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Biliary Tree Disease Flashcards

1
Q

Primary biliary cholangitis (AKA PB cirrhosis) is an autoimmune condition where T cells attack small bile ducts where? What does this cause?

A

In the liver

Bile leaks into intersitium ->
Chronic inflam in bile ducts ->
Destruction of bile ducts ->
Cirrhosis

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2
Q

Who is most likely to present with PBC? Who is most likely to present with PSC?

A

PBC - Middle aged woman
B = boobs

PSC - middle aged men

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3
Q

What symptoms would you get with PBC?

A

Linked to leakage of bile ducts:

Increased bilirubin

  • Jaundice
  • Pruritus (itchiness)

Increased cholesterol (from leaking bile)

  • Xanthoma
  • Xanthelasma (e = eye)
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4
Q

What condition is associated with Anti-Mt (mitochondria) antibodies (AMA)?

A

PBC

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5
Q

For what condition what you prescribe ursodeoxycholic acid and why?

A

PBC
Helps delay liver damage, improves bilirubin + aminotranferase levels

(Can also be prescribed obeticholic acid - improves bile flow and reduces inflammation)

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6
Q

What drug is given as an anti-pruritic? What must the patient be told when getting prescribed?

A

Colestryamine

  • takes a few weeks to work,
  • shouldn’t be taken at same time as ursodeoxycholic acid,
  • constipation
  • must be dissolved in solvent
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7
Q

What is PSC?

Where does it occur?

A

Primary scleorosing cholangitis

Autoimmune condition that causes progressive inflammation and fibrosis of bile duct

Can happen in bile ducts in OR out of liver

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8
Q

What condition will patients with PSC commonly have?

A

UC - ulcerative colitis

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9
Q

How do you diagnose PSC?

A

MRCP - with a BEADED APPEARANCE (can appear similar to carcinoma so must be ruled out)

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10
Q

How will PSC appear histologically?

A

Onion skin

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11
Q

What is the definitive treatment for PSC?

A 
Liver transplantation (use UKELD)
- Stents and balloon dilation can help to prevent obstruction
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12
Q

Cholelithiasis

A

Gallstones

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13
Q

Cholecystolithiasis

A

Gallstone in gallbladder

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14
Q

Coledocholithiasis

A

Gallstone in bile duct

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15
Q

Mnemonic for most likely to develop gallstones

A 
Fair - (caucasian)
Fat - (rapid weight loss as well)
Fertile - Pregnancy/HRT
Female
Forty
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16
Q

What is biliary colic?

A

Temporary obstruction of cystic duct/common bile duct by a gallstone

(“Gallbladder attack”)

INTENSE severe colicky pain 2-6hrs

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17
Q

Where can pain refer to in gallbladder inflammation/irritation?

A

Right shoulder/scapula

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18
Q

Severe colicky pain that lasts 2-6hrs after eating high fat foods e.g. big burger

A

Biliary colic

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19
Q

How do you manage biliary colic?

A

Better diet
Mod. pain = NSAIDS and paracetamol
Severe pain = diclofenac IM

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20
Q

What is cholecystis?

What kind of jaundice does it cause?

A

Obstruction of the cystic duct causes inflammation of gallbladder

Post-hepatic = obstructive jaundice =conjugated (light stools and dark urine)

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21
Q

What is Murphy’s sign and what is it assoc with?

A

Pain on deep inspiration when examiners fingers are over RUQ at costal margin (due to inflamed gallbladder coming into contact with examiners fingers)

Cholecystitis

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22
Q

What is acalculous cholecystitis?

A

Inflammation of gallbladder in absence of gallstone

Far worse prognosis than calculous cholecystitis

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23
Q

Who typically presents with acalculous cholecystitis?

A

Very ill patients who are no longer oral feeding (hence CCK not being released and bile not released)

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24
Q

What is ascending cholangitis and why is it so serious?

A

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

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25
Q

Gallstone ileus

A

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

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26
Q

What triad is used for the diagnosis of gallstone ileus?

Relate this to how a patient will present

A 
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

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27
Q

What is a stricture?

A

A narrowing of a structure

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28
Q

How do you treat a benign biliary stricture?

A

REMOVABLE Stent via ERCP

29
Q

Congential biliary atresia

A

ADD EVERYTHING - potentially move to congenital section

30
Q

Carcinoma of Ampulla of Vater

A

Rare cancer to form - very bad prognosis due to close proximity to other structures and very difficult to operate on

31
Q

What is acute pancreatitis

A

Inflammation of pancreas leading to auto digestion (exocrine enzymes eat away at pancreas)

32
Q

Nmemoic for causes of acute pancreatitis

What are the most common causes?

A

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)

33
Q

What signs would be present in haemorrhaging pancreatitis?

A

Cullen’s sign - (bruised kinda look around bellybutton)

Grey Turner’s sign (brusing around flanks)

34
Q

What criteria is used for pancreatis?

A

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
35
Q

How to treat acute pancreatitis?

A

IV fluid resuscitation
(plus antibiotics, O2, Analgesics)
Enteral feeding (still using GI tract) in moderate and severe cases

36
Q

What happens during chronic pancreatitis

A

Chronic inflammation of pancreas - progressive and irreversible

Eventually loses exocrine function

37
Q

Causes of chronic pancreatitis - take note of most common and what is the most common cause in children

A
  1. Chronic excessive alcohol consumption

Autoimmune type 1 - middle aged men
2 - IBD

CF - most common in children

Alpha1 anti-typrsin

38
Q

Pain associated with pancreatitis?

