E2: Biliary Disease Flashcards
What is the main function of bile?
- Digestion and absorption of fats
- vehicle for excretion of bilirubin, excess cholesterol and metabolic byproducts
What is cholelithiasis?
Stones in the gallbladder
What is cholecystitis?
Inflammation of the GB
What is choledocholithiasis?
Stones in the common bile duct
What is cholangitis?
Inflammation of the bile ducts
What is cholestasis?
Disruption of bile flow, regardless of cause
What are the 4 Fs that are risk factors for cholelithiasis?
Female
Forty
Fluffy
Fertile
What is the most common type of stone seen with cholelithiasis? What are the other types of stones?
- Cholesterol stones are most common
- Pigment stones (black pigment and brown pigment)
What are the 3 clinical manifestations of cholelithiasis?
- Asymptomatic gallstones (majority)
- Uncomplicated gallstone disease (biliary colic)
- Complicated gallstone disease
What is the test of choice to diagnose cholelithiasis?
US
What is the treatment for asymptomatic gallstones?
- Majority of patients do not require treatment
- managed expectantly
- referred for cholecystectomy if symptoms develop
** these patients are surgically treated IF they have increased risk of gallbladder cancer or hemolytic disorders
What is the etiology of biliary colic?
- There is NO inflammation of the GB
- As the GB contracts, it forces a stone against the GB outlet or cystic duct opening. This increases intra-GB pressure which results in pain. As the GB relaxes, the pain improves
What is the clinical presentation of biliary colic?
- Intense RUQ pain that may radiate to the R shoulder blade
- Postprandial pain that lasts at least 30 minutes (usually lasts less than 5-6 hours)
Will a patient with biliary colic have a positive Murphys sign?
No
What is the recommended management of biliary colic?
-Cholecystectomy is recommended to prevent recurrent symptoms and complications
What is a functional gallbladder disorder?
Characterized by biliary type pain in the absence of gallstones, sludge, microlithiasis, or microcrystal disease
-Thought to be a results from GB dysmotility
How is functional GB disorder diagnosed?
- Diagnosis of exclusion
- If no other causes of identified, order a HIDA
What HIDA results will support a diagnosis of functional GB disorder?
A GB ejection fraction <35-40% is considered low and supports the diagnosis
What does the Rome IV criteria require for a diagnosis of functional GB disorder to be made?
Requires: biliary pain and absence of gallstones
-criteria that support diagnosis but not requires: low GBEF and normal liver enzymes
What is biliary pain?
- pain in the epigastric and/or right upper quadrant that meets all of the following criteria
- lasts at least 30 minutes
- occurs at variable intervals
- severe enough to interrupt daily activity’s
- Not significantly relieved by BMs, postural changes or acid suppression
What is the management of functional GB disorder?
- Education and reassurance
- referral
- Cholecystectomy for topical biliary type pain and low GBED (< 40%)
What are the 3 types of complicated gallstone disease?
- Cholecystitis
- Choledocholithiasis
- acute cholangitis
What is acute cholecystitis?
Acute inflammation of the GB, predominately a complication of gallstone disease
When does a calculus cholecystitis occur?
In the setting of cystic duct obstruction
Will a patient with acute cholecystitis have a positive Murphys sign?
Yes
What will you see on US that supports a diagnosis of acute cholecystitis?
- Presence of gallstones
- wall thickening or edema
- pericholecystic fluid
- positive sonography could murphys sign
What HIDA result would support a diagnosis of acute cholecystitis?
Failure to visualized the gallbladder in setting of cystic duct obstruction
What are the possible complications of acute cholecystitis and which is the most common?
- Gangrene is the most common
- perforation (often after development of gangrene)
- cholecystoenteric fistula
- gallstone ileus
- emphysematous cholecystitis
- Mirizzi syndrome
What is the Mirizzi syndrome?
A complication of acute cholecystitis, occurs when a gallstone impacted in the distal cystic duct causing extrinsic compression of the CBD, may cause jaundice
What is the management of acute cholecystitis?
- Admit, NPO, IV fluids, IV pain control, IV abx
- Cholecystectomy is mainstay of treatment
What is acute acalculus cholecystitis?
Acute necroinflammatory disease of the gallbladder in the absence of gallstones
What is the pathogenesis of acute acalculus cholecystitis?
- GB stasis and ischemia leading to local inflammatory response in the gallbladder wall
- secondary bacterial infection is common
What is the clinical presentation of acute acalculous cholecystitis?
