biliary tree Flashcards
primary biliary cholangitis
autoimmune condition where T cells attack small bile ducts in the liver causing bile to leak into the interstitium
chronic inflammation of the bile ducts
progressive destruction of the small bile ducts leads onto cirrhosis
who gets primary biliary cholangitis
women in 40-50s
primary biliary cholangitis associated disease
sjogren’s
rheumatoid arthritis
hypothyroidism
primary biliary cholangitis signs and symptoms
jaundice xanthoma xanthelasma pruritus joint pain
primary biliary cholangitis investigations
ant-Mt antibodies high cholesterol high GGT and other LFT abnormalitis high IgM USS - used to rule out structural abnormalities
primary biliary cholangitis complications
osteoporosis portal hypertension ascites vitamin deficiencies ADEK cirrhosis
primary biliary cholangitis management
lifestyle
ursodeoxycholic acid - helps delay liver damage, improves bilirubin, aminotransferase levels
obeticholic acid - improves bile flow, reduces inflammation
vitamin ADEK
anti-pruritics
bisphosphonates
liver transplant
primary biliary cholangitis prognosis
very variable management only slows progression of cirrhosis
primary sclerosing cholangitis
autoimmune condition that causes that progressive inflammation and fibrosis of the bile duct
primary sclerosing cholangitis cause
unknown
combination between environmental triggers
genetic susceptibility
increased immunological response to stimulus
associated with UC
primary sclerosing cholangitis symptoms
asymptomatic
pruitus - itch
jaundice
RUQ pain
primary sclerosing cholangitis investigations
liver biochemistry - ALP examination - jaundice, weight loss ultrasound MRCP - beaded appearance from strictures ERCP
primary sclerosing cholangitis management
liver transplant
manage symptoms
good diet and nutrition
endoscopic investigations - preventing progression and obstruction, stenting, balloon dilation
primary sclerosing cholangitis progression
secondary biliary cirrhosis - prolonged obstruction of large bile duct can lead to liver cirrhosis
gallstones, strictures and duct cannulation
cholangiocarcinoma
types of gallstones
cholesterol - majority
pigmented - bilirubin
brown stones - associated with parasitic infection
cholelithiasis
gallstones
cholecystolithiasis
gallstone in gallbladder
choledocholithiasis
gallstone in bile duct
3 factors precipitating cholesterol gallstone formation
cholesterol supersaturation
not enough salt/acid/phospholipid
gallbladder stasis
risk factors for cholesterol stone formation
obesity rapid weight loss diet - high fat, low fibre family history female increased age HRT fair, fat, fertile, female, forty
biliary colic
temporary obstruction of the cystic/common bile duct by a gallstone
may last 2-6 hours
biliary colic signs and symptoms
RUQ epigastric colicky pain - right shoulder
associated with indigestion and over indulgence with high fat foods
mid-evening/early morning
nausea and vomiting
biliary colic investigations
clinical diagnosis
USS
biliary colic management
lifestyle modification
mild-moderation pain - paracetamol NSAIDs
severe pain - diclofenac IM
cholecystitis
when obstruction of the cystic duct causes inflammation of the gallbladder
also calculous cholecystitis
cholecystitis signs and symptoms
similar biliary colic fever RUQ pain Murphy's sign - pain on taking deep breath when examiner's fingers are over RUQ at costal margin obstructive jaundice
cholecystitis complications
perforation
fistula formation
peritonitis
sepsis
cholecystitis investigations
high ALP
abdominal USS
MRCP
ERCP
cholecystitis management
supportive - fluids, analgesia, IV antibiotics
ERCP
cholecystectomy
percutaneous cholecystostomy - to drain pus
acalculous cholecystitis
inflammation of the gallbladder in the absence of a gallstone
associated with higher rates if morbidity and mortality than calculous cholecystitis
more common in very ill patients
gallbladder stasis and bile stagnation
acalculous cholecystitis signs and symptoms
same as calculous cholecystitis
acalculous cholecystitis investigation
raised ALP
high CRP
USS - thickened gallbladder wall with absence of stones
acalculous cholecystitis management
cholecystectomy
percutaneous cholecystostomy
ascending cholangitis
a bacterial infection superimposed on an obstruction of the biliary tree due to stagnation of bile
obstruction increases the pressure in the bile ducts, widening the spaces between the cholangiocytes. this allows the contaminated bile access to the bloodstream
ascending cholangitis complications
sepsis
ascending cholangitis signs and symptoms
Charcot’s triad - fever, jaundice, RUQ pain
Reynold’s pentad - fever, jaundice, RUQ pain, hypotension, confusion
ascending cholangitis investigations
bloods - raised WCC, raised CRP LFTs - raised ALP, bilirubin, GGT blood culture USS MRCP ERCP
ascending cholangitis management
IV fluids
antibiotics
remove obstruction via ERCP
cholecystectomy
gallstone ileus
bowel obstruction caused buy a gallstone within the lumen of small bowel
repeated inflammation can cause thinning of gallbladder wall, fistula forms, between gallbladder and duodenum
small stones pass through bowel and out the stool
large stones get stuck causing mechanical bowel obstruction
gallstone ileus signs and symptoms
abdomenal distension
nausea and vomiting
recurrent RUQ pain - chronic cholecystitis
dehydration
gallstone ileus investigations
rigler’s triad - pneumobilia, evidence of small bowel obstruction, gallstone outside of gallbladder
gallstone ileus management
IV fluid resuscitation
NG tube
gallstone removal
biliary strictures
a narrowing of the bile duct