A

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

39
Q

What is a helpful investigation in acute pancreatitis but not chronic?

A

Amylase - peaks acutely (>3x upper limit of normal) - (due to leakage of amylase enzymes into blood)

(Lipase is more expensive test but more accurate)

40
Q

Most helpful investigation of chronic pancreatitis?

A

CT pancreas - sometimes see calcifications/stones in pancreas and pancreatic ducts due to proteins accumulating and forming plugs in ducts

41
Q

What kind of tumours form in pancreas and where?

A

Adenocarcionmas - form in exocrine component of pancreas

Head and neck of pancreas

42
Q

Symptoms of pancreatic cancer?

A

“Painless jaundice” (conjugated = dark urine and pale stools)
Midepigastric pain which may radiate to back pain

43
Q

Courvoisier’s sign

What disease is it associated with?

A

Palpable non-tender gallbladder and painless/obstructive jaundice

Pancreatic malignancies

44
Q

Prognosis of pancreatic cancer?

What sex is more likely to get it?

A

Very poor

Female

45
Q

How will a patient present with PSC?

A

Generally asymptomatic - raised LFTs

Can present like acute hepatitis - fever, jaundice, RUQ pain, pruritus

46
Q

Why may a patient with acute pancreatitis have hypocalcemia?

A

Lipases leaked into blood break down fatty deposits -> fatty necrosis

Fatty necrosis requires calcium -> hypocaleamia

47
Q

How may a patient present with acute pancreatitis?

A

Epigastric pain with vomitting and nausea
Jaundice
Tachycardia
Fever

48
Q

What management is important in chronic pancreatitis?

A

Stop smoking and drinking

Creon - replaces pancreatic enzymes (due to loss of exocrine function)

49
Q

Enteral feeding should be considered for patients with moderate/severe acute pancreatitis. What is enteral feeding?

A

Still using the GI tract - tube either through mouth or via stomach etc.

50
Q

What would make a case of acute pancreatitis change from moderately severe to severe?

Give 3 examples of local complications

A

Moderately severe - suffer local complications but resolve in 48hrs

Severe - persistent organ dysfunction with local complications

Local complications = pseudocysts, necrosis, abscess etc.

51
Q

Explain the 4 stages of pancreatitis

A
  1. Fluid shift -> enzymes in peritoneal cavity -> eat fats (fatty necrosis) -> hypocalciemia
  2. Autodigestion of blood vessels -> haemorrhage
  3. Infarction due to blood supply inefficiency -> pancreatic necrosis
  4. Necrotic tissue becomes infected -> abscess
52
Q

What may be seen on AXR for acute pancreatitis

A

sentinel loop - small region of adynamic ileus (blockage in intestine due to intra-abdominal inflammation)

53
Q

How do you investigate pancreatic cancer?

A

Endoscopic US - most accurate for diagnosis

CT scan
Most blood tests are pretty non-specific

54
Q

Management of pancreatic cancer?

A

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)

55
Q

What is a pseudocyst?

A

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

56
Q

What are the three types of gallstones which can be found?

A

Cholesterol - green/yellow - most common

Pigmented (bilirubin) black - assoc. with haemolytic anaemia - due to too much bilirubin in bile

Brown stones - parasites

57
Q

How would cholecystitis present differently to biliary colic?

A

Both with severe epigastric/RUQ pain - colicky in nature which is worse when lying flat

Cholecystitis - fever and RUQ tenderness

58
Q

How do you diagnose cholecystitis?

A

Abdo USS - look for thickened gallbladder wall and stones

Inflam pattern in bloods

59
Q

How would you treat cholecystitis and what would be the URGENT first surgical option?

A

Supportive

  • IV antibiotics
  • Fluids
  • Analgesia

Surgery = cholecystectomy

60
Q

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?

A

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)

61
Q

What is the difference between Charcot’s Triad and Reynolds Pentad?

What condition would these combination of symptoms be present in?

A

Charcot’s Triad =

  • obstructive jaundice
  • RUQ pain
  • fever

Reynolds Pentad
+ Hypotension
+ Confusion
(due to septic shock)

Ascending cholangitis

62
Q

What is the gold standard way to diagnose cholangitis? What must also be present?

How do you treat?

A

ERCP + jaundice + inflammatory picture in bloods (high WCC, CRP)

Symptom relief = IV fluids and antibiotics
Cholecystectomy
Removal of obstruction via ERCP

63
Q

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?

A

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

64
Q

Which oncogenic mutations is most commonly found in pancreatic adenocarcinomas?

A

KRAS (90% of cases)

65
Q

CA19-9 is a tumour marker associated with what cancer?

A

Cholangiocarcinoma

66
Q

What condition is associated with cholangiocarcinoma?

A

UC

67
Q

What is the “chain of lakes” appearance on ERCP associated with?

A

Chronic pancreatitis

Pancreatic duct has become dilated and tortuous

68
Q

What is the best test of pancreatic function?

A

Faecal elastase

69
Q

Loss of what enzyme is one of the biggest causes of the development of steatorrhea?

A

Lipase

GI (26 decks)

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