Disorders of the Biliary Tract - Exam 4 Flashcards
What are the 2 components of the common bile duct?
common hepatic duct and cystic duct
**What are the components of the Calot’s triangle? Why is it important clinically?
Medial-common hepatic duct
Inferior-cystic duct
Superior-inferior surface of the liver
important to verify in a lap chole to take into account any anatomical variation and allow cystic duct/artery to be delineated
What is the main function of a gallbaldder?
concentrate and store bile that is produced in the liver
to release bile after a meal that contain fats
What is the physiology of bile? The presence of lipids in the duodenum stimulates the release of _____ which in turn stimulates ______ and relaxation of ______
cholecystokinin (CCK)
gallbladder wall contraction
Sphincter of Oddi
Where does bile get released? Then where does it go?
release of the bile into the cystic duct and common bile duct
Bile then flows into the second part of the duodenum and causes emulsification of large fat droplets into small ones (Micelles)
What are the 5 main functions of bile?
- Aids in the digestion of fat via fat emulsification
- Absorption of fat and fat-soluble vitamins
- Excretion of bilirubin and excess cholesterol
- Provides an alkaline fluid in the duodenum to neutralize the acidic pH of the chyme that comes from the stomach
- It provides bactericidal activity against microorganisms present in the ingested food
What 4 things are in bile? What is the highlighted one?
Water
**Cholesterol
Bile Salts
Bilirubin
_______ A hormone which is secreted by cells in the duodenum and stimulates the release of bile into the intestine and the secretion of enzymes by the pancreas. What is an additional role?
Cholecystokinin (CCK)
inhibits gastric emptying and also acts a hunger suppressant. stimulates bile production in liver
What is the effect of CCK on the GI tract?
Cholecystokinin is secreted by I-cells in the small intestine and induces contraction of the gallbladder
Relaxes the sphincter of Oddi, increases bile acid production in the liver
Delays gastric emptying
Induces digestive enzyme production in the pancreas.
Gallstones form as a result of what 3 processes?
Ratio of cholesterol too high
Ratio of bilirubin too high
Gallbladder not emptying bile enough
What are the 2 different types of gallstones? Which one is the MC?
Cholesterol gallstones - m/c
Calcium Bilirubinate (pigmented) gallstones
What is the technical name for gallstones? Are they MC in men or women?
Cholelithiasis
MC in women, think excess estrogen from pregnancy, hormone replacement and OCPs
A ____ diet and a ____ diet as well as physical activity and cardiorespiratory fitness may help prevent gallstones. _____ appears to protect gallstones in women
low-carb
Mediterranean
caffeinated coffee
What is another name for biliary colic? What is happening?
Symptomatic Cholelithiasis
Gallbladder contracts in response to stimulation, forces gallstones to move blocking the cystic duct
**What is the hallmark symptom for biliary colic? **What is important to note about the pt’s appearance? **Where does the pain often radiate?
**RUQ pain
**Pt do NOT appear ill, just intense, dull discomfort, often associated with diaphoresis, nausea and vomiting that is usually constant often followed by a fatty meal
**may radiate to the RIGHT shoulder blade
**What is the time frame associated with a biliary colic attack? **How long is the total attack?
The severe pain lasts about 30 minutes
Plateaus in an hour, total attack about 6 hours
usually episodic!
What will the lab results be like in cholelithiasis? Will the pt have any guarding?
Lab results generally wnl:
Cbc, LFTs, amylase/lipase, alkaline phosphatase
NO GUARDING!
**What is the imaging of choice for cholelithiasis?
Abdominal Ultrasound (RUQ)
What is the tx of choice for cholelithiasis? _____ are given for pain control
Laparoscopic Cholecystectomy
NSAIDs for pain control
Do you need to treat asymptomatic cholelithaisis?
NOPE!
When do you need to do prophylactic cholecystectomy in asymptomatic cholelithaisis?
gallbladder is calcified
stones 3cm or greater in diameter
or the patient is a Native American (d/t higher rate of cholesterol stones)
When can cholecystectomy be preformed in a pregnant person?
can be performed in 2nd trimester preferably in pregnant women after conservative approach fails for repeated attacks
threat of harm during 1st semester, DO NOT DUE IN FIRST TRIMESTER
What is the surgeon actively trying to avoid damaging when preforming an lap chole?
common bile duct
What is the pharm tx for cholelithiasis if pt is NOT a surgical candidate? What is it?
