Biliary Tree Disease Flashcards
Primary biliary cholangitis (AKA PB cirrhosis) is an autoimmune condition where T cells attack small bile ducts where? What does this cause?
In the liver
Bile leaks into intersitium ->
Chronic inflam in bile ducts ->
Destruction of bile ducts ->
Cirrhosis
Who is most likely to present with PBC? Who is most likely to present with PSC?
PBC - Middle aged woman
B = boobs
PSC - middle aged men
What symptoms would you get with PBC?
Linked to leakage of bile ducts:
Increased bilirubin
- Jaundice
- Pruritus (itchiness)
Increased cholesterol (from leaking bile)
- Xanthoma
- Xanthelasma (e = eye)
What condition is associated with Anti-Mt (mitochondria) antibodies (AMA)?
PBC
For what condition what you prescribe ursodeoxycholic acid and why?
PBC
Helps delay liver damage, improves bilirubin + aminotranferase levels
(Can also be prescribed obeticholic acid - improves bile flow and reduces inflammation)
What drug is given as an anti-pruritic? What must the patient be told when getting prescribed?
Colestryamine
- takes a few weeks to work,
- shouldn’t be taken at same time as ursodeoxycholic acid,
- constipation
- must be dissolved in solvent
What is PSC?
Where does it occur?
Primary scleorosing cholangitis
Autoimmune condition that causes progressive inflammation and fibrosis of bile duct
Can happen in bile ducts in OR out of liver
What condition will patients with PSC commonly have?
UC - ulcerative colitis
How do you diagnose PSC?
MRCP - with a BEADED APPEARANCE (can appear similar to carcinoma so must be ruled out)
How will PSC appear histologically?
Onion skin
What is the definitive treatment for PSC?
Liver transplantation (use UKELD) - Stents and balloon dilation can help to prevent obstruction
Cholelithiasis
Gallstones
Cholecystolithiasis
Gallstone in gallbladder
Coledocholithiasis
Gallstone in bile duct
Mnemonic for most likely to develop gallstones
Fair - (caucasian) Fat - (rapid weight loss as well) Fertile - Pregnancy/HRT Female Forty
What is biliary colic?
Temporary obstruction of cystic duct/common bile duct by a gallstone
(“Gallbladder attack”)
INTENSE severe colicky pain 2-6hrs
Where can pain refer to in gallbladder inflammation/irritation?
Right shoulder/scapula
Severe colicky pain that lasts 2-6hrs after eating high fat foods e.g. big burger
Biliary colic
How do you manage biliary colic?
Better diet
Mod. pain = NSAIDS and paracetamol
Severe pain = diclofenac IM
What is cholecystis?
What kind of jaundice does it cause?
Obstruction of the cystic duct causes inflammation of gallbladder
Post-hepatic = obstructive jaundice =conjugated (light stools and dark urine)
What is Murphy’s sign and what is it assoc with?
Pain on deep inspiration when examiners fingers are over RUQ at costal margin (due to inflamed gallbladder coming into contact with examiners fingers)
Cholecystitis
What is acalculous cholecystitis?
Inflammation of gallbladder in absence of gallstone
Far worse prognosis than calculous cholecystitis
Who typically presents with acalculous cholecystitis?
Very ill patients who are no longer oral feeding (hence CCK not being released and bile not released)
What is ascending cholangitis and why is it so serious?
Bacterial infection in the bile duct due to obstruction (normally gallstones) causing bile stasis
Bacteria in the duodenum which is normally flushed away from travelling through the sphincter of Oddi up into the Ampulla of Vater by bile is no longer
Increase in pressure caused by obstruction -> spaces between cholangiocytes increase and bacteria can enter the bloodstream -> sepsis
Gallstone ileus
A fistula forms between gallbladder and duodenum which allows large gallstone to pass through intestine
A form of bowel obstruction caused by a gallstone within the lumen of the small bowel
Most likely to be lodged in terminal ileum (>2.5cm stones) - due to this being the narrowest point in small intestine
What triad is used for the diagnosis of gallstone ileus?
