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Disorders of the Gallbladder Flashcards

1
Q

Where is bile made?

A

Liver

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2
Q

What is the flow of bile from a hepatocyte?

A
  1. Canaliculi
  2. Interlobular ducts
  3. Collecting ducts
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3
Q

What forms the Common Bile Duct?

A
  • L & R Hepatic Duct
  • Cystic Duct
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4
Q

What are the 3 parts of the gallbladder?

A
  1. Fundus
  2. Body
  3. Neck
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5
Q

What forms the triangle of Calot?

A
  1. Medial - Common hepatic duct
  2. Inferior - cystic duct
  3. Superior - inferior surface of the liver
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6
Q

What is the main purpose of the gallbladder?

A

Concentrate and store bile.

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7
Q

What stimulates the release of bile?

A
  1. Cholecystokinin (CCK) from lipids in the duodenum
  2. CCK stimulates gallbladder wall contraction and Sphincter of Oddi relaxation
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8
Q

What are the 5 functions of bile?

A
  1. Fat emulsification
  2. Absorption of fat and fat-soluble vitamins
  3. Excretion of bilirubin and excess cholesterol
  4. Alkaline fluid to neutralize acidic chyme from stomach
  5. Bactericidal activity
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9
Q

What are gallstones formally called?

A

Cholelithiasis

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10
Q

What makes up bile?

A
  • Water
  • Bile Salts
  • Cholesterol
  • Bilirubin
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11
Q

What are the effects of CCK on the GI tract?

A
  1. Gallbladder contraction
  2. Relaxation of Sphincter of Oddi
  3. Delays gastric emptying
  4. Induces digestive enzyme production in the pancreas
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12
Q

What are the 3 underlying mechanisms behind gallstone formation?

A
  1. Ratio of cholesterol too high
  2. Ratio of bilirubin too high
  3. Gallbladder not getting rid of bile enough
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13
Q

What is the MC type of gallstone?

A

Cholesterol gallstone

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14
Q

What are the risk factors for cholelithiasis?

A
  • Western diet
  • Genetics (LITH gene in native americans)
  • Women (Pregnancy or OCPs or hormones)
  • Obesity
  • Pregnancy
  • Old people
  • Rapid weight loss
  • Medical conditions (hemolytic anemias, HLD, DM, Cirrhosis, hypertriglyceridemia)
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15
Q

What may help prevent cholelithiasis?

A
  • Medi or low-carb diet
  • Exercise
  • Caffeine :) for women
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16
Q

What makes a gallstone asymptomatic?

A

Staying in the gallbladder

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17
Q

What makes cholelithiasis symptomatic/biliary colic?

A
  • Gallbladder is contracting, but it is blocking the cystic duct
  • Pain will slowly subside

Biliary colic refers to the pain caused.

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18
Q

Hallmark sign of Biliary colic?

A

RUQ pain following fatty meals that may radiate to R shoulder and is often nocturnal

30mins-hour, resolving within 6 hours

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19
Q

How do biliary colic pts appear?

A

Everything normal except pain (usually not severe enough to go to ER)

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20
Q

What is the imaging of choice for cholelithiasis?

A

RUQ Abd US

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21
Q

How do we treat biliary colic?

A
  • NSAIDs
  • TOC: Laparoscopic Cholecystectomy
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22
Q

What would cause us to treat asymptomatic cholelithiasis?

A
  • Calcified gallstone
  • Stone > 3cm in diameter
  • Patient is a native american

Prophylactic cholecystectomy

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23
Q

How soon can you recover if you have a lap chole?

A

1 day!

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24
Q

When do you treat a pregnant women with gallstones?