Ursodeoxycholic acid (Ursodiol, Actigall)
bile salt given PO for up to 2 years and helps to dissolve cholesterol stones
What are the 3 different types of cholecystitis?
- Acute Calculous Cholecystitis
- Acute Acalculous Cholecystitis
- Chronic Cholecystitis
______ is due to gallstones and with a sudden, severe onset. What is the MC cause?
Acute Calculous Cholecystitis
stones becomes lodged in cystic duct
______ results from gallbladder stasis and ischemia, which then causes a local inflammatory response in the gallbladder wall. When is it commonly seen? What secondary infection is common?
Acute Acalculous Cholecystitis
Generally seen in critically ill patients/post op after major surgery
E. coli
________ result of mechanical irritation or recurrent attacks of acute cholecystitis.
Episodes of biliary colic. Stone becomes lodged, inflammation of gallbladder develops, stone moves, symptoms resolve
chronic cholecystitis
What is the MC cause of acute cholecystitis? What happens next?
> 90% d/t gallstones
Stone becomes impacted at cystic duct, causes inflammation, inflammatory mediators are released in response
have the potential to get infected if the pt is immunocompromised
What is the common presentation for acute cholecystitis? **Where is the pain located? **How long will the pain be present?
**ILL APPEARING
RUQ pain: that will be steady, sharp and severe pain that is precipitated by fatty meal
**May present as epigastric or shoulder blade pain
** >4-6hrs, up to 18, lasts LONGER than 6 hours
Will the pt want to move in acute cholecystitis? Will there be guarding present?
the pt will NOT want to move
GUARDING WILL BE PRESENT
What is murphy sign?
Inhibition of inspiration by pain on palpation of RUQ
Ask pt to inspire deeply, which makes gallbladder descend toward and press against examining fingers leading to discomfort
Associated with muscle guarding and rebound tenderness
aka pain on inspiration
What will the lab findings be in acute cholecystitis?
Leukocytosis with left shift
elevated serum bilirubin, Aminotransferases, Alkaline Phosphatase are NOT COMMON
____ is the first line imaging in acute cholecystitis. What will it show?
Ultrasound
Stone lodged at cystic duct
Gallbladder wall thickening
Greater than 4-5mm
What is sonographic murphy’s sign?
similar to abdominal palpation except use an US probe so you can indeed verify that the source of the pain is the gallbladder
_____ is used in acute cholecystitis if US is inconclusive. more _____. What is a very good at showing?
HIDA scan
sensitive
Useful in showing an obstructed cystic duct
What is a HIDA scan? What is generically going on during the procedure? What are you looking for?
Hepatobiliary Iminodiacetic Acid Scan (Cholescintigraphy)
IV injection of Technetium-labeled iminodiacetic acid
liver takes up the dye, then watch move to gallbladder (15-30 minutes), biliary ducts, & duodenum (60 minutes)
watch for filling defects
What does a nonvisualized gallbladder indicate on a HIDA scan?
acute cholecystitis
HIDA scan can also measure _______. How does it work? What is considered normal? What is considered gallbladder disease?
gallbladder ejection fraction
Cholecystokinin (CCK) is injected which stimulates contraction of the gallbladder
Normal is considered 35-75%
< 35% is indicative of gallbladder disease
What do you do if the gallbladder ejection fraction on HIDA scan is found to be less than 35%?
Indication for cholecystectomy
What are indications for a HIDA scan?
and inconclusive US
Is a HIDA scan safe in pregnancy? What is the pt education?
HIDA scan NOT safe in pregnancy
fast for 4 hrs before - can have clear liquids
need current list of medications
What are the 5 complications of acute cholecystitis?
Gangrenous Gallbladder
Gallbladder perforation
Hydrops of the gallbladder
Mirizzi syndrome
Porcelain gallbladder
______ results when acute cholecystitis subsides but cystic duct obstruction persists producing distention of the gallbladder with a clear mucoid fluid
Hydrops of the gallbladder
______ stone in neck of gallbladder may compress common hepatic duct and cause jaundice. Seen as one of the five complications of acute cholecystitis
Mirizzi syndrome
______ calcification of gallbladder wall due to chronic inflammation due to gallstones which results in scarring and calcification
Porcelain gallbladder
What is this?
porcelain gallbladder
What is the tx for acute cholecystitis?
ADMIT!!
IV Piperacillin/Tazobactam (Zosyn) OR
2nd or 3rd generation Cephalosporin or Cipro + metronidazole
NPO, IV fluids
IV meperidine or NSAIDs
lap cholecystectomy within 24- 48 hours
What is the new tx for acute cholecystitis? Who is commonly used on?
