Gallbladder Flashcards
Gallstone are caused by _
Gallstone are caused by precipitation of bilirubin and/or cholesterol in the bile
Gallstones can be diagnosed via (2) modalities _ or _
Gallstones can be diagnosed via (2) modalities ultrasound or hepatobiliary iminodiacetic acid (HIDA) scan
The (4) risk factors for cholelithiasis
Cholelithiasis risk factors: 4 F’s
1. Fat
2. Female
3. Fertile (pregnant)
4. Forty
The most common type of gallstone is _
The most common type of gallstone is cholesterol gallstone
_ is an enzyme that converts cholesterol –> bile
Cholesterol 7a-hydroxylase is an enzyme that converts cholesterol –> bile
* This is a rate limiting step of bile production
Cholesterol gallstone formation is associated with (high/low) cholesterol and (high/low) bile
Cholesterol gallstone formation is associated with high cholesterol and low bile
* Recall that cholesterol –> bile via 7a-hydroxylase
Explain the pathogenesis of cholesterol gallstones
Supersaturation of cholesterol + insufficient bile acids/salt + biliary stasis –> stone
Cholesterol gallstones are associated with the following risk factors:
Cholesterol gallstones are associated with the following risk factors:
* Native Americans
* Rapid weight loss
* Fibrates
* Age
* Obesity
* Crohn’s disease
Cholesterol gallstones are (radiolucent/radiopaque)
Cholesterol gallstones are radiolucent
Black pigmented gallstones result from _
Black pigmented gallstones result from hemolysis
Explain the pathogenesis of black pigmented gallstones
Hemolysis –> increase in unconjugated bilirubin –> increase in calcium bilirubinate
Brown pigmented gallstones result from _
Brown pigmented gallstones result from infection
Explain the pathogenesis of brown pigmented gallstones
Infection –> increase in beta-glucuronidase –> increase in calcium bilirubinate, increase in fatty acids
Brown pigmented gallstones most commonly result from infection with _ or _
Brown pigmented gallstones most commonly result from infection with E.coli or Clonorchis sinensis
Associated risk factors of pigmented gallstones include:
Associated risk factors of pigmented gallstones include:
* TPN
* Alcoholic cirrhosis
* Crohn’s disease
* Hemolysis
* Biliary infection
Cholecystitis is _
Cholecystitis is acute or chronic inflammation of the gallbladder due to cystic duct obstruction
Cholecystitis is caused by an obstruction in _
Cholecystitis is caused by an obstruction in cystic duct
Cholecystitis may be suspected with a positive _ (physical exam finding)
Cholecystitis may be suspected with a positive Murphy’s sign
_ sign is arrest of inspiration during palpation of the RUQ
Murphy’s sign is arrest of inspiration during palpation of the RUQ
A positive Murphy’s sign is arrest of inspiration during palpation of _ quadrant
A positive Murphy’s sign is arrest of inspiration during palpation of RUQ
_ is a form of cholecystitis caused by stasis, hypoperfusion, or infection (hypokinesis of gallbladder emptying) that mainly occurs in critically ill patients
Acalculous cholecystitis is a form of cholecystitis caused by stasis, hypoperfusion, or infection (hypokinesis of gallbladder emptying) that mainly occurs in critically ill patients
_ is a gallstone in the common bile duct
Choledocholethiasis is a gallstone in the common bile duct
Expected lab findings in a choledocholethiasis
Expected lab findings in a choledocholethiasis:
* Elevated ALP
* Elevated GGT
* Elevated conjugated bilirubin
* Elevated AST/ALT
Ascending cholangitis is _
Ascending cholangitis is infection of the biliary tree due to stasis/obstruction
Ascending cholangitis may present with _ phenomenon
Ascending cholangitis may present with Charcot’s triad
* Jaundice, fever, RUQ pain
Charcot’s triad presents with _ pathology
Charcot’s triad presents with ascending cholangitis
Charcot’s triad encompasses:
Charcot’s triad encompasses:
1. Jaundice
2. Fever
3. RUQ pain
Reynold’s pentad includes Charcot’s triad + _ and _
Reynold’s pentad includes Charcot’s triad + altered mental state and shock
A gallstone at the ampulla of vater can lead to _
A gallstone at the ampulla of vater can lead to acute pancreatitis
A fistula between the gallbladder and bowel can lead to _
A fistula between the gallbladder and bowel can lead to gallstone ileus
* The gallstone enters the intestinal lumen –> ileocecal valve
Signs of a gallstone ileus:
Signs of a gallstone ileus: Rigler triad
1. Pneumobilia (air in biliary tree)
2. Small bowel obstruction
3. Gallstone visualized
Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts is called _
Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts is called primary sclerosing cholangitis
PSC will show periductal fibrosis with _ appearance
PSC will show periductal fibrosis with onion-skin appearance
PSC will appear with _ sign on contrast imaging