benign or malignant
bengn causes - post-op injury, pancreatitis, PSC
biliary strictures complications
asymptomatic
biliary colic
cholangitis
obstructive jaundice
biliary strictures investigations
related to cause, need to rule out malignancy
biliary strictures management
treat cause
stenting
congenital biliary atresia
babies born with, abscence or deficiency of extra-hepatic biliary tree
leads to cholestasis and liver cirrhosis from back pressure of bile
congenital biliary atresia symptoms
3 months of birth
jaundice
dark urine, pale stool]growth and development delay
congenital biliary atresia investigations
blood tests - LFTs, bilirubin
US - fibrous tissue, changes to hepatic blood flow
HIDA scan
congenital biliary atresia management
excision of fibrous tissue
liver transplant
cholangiocarcinoma
cancer in the bile duct
intra hepatic (less common) or extra hepatic
bad prognosis due to late detection
hilar cholangiocarcinoma most common tumour where left and right bile ducts join together
cholangiocarcinoma risk factors
over 65s
SE Asia
previous biliary disease - PSC, gallstones and cysts
genetic predisposition
cholangiocarcinoma symptoms
aysmptomatic jaundice - dark urine, pale stool abdominal pain weight loss, fatigue, loss of appetite symptoms of cholangitis
cholangiocarcinoma investigations
LFTs abnormal bilirubin and marked elevation of ALP and GGT
contrast MRI
CT - staging and metastases
ERCP
cholangiocarcinoma management
surgical resection
stenting
adjuvant chemotherapy and radiotherapy
carcinoma of ampulla of vater
a rare cancer that forms at the junction of the common bile duct and the main pancreatic duct
bad prognosis due to invasion of important structures
similar to cholangiocarcinoma
extensive surgery
acute pancreatitis
inflammation of the pancreas leading to autodigestio
most common causes - gallstones, alcohol, systemic disease, trauma
acute pancreatitis causes
idiopathic gallstones ethanol trauma steroids mumps autoimmune scorpion bite hypercalcaemia. hyperthyroidism, hyperlipidaemia ERCP drugs - azathioprine, antibiotics, oestrogen
acute pancreatitis categorisation
mild - absence of complications, uneventful recovery
moderately severe - local complications +/- transient organ dysfunction, resolves within 48 hours
severe - persistent organ dysfunction, local complications
acute pancreatitis pathogenesis
due to premature activation of zymogen granules - releases proteases - autodigest pancreas 4 stages oedema and fluid shifts autodigestion of blood vessels infarction due to comprise blood supply necrotic tissue becomes infected
acute pancreatitis complications
systemic - SIRS, multiorgan dysfunction, hypovalaemic shock
kidney - AKI
pancreas - fluid collection, necrosis, pseudocyst, abscess
lungs - pleural effusion, ARDS
heart - carditis
GI - paralytic ileus, bleeding
metabolic - hypocalcaemia, hypo/hyperglycemia
acute pancreatitis signs and symptoms
acute, severe epigastric pain, may radiate to back
pain my be alleviated in foetal position/when leaning forward
pain by be associated with meals/excessive alcohol
nausea and vomiting
jaundice
fever
tachycardia
anorexia
abdomen tenderness in epigastric region
abdomen distention
Cullen’s sign - superficial oedema and bruising, peri-umbilical
Grey Turner’s sign - bruising of flank
acute pancreatitis investigation
high amylase
high lipase
high CRP
imaging - CXR, USS, CT
Glasgow prognostic criteria acute pancreatitis
PaO2 <8kPa/60mmHg Age >55 Neutrophils Calcium < 2 mmol/l Renal function (urea>16mmol/l) enzymes AST/ALT Albumin <32g/l sugar (glucose>10mmol/l)
acute pancreatitis management
IV fluid resuscitation O2 therapy pain relief nutritional support through enteral feeding antibiotics gallstones -ERCP/cholecystectomy alcohol advice treat compklicatioons
chronic pancreatitis
progressive and irreversible
will lose exocrine function and sometimes endocrine function
chronic pancreatitis pathogenesis
unclear, many theories
may be due to the premature activation of enzymes or impaired clearance of enzymes - trypsin
alcohol though to increase trypsin activation
chronic pancreatitis casues
alcohol idiopathic pancreatic duct obstruction autoimmune tropical countries alpha1-antitrypsin CF
chronic pancreatitis history
similar to acute pancreatitis - flare ups
epigastric pain, radiating back, nausea, vomiting
jaundice, itching, ascites, masses
alcohol intake, smoking
medication - antibiotics, steroids, ACEI
chronic pancreatitis investigations
blood tests - LFTs CXR and abdominal x-ray CT pancreas MRI USS ERCP
chronic pancreatitis management
manage acute phase
lifestyle - pain management, screen for other diseases
Creon - replacement pancreatic enzymes
surgery - Pustow’s or Frey’s procedure
pseudocysts
a collection of fluid that forms in the pancreas
sac is not lined by epithelial cells
pseudocysts causes
trauma idiopathic pancreatico-duodenal communication following surgery biliary obstruction gastruc outlet obstruction complication of acute pancreatitis
pseudocysts treatment
drained or resected in surgery
pancreatic tumours
95% adenocarcinoma in exocrine component
majority form in head or neck of the pancreas
pancreatic tumour risks
increasing age male smoking alcohol diabetes chronic pancreatitis
pancreatic tumour symptoms
painless jaundice weight loss back pain fatigue, nause, vomiting malbsorption
Courvoisier’s sign
palpable non-tender gallbladder, painless jaundice
biliary obstruction
most likely head of pancreas tumour
pancreatic tumour investigations
blood tests US triple phase CT MRI MRCP
pancreatic tumour management
chemotherapy
radiotherapy
possibly surgery