A

2nd trimester after conservative approach fails

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25
What is an intraoperative cholangiogram?
* XRAY of bile duct during a cholecystectomy. * Dye injected to show where the **common bile duct is to avoid injury**
26
How do you treat a non-surgical candidate with symptomatic cholelithiasis?
Ursodeoxycholic acid (bile salt PO) | Helps dissolve stones
27
What are the essentials of diagnosis for cholelithiasis?
* Usually **asymptomatic** * Classic pain is **steady severe pain in RUQ with radiation to R shoulder** * **Abd US** is imaging of choice
28
What is the MC type of cholecystitis?
**Acute calculous cholecystitis** due to gallstone becoming lodged in **cystic duct**
29
What is acute Acalculous cholecystitis and who is it MC in?
* Gallbladder **stasis & ischemia** * MC demographic: **Critically ill pts/post op after major surgery** * Secondary infection is common
30
What causes chronic cholecystitis?
* Episodic biliary colic * Progressive mechanical damage
31
What kind of demographic might have acute cholecystitis due to infection?
Immunocompromised pts
32
How does acute cholecystitis appear?
* Ill-appearing * **RUQ pain radiating to shoulder > 4-6 hours** * N/V * Fever * Tachy * **Lie still on exam table due to pain on movement** | A much sicker version of cholelithiasis. ## Footnote Note the presence of systemic symptoms vs none in cholelithiasis
33
What is Murphy's sign?
**Inspiratory pain on palpation of RUQ**, causing them to **stop their breath.** | Place fingers on RUQ
34
What labs are elevated in acute cholecystitis?
* **Leukocytosis (MC)** * Elevation of liver enzymes is **Rare**
35
How do you diagnose Acute cholecystitis?
* US showing **stone lodged at cystic duct and gallbladder thickening > 4mm** * Free fluid
36
What is the alternate version of murphy's sign?
Sonographic murphy's sign
37
What is the alternative, albeit more sensitive imaging for acute cholecystitis?
HIDA scan, which shows **obstructed cystic duct**
38
What is required for a HIDA scan?
* Injection of IV radioactive isotope tagged acid * **Nonvisualized gallbladder = positive** | It is a type of **nuclear medicine scan**, using technetium
39
What can a HIDA scan measure?
* Gallbladder EF using **injections of CCK.** * Disease = < 35% EF = lap chole | Poor EF = poor gallbladder function
40
What are the risks of a HIDA scan?
* Allergic reaction * Bruising * Radiation exposure (v smol amt) * NOT DONE IN PREGNANCY
41
What are the complications of acute cholecystitis?
1. Gangrenous gallbladder (ischemia and worsening) 2. Gallbladder perforation (late dx or failed treatment) 3. Hydrops of gallbladder (acute cholecystitis subsides but cystic duct still blocked) 4. Mirizzi syndrome (stone in neck of gallbladder causing jaundice) 5. Porcelain gallbladder (cholelithiasis + calcification of the gallbladder wall)
42
How do we treat acute cholecystitis?
1. Admit with **Zosyn OR (mid-gen cephalosporin OR cipro + metro)** 2. NPO with NG tube for vomiting 3. **IV Meperidine** (Demerol) for pain or NSAIDs 4. **Lap Chole in 1-2 days**
43
What is the new tx for higher risk acute cholecystitis pts?
Percutaneous cholecystostomy (draining the gallbladder)
44
What does choledo refer to?
Common bile duct
45
What is choledocholithiasis and the MC symptom?
* Gallstone in the **common bile duct** * RUQ pain
46
What is cholangitis?
* Gallstone **obstructing the common bile duct, resulting in infection** * Infection occurs due mainly to **E. coli**
47
What does risk of choledocholithiasis increase with?
Age
48
How does choledocholithiasis present as?
* Intermittent bilary colic * **SOMETIMES JAUNDICE** * Intermittent N/V * Epigastric tenderness
49
What labs are typically elevated in choledocholithiasis?
* Early: AST/ALT * Later: ALP and Gamma-glutamyl transpeptidase (GGT) * Hyperbilirubinemia
50
What would make us suspect **choledocholithiasis OVER cholelithiasis**?
* **Elevation of liver enzymes** with RUQ pain | Cholelithiasis usually has no liver enzyme elevation.
51
What is the imaging of choice for choledocholithiasis?
Transabdominal U/S showing CBD dilation
52
What is the **treatment of choice for Choledocholithiasis?**
ERCP with sphincterotomy + stone extraction/stent replacement + cholecystectomy
53
What would suggest only intermediate risk of choledocholithiasis?
* Abnormal LFTs * Age > 55 * Dilated CBD on US (but **no stone visualized**)
54
How do we confirm intermediate risk choledocholithiasis?
* **MRCP or Endoscopic US** * If stone present: ERCP * If stone absent: Lap Chole
55
Presence of what in choledocholithiasis indicates need for ERCP?
**Must have a stone present obstructing** the CBD.
56
What causes acute cholangitis and the MC organism?
Infection by **E. coli** from duodenum during CBD obstruction
57
How does the gallbladder protect itself from infection?
1. Sphincter of Oddi 2. Flushing via bile 3. Bile Salt bactericidal activity
58
What is the charcot triad and reynolds pentad for acute cholangitis?
1. **RUQ pain** 2. **Fever** 3. **Jaundice** 4. Hypotension 5. AMS | First 3 are the Charcot Triad
59
What labs are elevated in cholangitis?
* Leukocytosis * CRP * Minor LFT elevations * PTT increased
60
What is the **most accurate and diagnostic imaging** for cholangitis?
ERCP | US is initial
61
What is the primary complication from ERCP?
Acute Pancreatitis
62
What is the diagnostic criteria of acute cholangitis?
* Evidence of systemic inflammation via fever/chills OR lab evidence of inflammation * Evidence of cholestasis via elevated bilirubin of >= 2 or abnormal LFTs > 1.5x ULN * Imaging with dilation or presence of stone/stricture/stent | All 3!
