ary infection of gallbladder wall with gas-forming organisms
leads to gangrene and perforation
How is acute cholecystitis treated?
may ablate in 7-10 days w/o tx abx pain control (NSAIDS) gallbladder drainage Surgery
How does acalculous cholecystitis?
gallbladder stasis & ischemia -> local inflammatory response -> secondary infection
ie/w TPN b/c GB not used as much
How does acalculous cholecystitis present?
hospitalized, critically ill pts
unexplained fever, leukocytosis, abd pain
Dx of acalculous cholecystitis?
abdominal ultrasound
murphy’s sign
HIDA scan
CT
TX of acalculous cholecystitis?
abx
percutaneous or surgical cholecystectomy
Mortality of acute cholecystitis?
3%
likely b/c presents in older patients
Mortality of acalculous cholecystitis?
30%
75% w/delayed tx
What is xanthrogranulomatous cholecystitis?
extravasation of bile into the gallbladder wall, leads to inflammatory reaction and xanthoma cells
gallstones ALWAYS present
How does xanthrogranulomatous cholecystitis present?
hisotry or acute cholecystitis
can mimic gallbladder cancer
high rate of complications
How is xanthrogranulomatous cholecystitis diagnosed?
abd US
CT
How is xanthrogranulomatous cholecystitis treated?
cholecystectomy
preoperative cholangiogram to exclude bile duct cancer
What is porcelain gallbladder?
chronic cholecystitis with intramural calcification of the gallbladder wall
What is the epidemiology of porcelain gallbladder?
uncommon, more common in females
increased risk of gallbladder cancer (esp w/incomplete calcification)
How does procelain gallbladder present?
asymptomatic
biliary type pain
palpable gallbladder
How is procelain GB dx?
abd xray
ct
abd us
How is porcelain GB tx?
cholecystectomy for incomplete calcification or sx pts w/complete calcification
What are cholesterol GB polyps?
benign
abnormal deposits of TGs & cholesterols into theGB mucosa
What is an adenomyomatosis polyp?
benign
overgrowth of the mucosa, thickening of the muscle wall and intramural diverticula
What is an inflammatory polyp?
benign
granulation and fibrous tissue w/plasma cells and lymphocytes
What is an adenoma polyp?
benign glandular tumor w/potential for malignancy
How to gallbladder polyps present?
can be asymptomatic
biliary pain
possible association of dyspepsia w/cholesterolosis and adenomyomatosis
How are GB polyps Dx?
transabd us
endoscopic us
CT
How are gallbladder polyps managed?
cholecystectomy
w/cholelithiasis, PSC, biliary colic/pancreatitis, polyps >10mm, drastic growth
Features of acute (ascending) cholangitis?
fever, jaundice, abd pain that develops as a result of stasis and infection in the biliary tract due to bacteria entering from the SI or portal system, this causes disruption of the sphincter of oddi
What type of bacteria typically cause acute cholangitits?
gram negative and positive colonic bacteria
What important clinical signs are present in acute cholangitis?
charcot’s triad
reynolds pentad
cholestatis liver test elevations, leukocytosis
What is charcot’s triad?
fever, abd pain, jaundice
What is Reynolds’ pentad?
confusion, hTN w/charcot’s triad (fever, abd pain, jaundice)
What is seen for acute cholangitis on imaging?
dilated biliary system, choledocholitiasis
How is acute cholangitis treated?
abx biliary drainage (via ERCP)
What is biliary atresia?
progressive, idiopathic, fibroobliterative disease of the extrahepatic biliary tree
can be viral, toxic, genetic or due to immune dysregulation
How does biliary atresia present?
biliary obstruction exclusively in the neonatal period
babies have normal birth weight/thrive initially
jaundice birth to 8wks of age
What are the types of biliary atresia?
biliary atresia
biliary atresia splenic malformation
How is biliary atresia dx?
abd us
liver biopsy
cholangiogram
How is biliary atresia treated?
kasai procedure
liver transplant eventually
What are biliary cysts?
cystic dilations that may occur singly or in multiples throughout the biliary tree
associated with abnormal pancreaticobiliary junction
Epidemiology of biliary cysts?
asian, women, kids and adults
usually present before age 10
What are the different types of biliary cysts?
type 1-extrahepatic
type iv-mutliple cysts-extrahepatic +/- intrahepatic
type v-intrahepatic, caroli’s disease
What can presdispose to biliary cysts?
genetics/envrionment
developmental abnormalities
How are biliary cysts diagnosed?
abd US
cholangiogrphay
ct
What is the most important complication of biliary cysts?
increased risk for cholangiocarcinoma (type 1 and 4)
What is primary sclerosing cholangitis?
progressive inflammation, fibrosis and stricturing of the intrahepatic and extrahepatic bile ducts
Association of PSC?
w/IBD (UC>Crohn’s)
Epidemiology of PSC?
men, 40, women dx at later age
How does PSC occur?
