Biliary Tree Conditions

Question 1

What is primary biliary sclerosis

Answer 1

Immune system attacks the small bile ducts in the liver

Question 2

Presentation of primary biliary sclerosis

Answer 2

Fatigue, pruritis, GI disturbance and abdo pain, jaundice, pale stools, xanthoma, xanthelasma, signs of cirrhosis and failure

Question 3

Associations with primary biliary sclerosis

Answer 3

Middle aged women, other autoimmune diseases, rheumatoid conditions

Question 4

Diagnosis of primary biliary sclerosis

Answer 4

Liver function tests, autoantibodies, ESR raised and IGM raised, liver biopsy

Question 5

What will be found in the LFTs of primary biliary sclerosis

Answer 5

Alkaline phosphatase will be raised, other liver enzymes and bilirubin are raised in later disease.

Question 6

What autoantibodies are associated with primary biliary sclerosis

Answer 6

Anti-mitochonrial antibodies (most specific), anti-nuclear antibodies (35% patients)

Question 7

Treatment of primary biliary sclerosis

Answer 7

Ursodeoxycholic acid, colestyramine, immunosupression in some patients and liver transplant

Question 8

What does ursodeoxycholic acid do

Answer 8

reduces the intestinal absorption of cholesterol

Question 9

what does colestyramine do

Answer 9

bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritis due to raised bile acids

Question 10

End results of primary biliary sclerosis

Answer 10

Advanced liver cirrhosis and portal hypertension

Question 11

Complications of primary biliary sclerosis

Answer 11

symptomatic pruritis, fatigue, steatorrhoea, distal renal tubular acidosis, hypothyroidism, osteoporosis, hepatocellular carcinoma

Question 12

What is primary sclerosing cholangitis

Answer 12

Condition where the intrahepatic or extrahepatic ducts become strictured and fibrotic

Question 13

What is the pathogenesis behind primary sclerosing cholangitis

Answer 13

There is obstruction to the flow of the bile out of the liver and into the intestines. This leads to liver inflammation, fibrosis and cirrhosis.

Question 14

Risk factors of primary sclerosing cholangitis

Answer 14

Male, aged 30-40, ulcerative cholitis, family history

Question 15

Presentation of primary sclerosing cholangitis

Answer 15

jaundice, chronic right upper quadrant pain, pruritis, fatigue, hepatomegaly

Question 16

What do liver function tests show in primary sclerosing cholangitis

Answer 16

Alkaline phosphatase is most derranged LFT and may be the only abnormality at first. May be a rise in bilirubin, and ALT and AST can be derranged as disease progresses.

Question 17

What role do autoantibodies have in primary sclerosing cholangitis

Answer 17

None are highly sensitive but some may indicate whether they may respond to immunosuppression

Question 18

What is the gold standard investigation for primary sclerosing cholangitis

Answer 18

MRCP (magnetic resonance cholangiopancreatography)

Question 19

Associations and complications of primary sclerosing cholangitis

Answer 19

Acute bacterial cholangitis, cholangiocarcinoma, colorectal cancer, cirrhosis and liver failure, biliary strictures, fat soluble vit deficiencies

Question 20

Management of PSC

Answer 20

Liver transplant, ERCP, colestyramine, monitoring for complications

Question 21

What does ERCP do

Answer 21

Dilate and stent any strictures

Question 22

What is ascending cholangitis

Answer 22

Bacterial infection of the biliary tree

Question 23

Triad of symptoms in ascending cholangitis

Answer 23

Charcot’s triad - RUQ pain, jaundice, fever

Question 24

Symptoms in ascending cholangitis

Answer 24

Charcot’s triad, hypotension, tachycardia, confusion

Question 25

Causes of ascending cholangitis

Answer 25

Biliary stones (50%), benign biliary stricture, malignancy

Question 26

Investigations into cholangitis

Answer 26

Raised LFTs with WCC and CRP. US detect dilatation, CT for anatomical view of tree,

Question 27

What is the use of MRCP in cholangitis

Answer 27

Most accurate for detecting gallstones and strictures

Question 28

Management of cholangitis

Answer 28

Biliary drainage, ERCP for stent, percutaneous drainage. Assessment and management of predisposing cause.

Question 29

What is cholecystitis

Answer 29

Acute or chronic inflammation of the gall bladder usually due to infection

Question 30

Symptoms of acute cholecystitis

Answer 30

RUQ or epigastric pain, radiating to the right shoulder if diaphragm is irritated. Fever, nausea, vomiting, RUQ tenderness, jaundice

Question 31

Which sign is positive in acute cholecystitis

Answer 31

Murphy’s sign

Question 32

OVerall management of cholecystitis

Answer 32

Supportive unless threat to life, definitive treatment is cholecystectomy

Question 33

Supportive management of cholecystitis

Answer 33

Nil by mouth, IV fluids, antibiotics, analgesics

Question 34

Management of acute mild cholecystitis

Answer 34

Oral Abx - cefuroxime, hydration and simple analgesia

Question 35

Management of acute moderate cholecystitis

Answer 35

IV Abx - cefuroxime, IV fluids, strong analgesia and NBM, percutaneous cholecystectomy if pt is acutely unwell

Question 36

Features of severe acute cholecystitis

Answer 36

Resistant hypotensoin, lowered GCS, oliguria, hepatic dysfunction, lowered O2 sats

Question 37

Features of chronic cholecystitis

Answer 37

Flatulant dyspepsia, vague abdo pain, nausea, bloating, worse symptoms after fatty meals, sometimes colicky pain

Question 38

When should a lap chole be formed in acute mild cholecystitis

Answer 38

Within 1 week

Question 39

Risk factors for gallstones

Answer 39

Obesity, female, diabetes, family history, chronic loss of bile salts (Crohn’s), COCP, pregnancy, rapid weight change, chronic haemolysis, increasing age

Question 40

Gall bladder complications of gallstones

Answer 40

Biliary colic, acute/chronic cholecystitis, empyema/mucocoele, Mirizzi’s syndrome, cholangiocarcinoma

Question 41

Bile duct complications of gallstones

Answer 41

Obstructive jaundice, pancreatitis, cholangitis

Question 42

Duodenum complications of gallstones

Answer 42

Gallstone ileus, Bouveret’s syndrome