63
How do we treat acute cholangitis?
* Admit ASAP * **ERCP within 48 hours** * Lap Chole **after ERCP** * Mild-mod: Cipro + metro * Severe (organ damage): Zosyn + Metro
64
A 42 y/o female presents to the ED with severe RUQ pain x 12 hours, N/V, and fever. Physical examination is normal except for a positive Murphy’s sign. A gallbladder U/S reveals the presence of multiple large gallstones in the cystic duct and gallbladder wall thickening. Laboratory studies, including a hepatic panel, are normal except for a mildly elevated WBC. Which of the following is the most likely diagnosis?
Acute Cholecystitis
65
A 42 y/o female presents to the ED with severe RUQ pain x 12 hours, N/V, and fever. Physical examination is normal except for a positive Murphy’s sign. A gallbladder U/S reveals the presence of multiple large gallstones in the cystic duct and gallbladder wall thickening. Laboratory studies, including a hepatic panel, are normal except for a mildly elevated WBC. What is the best management plan for her?
* Admit * IV fluids, pain meds, ABX * Lap chole in 24-48hrs | Acute cholecystitis
66
A 62 year old male patient presents to the ER with severe RUQ pain. He states it started about 18 hours ago and has been worsening. He admits to vomiting, but denies diarrhea. On exam, you notice RUQ pain, fever and chills, and a yellow tint to the skin and sclera. You perform an abd. US and notice CBD dilation greater than 6mm. What does he have?
Acute cholangitis, given presence of Charcot's triad and confirmed imaging. Technically need a lab value proving cholestasis?
67
A 62 year old male patient presents to the ER with severe RUQ pain. He states it started about 18 hours ago and has been worsening. He admits to vomiting, but denies diarrhea. On exam, you notice **RUQ pain, fever and chills, and a yellow tint to the skin and sclera.** You perform an abd. US and notice **CBD dilation** greater than 6mm. Next step?
ERCP due to Charcot's triad, aka he probably has acute cholangitis
68
First and second-line imaging for acute cholecystitis?
1. Abdominal US 2. HIDA scan
69
What condition is primary sclerosing cholangitis MC due to?
Ulcerative colitis (IBD in general)
70
Who is primary sclerosing cholangitis MC in?
Men 20-50
71
What is primary sclerosing cholangitis?
* Fibrosis * Strictures of biliary system * **Immune response to endotoxins**
72
What things may help with primary sclerosing cholangitis?
* Coffee = decreased risk * Statins = better outcomes
73
How does primary sclerosing cholangitis present?
1. Asymptomatic 2. Obstructive jaundice 3. Progressive jaundice 4. Pruritis 5. Fatigue, anorexia, indigestion 6. Hepatosplenomegaly | Progressive condition
74
What labs are elevated in primary sclerosing cholangitis?
* Elevated AST/ALT, hyperbilrubinemia, and ALP * Hypergammaglobulinemia * IgM * P-ANCA
75
What is the preferred imaging for primary sclerosing cholangitis?
MRCP showing **beads on a string** | ERCP if it is inconclusive ## Footnote Dilation and stricture pattern
76
What is the **last resort imaging** for primary sclerosing cholangitis?
Liver biopsy showing **onion skin**
77
What are the essentials of diagnosis for primary sclerosing cholangitis?
* Men 20-50 * Ulcerative colitis (also more common in men) * Progressive jaundice, itching, and cholestasis * Characteristic cholangiographic findings (MRCP: beads on a string) * Increased risk of cholangiocarcinoma
78
What usually causes death in primary sclerosing cholangitis?
Cirrhosis/Liver failure
79
How do you treat primary sclerosing cholangitis?
* **Symptomatic treatment only and management only** * **Cipro** for acute episodes * **Ursodeoxycholic acid under testing** * ERCP for dilation and stents | Incurable disease with prognosis of 9-17 yrs :(
80
What is the **most common** carcinoma of the biliary tract and the **most deadly**?
* MC: Gallbladder cancer * Most deadly: **Cholangiocarcinoma (bile ducts)**
81
What are the typical co-existing factors in gallbladder carcinoma?
* Chronic infection with **salmonella typhi** * Polyps * Calcification (Porcelain gallbladder)
82
When is cholangiocarcinoma MC in?
50-70
83
Where is cholangiocarcinoma specifically MC in?
Confluence of the hepatic ducts (2/3) as a klatskin tumor/hilar ## Footnote Other locations are common bile duct and intrahepatic ducts
84
What 3 conditions is cholangiocarcinoma more common in?
* Primary sclerosing cholangitis * Biliary cirrhosis (chronic obstruction) * Immunocompromised states
85
What is the first sign of carcinoma of the biliary tract?
**Progressive jaundice**
86
Which of the cancers is RUQ pain more associated with?
Gallbladder carcinoma
87
What is a courvoisier sign?
Distended, palpable gallbladder
88
What PE findings are seen in carcinoma of the biliary tract?
* RUQ tenderness * Hepatomegaly * Courvoisier sign * Ascites (biliary cirrhosis)
89
What labs are elevated in carcinoma of the biliary tract?
* LFTs * **CA 19-9** * Hyperbilirubinemia
90
How do you diagnose carcinoma of the biliary tract?
* ERCP with biopsy * US guided percutaneous biopsy | AKA u need a biopsy
91
How do you treat **non-resectable carcinoma** of the biliary tract?
Roux-en-y-hepaticojejunostomy ## Footnote Bypasses bile duct, so digestive juices go from liver to jejunum. (hepatico => jejuno)
92
How is cholangiocarcinoma typically treated?
**Palliative treatment.** It is rarely resectable.

GI (17 decks)

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