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GI > disorders of the gallbladder and biliary tract > Flashcards

disorders of the gallbladder and biliary tract Flashcards

1
Q

Which way does blood flow in the liver? Bile?

A

Blood flows from portal veins–>central vein

Bile flows from the central vein–>bile ducts

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2
Q

Which zone is first affected by toxic injury? ischemia?

A

Zone I: portal area = toxic injury

Zone 3: central vein = ischemia

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3
Q

What are sinusoids?

A

fenestrated capillaries allowing macromolecules in blood to contact hepatocytes through the space of Disse

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4
Q

What prevents bile from exiting the bile canaliculus in between the hepatocytes and accessing the sinusoids?

A

tight gap junctions

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5
Q

Bile secretion i an active process. What does it depend on?

A
  1. microvilli
  2. cytoskeleton
  3. interaction of bile with secretory apparatus
  4. Permeability of bile canaliculus
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6
Q

What is the only mechanism for cholesterol excretion?

A

bile

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7
Q

What is in bile?

A 
bile salts
phospholipids
cholesterol
bilirubin
ions
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8
Q

What is a conjugated bile acid?

A

Adding an AA (glycine or taurine) to a bile acid which makes is amphiphilic

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9
Q

Where does bilirubin come from? How is it conjugated?

A

80% of bilirubin comes from erythrocytes. Glucoronyl transferase adds a glucoronic acid to conjugate it.

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10
Q

What do the ducts and ductules do?

A

Modify the bile by adding HCO3 and water

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11
Q

What is the purpose of the gallbladder?

A

Concentrates the bile

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12
Q

What elements are concentrated in the gallbladder?

A

Na
Bile acid
pH

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13
Q

Why do you need an acidic pH for the gallbladder?

A

Otherwise, CaCO3 will precipitate

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14
Q

What do the bile salts form? Why is this essential?

A

Micelles. These are essential for digestion, transport, and absorption of fat soluble vitamins (ADEK)

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15
Q

What is contained in micelles? Vesicles?

A

Micelles: bile acid+cholesterol+phospholipids
Vesicles: cholesterol+phospholipids

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16
Q

What factors can cause gallstone formation?

A
  1. Increased cholesterol, with decreased bile acids and phospholipids in the gallbladder
  2. Decreased contractility of the gallbladder
  3. High pH
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17
Q

What are the actions of cholescystokinin on the gallbladder?

A
  1. Gb contraction
  2. Sphincter relaxation
  3. Release of pancreatic enzymes
  4. Inhibition of gastric emptying
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18
Q

What is the total bile flow/day?

A

600 ml/day.
450mL=bile salts
150mL=water/salts from the ducts

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19
Q

What are the main functions of bile?

A

Fat digestion
Absorption of fat soluble vitamins
Cholesterol waste elimination

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20
Q

Which portion of the digestive system has lots of micelles?

A

jejunum/ileum

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21
Q

Where are most of the bile acids resorbed back into the blood?

A

Within the ileum (95%)

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22
Q

What are the names of the secondary bile acids? What produces them?

A

deoxycholate

lithocholate

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23
Q

How much of bile acids arrive in the colon?

A

1%

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24
Q

What would cause a rise in unconjugated bili (indirect), generally?

A
  1. Overproduction of bili
  2. Defective uptake
  3. Defective conjugation
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25
Q

What would cause a rise in conjugated (direct) bili?

A

defective excretion of bilirubin (extrahepatic)

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26
Q

Gilbert’s syndrome

A

Low levels of glucuronyl transferase (High indirect bili)

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27
Q

Crigler-Najar (type I/type II)

A

Type I: no GT
Type II: Very low GT
–>In both cases, high indirect bili

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28
Q

Which hereditary condition results in high direct bili?

A

Dubin Johnson and Rotor syndrome

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29
Q

What is cholestasis?

A

Blockage in bile flow

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30
Q

What are the clinical criteria for cholestasis?

A

Jaundice, gray stool, dark urine, pruritis

31
Q

What labs would you see in cholestasis?

A 
High bili
High ALP
High GGT
High cholesterol
Low levels of fat soluble vitamins
32
Q

What are causes of extrahepatic obsturction?

A

Gallstones
strictures
neoplasias
parasites

33
Q

What is a fancy name for gallstones?

A

cholelithiasis

34
Q

What are the two types of gallstones? which can you see on an xray?

A 
cholesterol (majority)
calcium carbonate (radiopaque)
35
Q

What are causes of calcium stones?

A

hemolysis
cirrhosis
biliary infection

36
Q

What are the physical manifestations of gallstone disease?

A

70-80% are asymptomatic

If symptomatic, risk of complications

37
Q

What are complications of gallsotnes?

