clin med- third set lectures Flashcards
Cystic duct comes from:
gallbladder
Common hepatic duct comes from:
liver
Common bile duct consists of:
Cystic and Common Hepatic duct joining.
The Common bile duct then empties into duodenum thru sphincter of Oddi
What organ does the Common bile duct pass thru before it empties into duodenum?
Pancreas
Who makes bile?
Liver
then stored and concentrated in the Gallbladder
Function of bile
Digest/absorb fats
Vehicle to excrete: bilirubin, extra cholesterol, and met byproducts
inflammation of the BILE DUCTS
Cholangitis
Inflammation of the Gallbladder
Cholecystitis
Stones in the Gallbladder
Cholelithiasis
Stones in the Common Bile Duct
CholeDOCHOlithiasis
Disruption of bile flow
Cholestasis
The Four F’s of Cholelithiasis (Gallstones)
Risk factors
Female
Fluffy
Forty
Fertile
Also: Pregnant, Estrogen use, Rapid weight loss, Fam hx/genetics, DM
What type of stone is most common?
Cholesterol
other types: Pigment, Black pigment (underlying hemolytic anemia), Brown pigment (bacterial infection)
Do most gallstone pts have sx?
NO
If they do, Biliary colic and possibly leading to Gallstone related complications
Test of choice for Cholelithiasis (gallstones)
US
Do you have to treat Gallstones if you have no sx?
No, UNLESS:
- increased risk of GB CA
- Hemolytic disorder
Uncomplicated Gallstone dz
Biliary colic in the absence of complications
Biliary colic
NO gallbladder inflammation
Gallbladder contracts forcing stone/sludge against GB outlet or duct opening, increased pressure–> pain, pain slowly subsides as gallbladder relaxes
Biliary colic sx
RUG or epigastric pain radiates to R shoulder blade
constant and steady
at least 30 min, often peak at 1 hour
post-prandial
Other sx with Biliary colic
n/v
diaphoresis
unchanged by movement
Nocturnal pain common (awakes pt from sleep)
Biliary colic PE
NO FEVER or tachy
vitals normal
no jaundice
Negative murphys
Basically, everything is normal besides
POSSIBLE RUQ or EPIGASTRIC tenderness
Biliary colic
order labs and US
labs: normal
US: expect Gallstones or Sludge
If pt has Stones and Biliary colic
Cholecystectomy recommended
Functional Gallbladder disorder
gallbladder DYSMOTILITY
Biliary type pain but NO stones, sludge, or dz
Normal labs, Normal imaging
Functional Gallbladder disorder dx
look at Ejection Fraction via HIDA scan
Diagnosis of exclusion
HIDA scan tells Ejection Fraction
CCK given to stimulate gallbladder contraction, if ejection fraction is <35-40%
Considered LOW
Supports dx of Functional gallbladder dz
Rome 4 Criteria required for Functional GB dz
Biliary Pain
Absence of stones or other structural path
Supportive:
Low EF, Normal liver enzymes
Biliary colic type pain must last at least
30 minutes
Tx for Functional gallbladder dz if EF <40
Cholecystectomy
Complicated gallstone dz
Cholecystitis
CholeDOCHOlithiasis
Acute cholangitis
Acute calculous cholecystitis
acute inflammation of gallbladder
usually a COMPLICATION from a STONE
What does Acalculous vs Calculous cholecystitis mean?
Acalculous: no obstruction
Calclous: occurs in the setting of Cystic duct obstruction
Starts with biliary pain that prog worsens
Prolonged >4-6 hours, steady, severe, RUQ or epigastric pain
FEVER
sx of Acute calculous Cholecystitis
can also have n/v, anorexia, radiating to r shoulder, often hx of fatty food eating
PE of Acute calculous cholecystitis
FEVER, tachy Ill appearing Lying still Guarding \+ Murphy's sign
Acute calculous Cholecystitis labs
+Leukocytosis w left shift
anytime we see “itis”, have an elevated WBC
Elevated AMYLASE usually associated w
Pancreatitis
If Total Bili and Alk Phos (ALP) are elevated, we should be concerned about
Cholangitis
Choledocholithiasis
both of which can result in Biliary obstruction
Dx Acute calculous cholecystitis
US preferred initial
Can progress to HIDA if above not helpful
+ “Sonographic Murphy’s sign”
US tech produced Murphy’s pain while obtaining the US
Most common Complication of acute calculous cholecystitis
Gangrene
Acute calculous cholecystitis tx
Admit, NPO, IVF, Pain meds, IV empiric Abx
Mainstay: CHOLECYSTECTOMY
Gallbladder inflammation
Leukocytosis
RUQ pain
Fever
Acute Cholecystitis
Acute ACALCULOUS Cholecystitis
Acute necro-inflammatory dz of gallbladder in ABSENCE of stones
High morbidity/mortality
Pathogenesis of Acute ACALCULOUS cholecystitis
gallbladder stasis/ischemia –> local inf response
secondary bacterial infection is common
perforation in severe cases
Acute ACALCULOUS cholecystisi
Hospitalized and Critically ill people
may have sepsis or jaundice
Suspect Acalculous cholecystitis in
Critically ill, sepsis without clear source of jaundice
Post op jaundice
Acalculous Cholecystitis tx
Start Abx
Cholecystectomy vs Gallbladder drainage
Choledocholithiasis
Gallstones in Common bile duct
incidence increases w age
JAUNDICE if blocking flow of bile
Biliary type pain and JAUNDICE
Vitals normal
RUQ /epigastric pain
Courvoiser sign (palpable gallbladder)
be thinking CholeDOCHOlithiasis
stone in common bile duct
Choledocholithiasis labs
early vs late dz
early: elevated ALT and AST
late: elevated Bili, ALP, and GGT
for Choledocholithiasis, if US is not helpful, next consider
MRCP or Endoscopic US
What is the test to CONFIRM Choledocholithiasis (common bile duct stone)
MRCP
Tx of Choledocholithiasis
ERCP is therapeutic and diagnostic !!