-Critically ill patients with sepsis without a clear source, or jaundice
Patient presents with biliary type pain. On physical exam, patient appears jaundiced. Upon abdominal palpation, patient has RUQ tenderness and Courvoisier sign. What are you suspicious of?
Choledocolithiasis
What is Courvoisier sign?
Palpable gallbladder
What will liver function tests show if a patient has choledocholithiasis?
-Elevated ALT and AST in the early course of biliary obstruction. Later, liver tests are elevated in a cholestatic pattern
If you are unable to confirm a diagnosis of choledocholithiasis with US, what should you order next?
MRCP is used to confirm dx of CBD stone
What is the management of Choledocholithiasis?
- Removal of stone
- Identify and treat complications (acute cholangitis, acute pancreatitis)
- ERCP (therpeutic and diagnostic)
- Cholecystectomy
What causes acute cholangitis?
- caused primarily by a bacterial infection in a patient with biliary obstruction (choledocholithiasis, benign biliary stricture, s/p ERCP, malignancy)
- bacteria typical ascend from the duodenum
What is the clinical manifestation of acute cholangitis?
Fever, abdominal pain, and jaundice
-possible mental status change and hypotension, which are signs of significant morbidity
What is Charcots triad?
Fever, abdominal pain and jaundice
What is Reynolds Pentad?
Fever, abdominal pain, jaundice, mental status changes, and hypotension
What is the management of acute cholangitis?
- admit
- monitor for and treat sepsis (empiric abc coverage)
- emergent consult with GI and surgery (establishing biliary drainage, typically with ERCP)
How can biliary drainage be established in acute cholangitis?
-ERCP with sphincterotomy and stone extraction
Which two biliary problems would have leukocytosis?
Acute cholecystitis and acute cholangitis
What is primary biliary cholangitis (PBC)?
Autoimmune destruction of the intrahepatic bile ducts which causes cholestasis
-may result in cirrhosis and liver failure
What is the clinical presentation of PBC?
- ma be asymptomatic
- fatigue and pruritis are the most common
- RUQ pain, skin hyperpigmentation, hepatomegaly, jaundice
What lab tests should you order if you suspect PBC?
- Antimitochondrial antibodies (AMA) is the serologic hallmark of PBC
- elevated liver tests in a cholestatic pattern
What are the possible complications associated with PBC?
-Cirrhosis, hepatocellular carcinoma, malabsorption, and metabolic bone disease
What is the criteria to diagnose PBC?
- No extrahepatic biliary obstruction
- No comorbidity affecting the liver
- and at least two of the following are present: elevated alk phos, positive AMA, and histological evidence of PBC (liver biopsy)
What is primary sclerosis cholangitis (PSC)?
- A sclerosing, inflammatory, obliterative process involving the intrahepatic and/or extrahepatic biliary tree
- chronic and progressive disorder of unknown etiology
What is PSC commonly associated with?
IBD ( UC more than CD)
What are the symptoms of PSC?
Asymptomatic, fatigue, pruritis, jaundice, and hepatomegaly
Will PSC have a positive AMA?
No
How is PSC diagnosed?
- Elevated liver tests in a cholestatic pattern
- cholangiography (MRCP or ERCP showing multifocal strictures and dilation of intrahepatic and/or extrahepatic ducts)
- Liver biopsy
What are the possible complications of PSC?
- ESRD
- vitamin deficiency
- metabolic bone disease
- Hepatobiliary cancer
- colon cancer
What is Gilbert syndrome?
- And inherited disorder that results in deficiency in the enzyme for glucuronidation of bilirubin in the liver
- results in unconjugated hyperbilirubinemia in the absence of hemolysis
What is the clinical presentation of Gilbert syndrome?
- Mild intermittent episodes of jaundice triggered by dehydration, fasting, menstruation, etc
- otherwise more are asymptomatic with a normal PE
What is the most common cancer arising in the biliary tract?
Gallbladder cancer
What are the risk factors for GB cancer?
- Gallstone disease
- porcelain GB
- GB polyps
- PSC
- chronic infection
- obesity
What is cholangiocarcinoma?
Cancer that arise from the epithelial cells of the bile duct
What is cholangiocarcinoma commonly associated with?
PSC and choledochal cysts
What is the clinical presentation of cholangiocarcinoma?
- Jaundice, pruritis, abdominal pain, weight loss, fever, and rarely a palpable gallbladder
- labs may indicate cholestasis
Where does ampullary carcinoma occur?
-arise in the vicinity of the ampulla of vater, distal to the bifurcation of the distal CBD and pancreatic duct
What condition increases the risk of ampullary carcinoma?
Familial adenomatous polyposis
