Disease of the Biliary Tree

Question 1

M/F gallstones

Answer 1

female predominance –> older people

Question 2

Cholelithiasis

Answer 2

gallbladder stones –> asymptomatic gallstones, but can cause biliary pain/cholic, can migrate out and cause choledocolithiasis (duct stones), acute cholecystitis, cholangitis, or gallstone pancreatitis

Question 3

How do you know something is a stone on imaging?

Answer 3

shadowing

Question 4

Nature of biliary colic

Answer 4

rapid onset, severe, steady pain in RUQ/epigastric w/radiation to R shoulder or scapula, duration 15 mins-several hours, not relieved by position, antacids, flatus, possible relation to fatty food intolerance

Question 5

What causes biliary colic

Answer 5

stone lodged in neck of gallbladder or at junction with common bile duct

Question 6

Tx of biliary colic

Answer 6

watch and wait for further episode of pain –> delay surgery

Question 7

Pathophysiology of acute cholecystitis

Answer 7

obstructed cystic duct + other irritant factor –> inflammatory mediator release –> inflammation +/- infection

Question 8

Presentation of acute cholecystitis

Answer 8

RUQ pain, fever, leukocytosis –> medical emergency due to gangrene, perforation, sepsis

Question 9

Pathophysiology of bacterial cholangitis

Answer 9

stasis due to biliary obstruction raises intrabiliary pressure which promotes migration and colonization of bacteria from the portal circulation into the biliary tract

Question 10

Presentation of cholangitis

Answer 10

Charcot’s triad: fever, RUQ pain, jaundice + confusion, hypotension

Question 11

Tx of cholangitis

Answer 11

antibiotics, duct clearance

Question 12

ERCP

Answer 12

endoscopic retrograde cholangiopancreatography

Question 13

Risk of MRCP vs ERCP pancreatitis

Answer 13

ERCP has a substantial risk, MRCP has 0

Question 14

Pathophysiology of gallstone pancreatitis

Answer 14

blockage at juncture of bile ducts –> leads to reflux into pancreas resulting in pressure and subsequent pancreatitis

Question 15

Higher or lower risk of gallstone pancreatitis? wide cystic duct

Answer 15

higher

Question 16

Higher or lower risk of gallstone pancreatitis? many stones

Answer 16

higher

Question 17

Higher or lower risk of gallstone pancreatitis? smaller stone

Answer 17

higher

Question 18

Should we clear asymptomatic CBD stones?

Answer 18

yes –> risk of cholangitis, pancreatitis …vs asymptomatic gallbladder stones which can stay in.

Question 19

Radiographic sign of pancreatic head carcinoma

Answer 19

double duct sign

Question 20

Antibody in PSC

Answer 20

pANCA

Question 21

Gene in PSC

Answer 21

HLA B8 (60-80%)

Question 22

PSC cholangiography findings

Answer 22

multifocal stricturing and dilation of intra/extrahepatic bile ducts (vs normal in PBC)

Question 23

Risk of cholangiocarcinoma in PSC

Answer 23

15% –> poor prognosis (10% 2 year survival)

Question 24

What should be done after an episode of cholangitis or biliary pancreatitis?

Answer 24

cholecystectomy to prevent future complications