PSC will appear with beading on contrast imaging
* Uninvolved regions are dilated
* Alternating strictures and dilations
PSC most commonly presents with _
PSC most commonly presents with obstructive jaundice
* Pruritis, pale stool, dark urine
A late complication of PSC is _
A late complication of PSC is cirrhosis
Etiology of PSC is largely unknown but it is commonly associated with _ and may have a positive _
Etiology of PSC is largely unknown but it is commonly associated with ulcerative colitis and may have a positive p-ANCA
PSC is associated with HLA markers _ and _
PSC is associated with HLA markers HLA-B8 and HLA-DR3
PSC is associated with an increased risk of _ malignancy
PSC is associated with an increased risk of cholangiocarcinoma
Both PSC and PBC are associated with an increase in _ antibody
Both PSC and PBC are associated with an increase in IgM
Primary biliary cholangitis is _
Primary biliary cholangitis is autoimmune granulomatous destruction of intrahepatic bile ducts
PBC presents with _ ; _ is a late complication
PBC presents with obstructive jaundice ; cirrhosis is a late complication
* Pruritis, pale stools, dark urine (same as PSC)
PBC is commonly associated with _ and _ autoantibodies may be present
PBC is commonly associated with autoimmune disorders and anti-mitochondrial autoantibodies may be present
PSC tends to present in _ population
PSC tends to present in middle aged men
PBC tends to present in _ population
PBC tends to present in middle aged women
(PBC/PSC) is associated with auto-mitochondrial antibodies
PBC is associated with auto-mitochondrial antibodies
(PBC/PSC) is associated with p-ANCA
PSC is associated with p-ANCA
Histology of primary biliary cholangitis will show _
Histology of primary biliary cholangitis will show lymphocytic infiltrate and granulomas
(PBC/PSC) involves the intra AND extrahepatic bile ducts
PSC involves the intra AND extrahepatic bile ducts
* PBC only affects the intrahepatic bile ducts
PBC causes an increased risk of _
PBC causes an increased risk of hepatocellular carcinoma
* Progression from chronic cirrhosis
Secondary biliary cholangitis/cirrhosis is _
Secondary biliary cholangitis/cirrhosis is extrahepatic obstruction of the bile ducts –> causing duct fibrosis and bile stasis
* Associated with bile duct obstruction
Chronic cholecystitis –> gallbladder calcification –> increase risk of _
Chronic cholecystitis –> gallbladder calcification –> increase risk of adenocarcinoma
* We call this a “porcelain gallbladder”
_ is an adenocarcinoma of the bile duct epithelium
Cholangiocarcinoma is an adenocarcinoma of the bile duct epithelium
Risk factors of cholangiocarcinoma include things that cause _
Risk factors of cholangiocarcinoma include things that cause chronic inflammation of bile duct epithelium
* Chronic cholecystitis
* Choledochal cysts
* PSC
* Clonorchis sinensis (Liver fluke)
Cholangiocarcinoma is characterized by _ on histology
Cholangiocarcinoma is characterized by glands and mucin on histology (very disorganized)
Cholangiocarcinoma presents with _
Cholangiocarcinoma presents with obstructive jaundice
* Pruritis, pale stool, dark urine
Pruritus associated with jaundice occurs due to the build up of _
Pruritus associated with jaundice occurs due to the build up of bile salts
Pale stools occur in obstructive jaundice due to the decrease in _
Pale stools occur in obstructive jaundice due to the decrease in stercobilin
* Decreased intestinal bilirubin
Dark urine occurs in obstructive jaundice due to _
Dark urine occurs in obstructive jaundice due to increased conjugated bilirubin in blood
* Increase bilirubin going to the kidneys for excretion –> dark urine
Jaundice is yellowing of the skin and sclera due to _ deposition
Jaundice is yellowing of the skin and sclera due to bilirubin deposition
Conjugated jaundice most commonly occurs due to _
Conjugated jaundice most commonly occurs due to obstruction
* ie gallstones, cancers, Clonorchis sinensis, PBC, PSC
Unconjugated jaundice most commonly occurs due to _
Unconjugated jaundice most commonly occurs due to hemolysis or enzyme deficiency
Hepatitis and cirrhosis tend to cause a _ type jaundice
Hepatitis and cirrhosis tend to cause a mixed jaundice
* They impair enzymes and export
Neonatal jaundice is caused by _
Neonatal jaundice is caused by immature UDP-glucuronosyltransferase (UDP-GT)
* Typically resolves within weeks of birth
Babies at risk of kernicterus will need _ therapy
Babies at risk of kernicterus will need non-UV phototherapy
Non-UV phototherapy treats newborn jaundice by _
Non-UV phototherapy treats newborn jaundice by increasing water solubility of bilirubin to increase excretion
Bilirubin is a byproduct of _
Bilirubin is a byproduct of RBC breakdown