Immune activation: humoral and cellular abnormalities genetic factors bacterial? ischemia? CF
How does PSC present?
asymptomatic elevated liver tests in cholestatic pattern fatigue pruritus jaundice hypergammaglobulinemia P-ANCA
What are the types of PSC?
Classic (intrahepatic & extrahepatic, intrahepatic only, extrahepatic only)
Smll Duct
How is PSC dx?
CT
abd US
cholangiography (MRI ERCP)
liver biopsy (not necessary)
What is a histologic feature of PSC?
onion skin pattern around bile ducts
What are complications of PSC?
cirrhosis, portal HTN, (due to progressive hepatic fibrosis) steatorrhea, fat soluble viamin malabsoroption (decreased bile acids), osteoporosis (unknown), dominant biliary structures, acute cholangitis, cholelithiasis, hepatobiliary cancers (cholangiocarcinoma), colon cancer
How is PSC treated?
ERCP for dominant extrahepatic strictures
Surgery-biliary reconstruction/liver transplantation
What is AIDS cholangiopathy?
biliary obstruction resulting from infection-related (crypto) strictures of the biliary tract
usuallly pts w CD4 <100
How does AIDS cholangiopathy present?
RUQ & epigastric pain, diarrhea
cholestatic liver enzyme elevations
How to dx AIDS cholangiopathy?
transabd us
mrcp
ercp
How to tx AIDS cholangiopathy?
biliary sphincterotomy
stenting of dominant extrahepatic stricutres
Ursodeoxycholic acid maybe
What parasites most commonly cause biliary parasitosis?
ascaris lumbricoides echinococcus granulosus clonorchis sinensis opisthorchiasis fasciola hepatica
Features of Ascaris lumbricoides biliary parasitosis?
roundworm
US
ERCP for dx and removal
anti-helminthic therapy
Features of echinococcus granulosus biliary parasitosis?
tapeworms w/canine host
rupture of hepatic cyst into biliary system
jaundice & hepatomegaly
surgical resection or percutaneous injection of scolicidal agents & anti helminthic therapy
Features of clonorchis sinensis (&opisthorchiasis) biliary parasitosis?
far east/east russia (SE asia, central & e europe)
asymptomatic, cholangitis
chronic infection associated w/cholangiocarcinoma
ERCP for acute cholangitis
tx w/antihelminthic tx
Features of fasciola hepatic biliary parasitosis?
from eating raw veggies infected w/metacercariawe
penetrate duodenum, migrate and enter biliary system
ERCP for acute cholangitis
tx w/anti helminthis therapy
What is recurrent pyogenic cholangitis?
pigment stone formation in the intrahepatic biliary system resulting in intrahepatic stricutring and biliary obstruction w/recurrent bouts of acute cholangitis
Who gets recurrent pyogenic cholangitis?
pts from SE Asia
Sx of recurrent pyogenic cholangitis?
acute cholangitis
Dx of recurrent pyogenic cholangitis?
abd us, mri, ct, ptc, ercp
What can cause recurrent pyogenic cholangitis?
biliary parasitosis
bacterial infection
stasis
Tx for recurrent pyogenic cholangitis?
tx acute cholangitis
stone clearance
ursodeoxycholic acid ?
hepatic resection & renastomosis
Prognosis for recurrent pyogenic cholangitis?
cirrhosis from secondary sclerosis cholangitis
increased risk of cholangiocarcinoma
What is Cholelithiasis?
stones/sludge in the gallbladder
usually asymptomatic
Who gets gallstones?
fat, fertile, forty, female
How can cholelithiasis manifest?
biliary colic (intermittent cystic duct obstruction) asymptomatic
Dx cholelithiasis?
transabd US
endoscopic US
Tx cholelithiasis?
prophylacic cholecystectomy w/risk factors (sickle cell, hereditary spherocytosis, gastric bypass surgery)
cholecystectomy w/biliary colic sx
What is choledocholithiasis?
stones/sludge in the common bile duct, secondary to passage of cholelithiasis usually
Sx of choledocholithiasis?
asymptomatic
intermittent RUQ pain
nausea & vomiting
elevated liver test in cholestatic pattern
Dx of choledocholithiasis?
abd us
endoscopic us
cholangiography (ercp, mrcp)
What is Mirizzi syndrome?
common hepatic duct obstruction from extrinsic compression by an impacted stone in the cystic duct or Hartmann’s pouch of the gallbladder
What are the sx of Mirizzi syndrome?
jaundice RUQ pain Fever Elevated liver tests in a cholestatic pattern assoc. w/GB cancer
How is Mirizzi sndrom dx?
abd ultrasound
cholangiogrphay
Tx for Mirizzi syndrome?
surgery
-cholecystectomy +/- bilioenteric anastomosis