Relate this to how a patient will present
Rigler's Triad - Pneumobilia (air in biliary tree) - Small bowel obstruction - Gallstone outside gallbladder ^^ all seen radiologically ^^
Small bowel obstruction = Nausea and vomiting Abdo distension Abdo pain Dehydration
Cholecystitis
= RUQ pain
What is a stricture?
A narrowing of a structure
How do you treat a benign biliary stricture?
REMOVABLE Stent via ERCP
Congential biliary atresia
ADD EVERYTHING - potentially move to congenital section
Carcinoma of Ampulla of Vater
Rare cancer to form - very bad prognosis due to close proximity to other structures and very difficult to operate on
What is acute pancreatitis
Inflammation of pancreas leading to auto digestion (exocrine enzymes eat away at pancreas)
Nmemoic for causes of acute pancreatitis
What are the most common causes?
I GET SMASHED
IDIOPATHIC
GALLSTONES
ETHANOL
Trauma
Steroids
Mumps
Autoimmune
Scorpion bite
Hypercalcaemia, hyperparathyroidism, hyperlipidemia
ERCP
Drugs (azathriorpine, antibiotics, oestrogen)
(no.1 = gallstones, plus alcohol and idiopathic)
What signs would be present in haemorrhaging pancreatitis?
Cullen’s sign - (bruised kinda look around bellybutton)
Grey Turner’s sign (brusing around flanks)
What criteria is used for pancreatis?
Glasgow Prognostic Criteria (>/= 3 = severe pancreatitis)
IMPORTANT TO KNOW: >/=3 and PANCREAS is used
PaO2 (<8kPa) Age (>55) Neutrophils Calcium (<2mmol/l) Renal function (>16mmol/l) Enzymes (AST/ALT) Albumin <32g/l (low levels = low osmotic pressure = ascites) Sugar -> glucose >10mmol/l
How to treat acute pancreatitis?
IV fluid resuscitation
(plus antibiotics, O2, Analgesics)
Enteral feeding (still using GI tract) in moderate and severe cases
What happens during chronic pancreatitis
Chronic inflammation of pancreas - progressive and irreversible
Eventually loses exocrine function
Causes of chronic pancreatitis - take note of most common and what is the most common cause in children
- Chronic excessive alcohol consumption
Autoimmune type 1 - middle aged men
2 - IBD
CF - most common in children
Alpha1 anti-typrsin
Pain associated with pancreatitis?
Epigastric pain with vomiting and nausea - radiates to back
Worse on movement
Better in foetal position
In chronic it may worsen when eating fatty foods or alcohol
What is a helpful investigation in acute pancreatitis but not chronic?
Amylase - peaks acutely (>3x upper limit of normal) - (due to leakage of amylase enzymes into blood)
(Lipase is more expensive test but more accurate)
Most helpful investigation of chronic pancreatitis?
CT pancreas - sometimes see calcifications/stones in pancreas and pancreatic ducts due to proteins accumulating and forming plugs in ducts
What kind of tumours form in pancreas and where?
Adenocarcionmas - form in exocrine component of pancreas
Head and neck of pancreas
Symptoms of pancreatic cancer?
“Painless jaundice” (conjugated = dark urine and pale stools)
Midepigastric pain which may radiate to back pain
Courvoisier’s sign
What disease is it associated with?
Palpable non-tender gallbladder and painless/obstructive jaundice
Pancreatic malignancies
Prognosis of pancreatic cancer?
What sex is more likely to get it?
Very poor
Female
How will a patient present with PSC?
Generally asymptomatic - raised LFTs
Can present like acute hepatitis - fever, jaundice, RUQ pain, pruritus
Why may a patient with acute pancreatitis have hypocalcemia?
Lipases leaked into blood break down fatty deposits -> fatty necrosis
Fatty necrosis requires calcium -> hypocaleamia
How may a patient present with acute pancreatitis?
Epigastric pain with vomitting and nausea
Jaundice
Tachycardia
Fever
What management is important in chronic pancreatitis?
