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biliary tree Flashcards

1
Q

primary biliary cholangitis

A

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

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2
Q

who gets primary biliary cholangitis

A

women in 40-50s

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3
Q

primary biliary cholangitis associated disease

A

sjogren’s
rheumatoid arthritis
hypothyroidism

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4
Q

primary biliary cholangitis signs and symptoms

A 
jaundice
xanthoma
xanthelasma
pruritus
joint pain
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5
Q

primary biliary cholangitis investigations

A 
ant-Mt antibodies
high cholesterol
high GGT and other LFT abnormalitis
high IgM
USS - used to rule out structural abnormalities
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6
Q

primary biliary cholangitis complications

A 
osteoporosis
portal hypertension 
ascites
vitamin deficiencies ADEK
cirrhosis
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7
Q

primary biliary cholangitis management

A

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

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8
Q

primary biliary cholangitis prognosis

A

very variable management only slows progression of cirrhosis

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9
Q

primary sclerosing cholangitis

A

autoimmune condition that causes that progressive inflammation and fibrosis of the bile duct

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10
Q

primary sclerosing cholangitis cause

A

unknown
combination between environmental triggers
genetic susceptibility
increased immunological response to stimulus
associated with UC

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11
Q

primary sclerosing cholangitis symptoms

A

asymptomatic
pruitus - itch
jaundice
RUQ pain

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12
Q

primary sclerosing cholangitis investigations

A 
liver biochemistry - ALP
examination - jaundice, weight loss
ultrasound 
MRCP - beaded appearance from strictures
ERCP
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13
Q

primary sclerosing cholangitis management

A

liver transplant
manage symptoms
good diet and nutrition
endoscopic investigations - preventing progression and obstruction, stenting, balloon dilation

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14
Q

primary sclerosing cholangitis progression

A

secondary biliary cirrhosis - prolonged obstruction of large bile duct can lead to liver cirrhosis
gallstones, strictures and duct cannulation
cholangiocarcinoma

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15
Q

types of gallstones

A

cholesterol - majority
pigmented - bilirubin
brown stones - associated with parasitic infection

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16
Q

cholelithiasis

A

gallstones

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17
Q

cholecystolithiasis

A

gallstone in gallbladder

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18
Q

choledocholithiasis

A

gallstone in bile duct

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19
Q

3 factors precipitating cholesterol gallstone formation

A

cholesterol supersaturation
not enough salt/acid/phospholipid
gallbladder stasis

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20
Q

risk factors for cholesterol stone formation

A 
obesity 
rapid weight loss
diet - high fat, low fibre
family history
female 
increased age 
HRT
fair, fat, fertile, female, forty
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21
Q

biliary colic

A

temporary obstruction of the cystic/common bile duct by a gallstone
may last 2-6 hours

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22
Q

biliary colic signs and symptoms

A

RUQ epigastric colicky pain - right shoulder
associated with indigestion and over indulgence with high fat foods
mid-evening/early morning
nausea and vomiting

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23
Q

biliary colic investigations

A

clinical diagnosis

USS

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24
Q

biliary colic management

A

lifestyle modification
mild-moderation pain - paracetamol NSAIDs
severe pain - diclofenac IM