Percutaneous cholecystostomy
Drainage under radiologic guidance via a percutaneous cholecystostomy tube
Decompressing the gallbladder allows both local inflammation and systemic illness to resolve. Tube left in place until resolved
high risk pts: elderly and dm
What is choledocolithiasis?
occurs when gallstones are present in the common bile duct
What is considered “uncomplicated” Choledocholithiasis? What is the MC symptom?
passes on their own
RUQ pain
What is cholangitis?
gallstones becomes lodged and causes obstruction in common bile duct and then become infected!
What is the MC pathogen to cause cholangitis? From what location?
E. Coli
ascend from the duodenum
About ____ of patients with symptomatic gallstones will develop choledocolithiasis. Risk increases with _____
15%
risk increases with age
Intermittent biliary colic symptoms (RUQ pain);
severe and persists for hours
Jaundice (sometimes without pain)
Intermittent N/V
Epigastric tenderness
What am I?
Choledocholithiasis
aka RUQ pain WITH jaundice
in choledocholithiasis, _____ typically elevated early in course. Followed by ______, ______ and ______
AST/ALT
Alkaline Phosphatase, Gamma-glutamyl Transpeptidase
______ is another enzyme found in liver that raises in response to liver damage/bile duct damage
GGT
Patients are often suspected of having _______ when they present with RUQ pain with elevated liver enzymes with elevation of alkaline phosphatase, gamma-glutamyl transferase, and bilirubin. What is the imaging of choice?
choledocholithiasis
transabdominal U/S first
What will an US show in Choledocholithiasis? Where is NOT good for visualization? Why?
Will show CBD dilation and impaired flow with stones
Has poor sensitivity for stones in the distal CBD
b/c distal CBD is often obscured by bowel gas in imaging field
What is the tx of choice for Choledocholilithiasis?
ERCP with sphincterotomy and stone extraction/stent replacement
Choledocholilithiasis with _______, _______ and or should go directly to ERCP with cholecystectomy
Acute Cholangitis
Hyperbilirubinemia (>4mg/dL) and CBD dilation
> 50% chance of CBD stone
What are the 3 factors that qualifies as an intermediate risk for Choledocholilithiasis? What is the next step?
Abnormal LFTs
Age >55
Dilated CBD on US
Go to MRCP or EUS for confirmation
stone present: ERCP
no stone present: laparoscopic cholecystectomy
What is cholangitis? What is the MC pathogen?
inflammation in the bile duct caused by bacterial infection in pt with CBD obstruction
e. coli
think stasis which leads to infection
**What is Charcot triad? **What dz is it associated with? Is it considered a medical emergency?
RUQ Pain
Fever (and chills)
Jaundice
acute cholangitis
YES! medical emergency
**What is Reynolds Pentad? What does it indicate?
RUQ Pain
Fever
Jaundice
Hypotension
Mental Status Change
acute suppurative severe cholangitis
What will the PE show on a pt with cholangitis?
RUQ tenderness
Hepatomegaly possible
What are the diagnostic imaging in cholangitis? What will it reveal? **What is the diagnostic procedure of choice in acute cholangitis?
US/CT
reveal stones and dilated ducts
ERCP
______ is a complication associated with ERCP. Why?
Pancreatitis
d/t mechanical injury of pancreatic duct and hydrostatic injury from contrast injection
What is the dx criteria for cholangitis?
need ONE of the following:
●Fever and/or shaking chills.
●Laboratory evidence of an inflammatory response (abnormal white blood cell count, increased serum C-reactive protein, or other changes suggestive of inflammation).
AND BOTH of the following
●Evidence of cholestasis: Bilirubin ≥2 mg/dL or abnormal liver chemistries (elevated alkaline phosphatase, gamma-glutamyl transpeptidase, alanine aminotransferase, or aspartate aminotransferase, to >1.5 times the upper limit of normal).
●Imaging with biliary dilation or evidence of the underlying etiology (eg, a stricture, stone, or stent).
What are the complications of cholangitis?
liver damage: cirrhosis and liver failure if left untreated
septic shock
What is the tx for cholangitis? **What is the procedure of choice? What is the pt still have gallbladder?
ADMIT!!!