Cholecystectomy to follow if appropriate
Acute cholangitis
Charcot’s triad:
Fever
RUQ pain
Jaundice
Bacteria ascending from duodenum can cause
Acute cholangitis
“pus under pressure” surgical emergency
Reynold’s Pentad
like Charcot triad, but more
+ AMS and Hypotension
Reynold’s Pentad
Fever RUQ pain Jaundice AMS Hypotension (low BP)
High morbidity and mortality
Acute cholangitis Labs
Leuk w/ left shift
Elev CRP/ESR
Evidence of cholestasis: elevated Bili, ALP, GGT, maybe AST/ALT
Serum amylase/lipase can be 3-4x elevated (associated pancreatitis)
Acute cholangitis tx
Admit
Monitor/tx for Sepsis
(EMPIRIC ABX)
Emergent consult w GI and Surgery
ERCP !!!
Acute cholangitis procedural tx
ERCP w/Sphincterotomy and stone extraction
Cholecystectomy after prn
Progression of gallbladder dz, increasing severity
A-sx gallstones Sx gallstones Acute cholecystitis Chole-docholithiasis Acute Cholangitis
Tx for Gallstones and Acute cholecystitis
Cholecystectomy
with cholecystitis, add abx
Tx for Choledocho and Acute cholangitis
ERCP w/stone extraction
For acute cholangitis, add Abx
PBC: Primary Biliary Cholangitis
Women 30-65 YO
AUTOIMMUNE destruction of bile ducts in the Liver which cause Cholestasis
Sx of PBC
Fatigue and Pruritis most common
Also, RUQ discomfort, skin hyperpigmentation, hepatomegaly, xanthomas, jaundice
Assoc w other autoimmune dz
Autoimmune dz
be thinking of PBC- Primary Biliary Cholangitis
PRURITIS and FATIGUE
PBC and PSC
Elevated ALP
AMA !!!***
Hyperlipidemia may be strikingly elevated
Primary Biliary Cholangitis
AMA is a serologic hallmark of PBC
Tx of PBC Primary Biliary Cholangitis
Refer to GI
Meds
Treat complications
PSC Primary Sclerosing Cholangitis
Sclerosing, inflammatory, obliterative process involving Biliary tree
Chronic, progressive disorder
unknown etiology
Higher incidence in MEN age ~40
Strong association with IBD (specifically ulcerative colitis)
Primary Sclerosing Cholangitis
PSC
Men 40 YO
assoc w IBD (Ulcerative colitis)
Complications of Primary Sclerosing Cholangitis
Cholestasis
End stage liver dz
Hepatobiliary CA
Colon CA
Cholestatic pattern of liver labs
Elevated ALP, GGT, and Bili
PSC primary sclerosing cholangitis labs
Elevated ALP, GGT, and Bili (cholestatic pattern)
but negative AMA
What will you see on ERCP or MRCP with Primary sclerosing cholangitis?
Multifocal strictures and dilation of bile ducts
Tx of PSC
Meds
Treat complications
Gilbert syndrome
Teen men (post puberty) Unconjugated hyperbilirubinemia
Intermittent jaundice
Gilbert syndrome
Deficiency in enzyme for Glucuronidation
NO hemolysis (CBC and other blood labs are normal)
Presentation of Gilbert syndrome
Teen males
INTERMITTENT jaundice
Triggers: dehydration, fasting, menses
No specific tx
Gallbladder CA
Most common CA of biliary tract
HIGHLY FATAL
often found incidentally
Risk factors for GB CA
Porcelain bladder
Cholangiocarcinoma (bile duct CA)
Arise from Epithelial cells of bile ducts
CA that has jaundice, pruritis, Courvoiser sign
Cholestatic pattern labs
Cholangiocarcinoma
Ampullary CA
Ampulla of Vater (right where it empties into duodenum)
Increased inc w FAP and HNPCC
CA with these sx: Obstructive jaundice, occult GI bleed, microcytic anemia, abd pain
Ampullary CA
blocking where the GB usually empties into duodenum
