Diseases of the Biliary Tree Flashcards
What does cholelithiasis refer to?
Stones in the gallbladder
What does choledocolithiathis refer to?
Stones in the ducts
What should you do if you see some stones in a gallbladder of an asymptomatic patient?
Leave them alone.
Describe biliary colic? (Location, radiation, duration, etc.)
Rapid onset, severe, steady RUQ pain.
Radiation to R shoulder or scapula common.
Duration >15 up to several hours.
(Provoked by fatty foods is suggestive but not specific.)
What do you do with a patient who comes in with the first occurrence of symptomatic gallstones?
Watch and wait - because the pain might never come back, and delaying surgery doesn’t cause problem.
(note - only if these stones are definitely just in the gallbladder)
What is cholecystitis?
Inflammation of gallbladder with obstructed cystic duct, +/- infection.
What is the classic presentation of acute cholescystitis? (it’s a triad)
RUQ pain
Fever
Leukocytosis
What feature on imaging is highly suggestive of cholecystitis?
Thickened gallbladder wall.
What should you do for a patient with acute cholecystitis?
Cholecystectomy right away.
Don’t just watch and wait when there’s fever and leukocytosis.
Imaging test for cystic duct obstruction?
99-Tc labeled “HIDA” radioscan….
Liver takes up stuff, should see it see fill up gallbladder. Non-filling gallbladder shows cystic duct obstruction.
Can gallstones kill you?
Yes, They can cause cholangitis that leads to sepsis.
Where do the bacteria that cause cholangitis tend to come from?
Portal circulation.
What is Charcot’s triad for cholangitis?
Fever
RUQ pain
Jaundice
(Can progress to confusion and hypotension
What’s the treatment for cholangitis?
ABx and duct clearance, usually via ERCP.
Why is MRCP preferable to ERCP if you’re just doing diagnostic imaging?
Injection of the ERCP contrast into the pancreatic duct can cause pancreatitis.
What does ERCP removal of a bile duct stone involve?
Sphincterotomy - widen the sphincter of Oddi.
Remove the stone - either grab with basket, or snake catheter past it then inflate balloon and pull out.
Most gallstone pancreatitis resolves with supportive care. But what are 2 circumstances must you do ERCP right away?
Severe acute pancreatitis.
“Evidence of ongoing biliary obstruction” (meaning… it doesn’t clear on its own.)
Even if a stone causing gallstone pancreatitis clears, what must be done later?
Cholecystectomy, because the stones will recur.
Which are more likely to cause pancreatitis: large stones or small stones in the gallbladder?
Small stones - they’re more able to get out and cause trouble.
What’s a surgical way to prevent sequelae of biliary sludge?
Sphincterotomy - make it easier for any stuff formed to get out.
Should you take out asymptomatic common bile duct (CBD) stones?
Yep.
What’s the double-duct sign?
Both CBD and pancreatic duct occluded - strongly suggestive of cancer.
What palliative treatment can be done for duct occlusions caused by malignancy?
Stents placed in the ducts.
Plastic ones can clog… self-expanding metallic stents are perhaps better.
Treatment for benign biliary strictures?
Balloon dilatation.
Say a gun shot wound causes a bile leak seen on ERCP. What’s the treatment? Why does that work?
Stent and/or sphincterotomy.
By creating a path of least resistance, bile will drain into the duodenum instead of into the peritoneum and cause peritonitis.
Review: What’s primary sclerosing cholangitis? How do you diagnose it?
Autoimmune-mediated inflammation, fibrosis, and stricturing of biliary tree.
Cholangiogram will show “beads on a string.”
Main treatments for PSC? Goal of treatment?
Ursodiol, ABx (if necessary)
Dilation, stenting.
Liver transplant
Goal = Keep patient alive until transplantation.
What do you want to rule out if you think something looks like PSC?
Cholangiocarcinoma - and note that PSC increases the risk for it.
Review: With what other autoimmune disease is PSC strongly associated?
IBD, especially UC.