IV fluids, pain control, NPO
**ERCP with stone extraction & sphincterotomy is the procedure of choice for Acute Cholangitis within 48 hours
lap chole AFTER the ERCP
What abx is given in mild/moderate cholangitis? Severe? What differenitiates mild/mod from severe?
mild/mod: Cipro plus Metronidazole (Flagyl)
severe: IV Zosyn plus Flagyl
organ damage equals severe
________ is Chronic inflammatory disease of the biliary tract. What does it result from?
Primary Sclerosing Cholangitis
Results from increased immune response to intestinal endotoxins
**What other dz is Primary Sclerosing Cholangitis associated with? Who is the MC pt type?
UC and Crohns but more so with ulcerative colitis
men age 20-50, some hereditary component
What does Primary Sclerosing Cholangitis eventually lead to?
Inflammation can lead to obstructive symptoms and cholestasis, fibrosis, and strictures of biliary system
_____ and _____ are helpful in primary sclerosing cholangitis
coffee consumption and statin use
Asymptomatic phase
Obstructive jaundice
Progressive jaundice
Pruritus
Fatigue, anorexia, indigestion
Hepatomegaly/splenomegaly
What am I?
primary sclerosing cholangitis
What are some common lab findings seen with primary sclerosing cholangitis?
What is the diagnostic imaging you should order for primary sclerosing cholangitis?
MRCP
can due ERCP if MRCP is inconclusive
**What is the MRCP finding consistent with primary sclerosing cholangitis?
MRCP: “beads on a string”
What will a detailed report show that is consistent with Primary Sclerosing Cholangitis?
The inflammation of the ducts show irregularity and tortuosity of ducts along with multifocal structuring
Segmental fibrosis with saccular dilatations between areas of stricture
In primary sclerosing cholangitis, if the MRCP/ERCP is inconclusive, what do you do next? **What will it show?
liver biopsy
Periductal fibrosis “onion skinning”
What are the essentials of diagnosis for primary sclerosis cholangitis?
What are the complications of primary sclerosing cholangitis?
Cirrhosis/Liver Failure: Ultimate cause of death
Cholangiocarcinoma (10%)
Cholelithiasis, Cholecystitis
Acute Cholangitis
What is the tx for primary sclerosing cholangitis?
no cure!!!
cipro for acute episodes, variety of immunosuppresives and anti-inflammatory agents have been studied
ERCP with dilation and stenting
liver transplant if advanced sz
have the potential to advance to cancer
What is the prognosis in PSC? What is the health maintenance?
9 - 17 years from onset of diagnosis
some have argued for annual screening with imaging studies (MRCP) and a serum CA 19-9
______ is the MC cancer of the biliary tract. _____ is the most deadly
Carcinoma of the gallbladder - most common
Cholangiocarcinoma (bile ducts) - most deadly
What are the 3 co-exisitng factors for gallbladder carcinoma? Where does it often invade next?
-Chronic infection of gallbladder (Salmonella typhi)
-Gallbladder polyp (growths that protrude from lining of gallbladder); can be cancerous, but rare
-Calcification of the gallbladder (porcelain gallbladder)
liver
Where does cholangiocarcinoma most commonly arise? What is a Klatskin tumor? What age range?
⅔ arise at confluence of right and left hepatic ducts, then 1/4 in common bile duct, then intrahepatic duct
hilar cholangiocarcinoma
50-70 years old
Will find increased incidences of Cholangiocarcinoma with what 3 things?
Primary sclerosing cholangitis
Biliary cirrhosis (chronic obstruction)
immunocompromised states
Progressive jaundice
RUQ pain/tenderness
Anorexia, weight loss
Acute cholangitis commonly develops
Pruritus
fever
chills
hepatomegaly
distended, palpable gallbladder
ascites
What am I?
**What is often the first sign? Especially in _____
Carcinoma of the Biliary Tract
progressive jaundice
Esp. in Cholangiocarcinoma
What is the Courvoisier sign?
painless jaundice with palpable gallbladder
What are common labratory findings with carcinomas of the biliary tract?**What is required for dx?
Elevated LFT’s
Elevated CA 19-9
Hyperbilirubinemia
ERCP with biopsy or US guided percutaneous biopsy required for diagnosis
What is the tx for biliary tract carcinomas? What if the tumor is unresectable?
sx: curative if well localized
Biliary-enteric bypass surgery (roux-en-Y hepaticojejunostomy)
What is a brief description of the Roux-en-Y procedure?
Biliary stent placement helps reduce stricture at the anastomosis. Once stent has been positioned, the small bowel is divided and distal small bowel brought up and sutured to the bile duct. An end-to-side bowel-bowel anastomosis completes the reconstruction.
Bypasses the bile duct to allow digestive juices to drain from liver directly to jejunum