Stop smoking and drinking
Creon - replaces pancreatic enzymes (due to loss of exocrine function)
Enteral feeding should be considered for patients with moderate/severe acute pancreatitis. What is enteral feeding?
Still using the GI tract - tube either through mouth or via stomach etc.
What would make a case of acute pancreatitis change from moderately severe to severe?
Give 3 examples of local complications
Moderately severe - suffer local complications but resolve in 48hrs
Severe - persistent organ dysfunction with local complications
Local complications = pseudocysts, necrosis, abscess etc.
Explain the 4 stages of pancreatitis
- Fluid shift -> enzymes in peritoneal cavity -> eat fats (fatty necrosis) -> hypocalciemia
- Autodigestion of blood vessels -> haemorrhage
- Infarction due to blood supply inefficiency -> pancreatic necrosis
- Necrotic tissue becomes infected -> abscess
What may be seen on AXR for acute pancreatitis
sentinel loop - small region of adynamic ileus (blockage in intestine due to intra-abdominal inflammation)
How do you investigate pancreatic cancer?
Endoscopic US - most accurate for diagnosis
CT scan
Most blood tests are pretty non-specific
Management of pancreatic cancer?
Chemo
Majority is non-operable
ERCP and stents can be used to improve bile flow and reduce symptoms
Surgery = Whipple’s procedure - (removal of head of pancreas, gallbladder, duodenum and bile duct)
What is a pseudocyst?
A complication of pancreatitis
Collection of fluid in pancreas (not an epithelial lined pouch)
Requires drainage/resection (removal) during surgery
Not known to become malignant
What are the three types of gallstones which can be found?
Cholesterol - green/yellow - most common
Pigmented (bilirubin) black - assoc. with haemolytic anaemia - due to too much bilirubin in bile
Brown stones - parasites
How would cholecystitis present differently to biliary colic?
Both with severe epigastric/RUQ pain - colicky in nature which is worse when lying flat
Cholecystitis - fever and RUQ tenderness
How do you diagnose cholecystitis?
Abdo USS - look for thickened gallbladder wall and stones
Inflam pattern in bloods
How would you treat cholecystitis and what would be the URGENT first surgical option?
Supportive
- IV antibiotics
- Fluids
- Analgesia
Surgery = cholecystectomy
Cholangiocarcinoma
Where is it most commonly found and how do patients present?
What is the optimum way to diagnose?
What is the only form of definitive treatment?
Cancer of the bile ducts - more commonly extra-hepatically
Hilar cholangiocarcinoma is most common (at site where L and R hepatic ducts meet)
Present with painless jaundice with weight loss etc.
MRCP
Surgery resection (removal)
What is the difference between Charcot’s Triad and Reynolds Pentad?
What condition would these combination of symptoms be present in?
Charcot’s Triad =
- obstructive jaundice
- RUQ pain
- fever
Reynolds Pentad
+ Hypotension
+ Confusion
(due to septic shock)
Ascending cholangitis
What is the gold standard way to diagnose cholangitis? What must also be present?
How do you treat?
ERCP + jaundice + inflammatory picture in bloods (high WCC, CRP)
Symptom relief = IV fluids and antibiotics
Cholecystectomy
Removal of obstruction via ERCP
Patient with 3mnth history of weight loss and dull midepigastric pain which radiates to the back is most likely to have what carcinoma of head and neck of panceras or body/tail?
Body/tail more likely as patient does not report jaundice
Jaundice is caused by obstruction of common bile duct which runs behind the head and neck of pancreas
Which oncogenic mutations is most commonly found in pancreatic adenocarcinomas?
KRAS (90% of cases)
CA19-9 is a tumour marker associated with what cancer?
Cholangiocarcinoma
What condition is associated with cholangiocarcinoma?
UC
What is the “chain of lakes” appearance on ERCP associated with?
Chronic pancreatitis
Pancreatic duct has become dilated and tortuous
What is the best test of pancreatic function?
Faecal elastase
Loss of what enzyme is one of the biggest causes of the development of steatorrhea?
Lipase