A

cholecystitis
-empyema/perforation

choledocholithiasis(stone stuck in duct)
-obstructive jaundice
-ascending cholangitis
-gangrenous GB
Pancreatitis (acute mostly)
38
Q

What are the less common complications of gallstones?

A
  1. biliary enteric fistula (can cause a gallstone ileus)
  2. Gallstone ileus (impaction of a gallstone within the lumen of the small intestine.)
  3. Porcelain gallbladder (calcification of the gallbladder)
39
Q

What is a common presentation of cholecystitis?

A

Epigastric/RUQ pain
Crescendo-plateau-decrescendo pain over a few hours without resolution
N/V

40
Q

What sign is positive in cholecystitis?

A

Murphy’s sign

41
Q

Which labs will be elevated in acute cholecystitis with obstruction?

A

bilirubin, AST, ALT

42
Q

What might you see on histology of chronic cholecystitis?

A

Rokitansky-Aschoff sinus (i.e. infiltration of muscle layer into the mucosa. important to distinguish this from cancer

43
Q

What is a complication of porcelain gallbladder?

A

carcinoma of the gallbladder in 20% of patients

44
Q

n which patients would you see a strawberry gallbladder?

A

In chronic cholecystitis or cholesterol rich stones. Pathologists will see cholesterol esters in the lamina propria and foamy lipid laden macrophages

45
Q

Choledocholithiasis

A

Stones in the duct

46
Q

What are the lab findings of choledocholithiasis?

A

Bili
ALP
GGT (AST, ALT)

47
Q

What imaging do you want if you suspect choledocholithiasis?

A

Ultrasound will show a dilated CBD

48
Q

Would you see murphy’s sign in a pt with choledocholithiasis?

A

NO. the gallbladder is not inflammed.

49
Q

What are the complications of choledocholithiasis?

A

cholangitis
pancreatitis
cirrhosis

50
Q

Is ascending cholangitis a life threatening episode?

A

YES

51
Q

What are the Sx of cholangitis?

A

Charcot’s triad

Reynold’s pentad

52
Q

What are the components of charcot’s triad?

A

RUQ pain, jaundice, fever

53
Q

What are the components of reynold’s pentad?

A

Charcot + MS changes + shock

54
Q

What are the risk factors for forming gallstones?

A 
Female
Obesity
Forty
Family history
Fertile (or pregnant)
-->also, a fatty diet
RAPID WEIGHT LOSS
Diabetes
55
Q

If you see cholecystitis in a pregnant woman, what should you do?

A

perform a cholecystectomy. Safest in 2nd trimester

56
Q

What is different about cholecystitis in a pregnant woman?

A

Absent murphy’s sign and AP is less helpful

57
Q

What is the most sensitive imaging test for gallstones?

A

US, endoscopic

95% sensitivity

58
Q

What are the ultrasound findings in choecystitis?

A
  1. pericholecystic fluid

2. thickened wall

59
Q

What is the gold standard diagnostic procedure for choledocholithiasis?

A

ERCP. Only for therapy–>pull out stone. This is because we have lots of safer diagnostic techniques out there.

Also, There is a 5% risk of pancreatitis

60
Q

What is a non-invasive way to detect CB

A

MRCP

It’s also very sensitive and specific

61
Q

If someone has asymptomatic gallstones, what should you do?

A

Watch and wait

62
Q

What is the risk of ERCp?

A

5% chance of causing pancreatitis

63
Q

What is an oral therapy for gallstones?

A

ursodeoxycholic acid. But only for small cholesterol stones with high recurrence rates

64
Q

What is a definitive treatment for symptomatic gallstones?

A

cholecystectomy

65
Q

What is the cause of acute acalculous cholecystitits?

A

In patients with severe systemic illnesses (ICU) likely cause of ischemia

66
Q

If you see gallbladder polyps, should you resect?

A

Yes, if over 1 cm b/c the bigger it is, the greater the risk of becoming cancerous

67
Q

What is the prognosis for gallbladder carcinoma?

A

Poor

68
Q

What are the risk factors for GB carcinoma?

A

gallstones, chronic cholecystitis, choledochal cysts

69
Q

Primary sclerosing cholangitis

A

chronic, fibrosing, inflammatory process of the bile ducts, destroying the biliary tree and causing cirrhosis

70
Q

What is secondary sclerosing cholangitis?

A

Chronic biliary obstruction causing secondary fibrosis

71
Q

What are the different types of choledochal cysts?

A

Type I: segmental dilations of CBD
Type II: diverticular cysts
Type III: intra and extra hepatic cysts
Type IV: intrahelpatic cysts

72
Q

Cholangiocarcinoma

A

Tumor of cholangiocytes in the ducts. Poor survival

73
Q

Klatskin tumor

A

Cholangiocarcinoma of the bifurcation

GI (27 decks)

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