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25
cholecystitis
when obstruction of the cystic duct causes inflammation of the gallbladder also calculous cholecystitis
26
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 ```
27
cholecystitis complications
perforation fistula formation peritonitis sepsis
28
cholecystitis investigations
high ALP abdominal USS MRCP ERCP
29
cholecystitis management
supportive - fluids, analgesia, IV antibiotics ERCP cholecystectomy percutaneous cholecystostomy - to drain pus
30
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
31
acalculous cholecystitis signs and symptoms
same as calculous cholecystitis
32
acalculous cholecystitis investigation
raised ALP high CRP USS - thickened gallbladder wall with absence of stones
33
acalculous cholecystitis management
cholecystectomy | percutaneous cholecystostomy
34
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
35
ascending cholangitis complications
sepsis
36
ascending cholangitis signs and symptoms
Charcot's triad - fever, jaundice, RUQ pain | Reynold's pentad - fever, jaundice, RUQ pain, hypotension, confusion
37
ascending cholangitis investigations
``` bloods - raised WCC, raised CRP LFTs - raised ALP, bilirubin, GGT blood culture USS MRCP ERCP ```
38
ascending cholangitis management
IV fluids antibiotics remove obstruction via ERCP cholecystectomy
39
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
40
gallstone ileus signs and symptoms
abdomenal distension nausea and vomiting recurrent RUQ pain - chronic cholecystitis dehydration
41
gallstone ileus investigations
rigler's triad - pneumobilia, evidence of small bowel obstruction, gallstone outside of gallbladder
42
gallstone ileus management
IV fluid resuscitation NG tube gallstone removal
43
biliary strictures
a narrowing of the bile duct benign or malignant bengn causes - post-op injury, pancreatitis, PSC
44
biliary strictures complications
asymptomatic biliary colic cholangitis obstructive jaundice
45
biliary strictures investigations
related to cause, need to rule out malignancy
46
biliary strictures management
treat cause | stenting
47
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
48
congenital biliary atresia symptoms
3 months of birth jaundice dark urine, pale stool]growth and development delay
49
congenital biliary atresia investigations
blood tests - LFTs, bilirubin US - fibrous tissue, changes to hepatic blood flow HIDA scan
50
congenital biliary atresia management
excision of fibrous tissue | liver transplant
51
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
52
cholangiocarcinoma risk factors
over 65s SE Asia previous biliary disease - PSC, gallstones and cysts genetic predisposition
53
cholangiocarcinoma symptoms
``` aysmptomatic jaundice - dark urine, pale stool abdominal pain weight loss, fatigue, loss of appetite symptoms of cholangitis ```
54
cholangiocarcinoma investigations
LFTs abnormal bilirubin and marked elevation of ALP and GGT contrast MRI CT - staging and metastases ERCP
55
cholangiocarcinoma management
surgical resection stenting adjuvant chemotherapy and radiotherapy
56
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
57
acute pancreatitis
inflammation of the pancreas leading to autodigestio | most common causes - gallstones, alcohol, systemic disease, trauma
58
acute pancreatitis causes
``` idiopathic gallstones ethanol trauma steroids mumps autoimmune scorpion bite hypercalcaemia. hyperthyroidism, hyperlipidaemia ERCP drugs - azathioprine, antibiotics, oestrogen ```
59
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
60
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 ```
61
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
62
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
63
acute pancreatitis investigation
high amylase high lipase high CRP imaging - CXR, USS, CT
64
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) ```
65
acute pancreatitis management
``` IV fluid resuscitation O2 therapy pain relief nutritional support through enteral feeding antibiotics gallstones -ERCP/cholecystectomy alcohol advice treat compklicatioons ```
66
chronic pancreatitis
progressive and irreversible | will lose exocrine function and sometimes endocrine function
67
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
68
chronic pancreatitis casues
``` alcohol idiopathic pancreatic duct obstruction autoimmune tropical countries alpha1-antitrypsin CF ```
69
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
70
chronic pancreatitis investigations
``` blood tests - LFTs CXR and abdominal x-ray CT pancreas MRI USS ERCP ```
71
chronic pancreatitis management
manage acute phase lifestyle - pain management, screen for other diseases Creon - replacement pancreatic enzymes surgery - Pustow's or Frey's procedure
72
pseudocysts
a collection of fluid that forms in the pancreas | sac is not lined by epithelial cells
73
pseudocysts causes
``` trauma idiopathic pancreatico-duodenal communication following surgery biliary obstruction gastruc outlet obstruction complication of acute pancreatitis ```
74
pseudocysts treatment
drained or resected in surgery
75
pancreatic tumours
95% adenocarcinoma in exocrine component | majority form in head or neck of the pancreas
76
pancreatic tumour risks
``` increasing age male smoking alcohol diabetes chronic pancreatitis ```
77
pancreatic tumour symptoms
``` painless jaundice weight loss back pain fatigue, nause, vomiting malbsorption ```
78
Courvoisier's sign
palpable non-tender gallbladder, painless jaundice biliary obstruction most likely head of pancreas tumour
79
pancreatic tumour investigations
``` blood tests US triple phase CT MRI MRCP ```
80
pancreatic tumour management
chemotherapy radiotherapy possibly surgery

GI (10 decks)

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