* Senescent RBCs (120 day lifespan) get broken down by macrophages into iron, globin, bilirubin
Unconjugated bilirubin is water (soluble/insoluble)
Unconjugated bilirubin is water insolube; cannot be excreted in the urine
Unconjugated bilirubin is (free/bound) in the blood
Unconjugated bilirubin is bound to albumin in the blood
The enzyme that converts unconjugated bilirubin to conjugated bilirubin is _
The enzyme that converts unconjugated bilirubin to conjugated bilirubin is UDP-glucuronosyl-transferase
* Found in the liver
Conjugated bilirubin is excreted from the liver as _ and goes into the intestine where gut bacteria turn it into _
Conjugated bilirubin is excreted from the liver as bile and goes into the intestine where gut bacteria turn it into urobilinogen
Urobilinogen becomes _ (excreted in stool) and _ (excreted in urine)
Urobilinogen becomes stercobilin (excreted in stool) and urobilin (excreted in urine)
Some pediatric jaundice is caused by improper formation of the bile ducts/ fibrosis and destruction of the extrahepatic bile ducts called _
Some pediatric jaundice is caused by improper formation of the bile ducts/ fibrosis and destruction of the extrahepatic bile ducts called biliary atresia
* Cholestasis can cause worsening jaundice, dark urine, pale stool, hepatomegaly
* Liver damage from high direct bilirubin
G6PD deficiency can result in an increase in (conjugated/unconjugated) bilirubin
G6PD deficiency can result in an increase in unconjugated bilirubin
* Recall that G6PD converts NADP –> NADPH which protects RBCs from ROS damage
* Deficiency leads to RBC hemolysis
All hereditary hyperbilirubinemias have _ inheritance
All hereditary hyperbilirubinemias have autosomal recessive inheritance
_ is a condition of reduced UDP-GT that causes an increase in unconjugated bilirubin and jaundice during stress, fasting, illness
Gilbert syndrome is a condition of reduced UDP-GT that causes an increase in unconjugated bilirubin and jaundice during stress, fasting, illness
Crigler-Najjar syndrome is caused by _
Crigler-Najjar syndrome is caused by absent UDP-GT
* Leads to severe jaundice, kernicterus
Kernicterus is caused by _
Kernicterus is caused by basal ganglia bilirubin deposition
We treat Crigler-Najjar syndrome with _ and _
We treat Crigler-Najjar syndrome with plasmapheresis and phototherapy
* Increase polarity and water solubility to increase excretion
The curative treatment for Crigler-Najjar is _
The curative treatment for Crigler-Najjar is liver transplant
Type II Crigler-Najjar is a more (severe/mild) form
Type II Crigler-Najjar is a more mild form
Type II Crigler-Najjar can be treated with _
Type II Crigler-Najjar can be treated with phenobarbital
Phenobarbital improves jaundice by _
Phenobarbital improves jaundice by increasing liver enzyme synthesis
Dubin-Johnson syndrome is a hyperbilirubinemia condition caused by _
Dubin-Johnson syndrome is a hyperbilirubinemia condition caused by impaired liver excretion of conjugated bilirubin
_ is a benign condition notable for black liver due to accumulated epinephrine metabolites
Dubin-Johnson syndrome is a benign condition notable for black liver due to accumulated epinephrine metabolites
Rotor syndrome is caused by _
Rotor syndrome is caused by impaired hepatic uptake/excretion of conjugated bilirubin
* A milder version of Dubin-Johnson without a black liver
Common bile duct
ALT, AST, ALP, bilirubin will be (normal/elevated) in cholecystitis
ALT, AST, ALP, bilirubin will be normal in cholecystitis
_ is often asymptomatic; stones are just sitting in the gallbladder
Cholelithiasis is often asymptomatic; stones are just sitting in the gallbladder
Biliary colic is when _
Biliary colic is when stones intermittently obstruct the gallbladder neck/cystic duct, causing transient episodes of pain/discomfort
_ is when a stone gets wedged in the cystic duct causing inflammation of the gallbladder
Acute cholecystitis is when a stone gets wedged in the cystic duct causing inflammation of the gallbladder
Cholecystitis is associted with (colicky/ persistent) pain
Cholecystitis is associted with persistent pain
_ occurs when a stone gets impacted in the common bile duct causing bile to back up into the hepatic bile ducts and LFTs to go up
Choledocholithiasis occurs when a stone gets impacted in the common bile duct causing bile to back up into the hepatic bile ducts and LFTs to go up
_ is a progression of choledocholithiasis in which bile fluid gets infected from the obstruction
Ascending cholangitis is a progression of choledocholithiasis in which bile fluid gets infected from the obstruction
We manage biliary colic via _
We manage biliary colic via observation, elective cholecystectomy
Acute cholecystitis will have an elevation in (WBC/LFTs)
Acute cholecystitis will have an elevation in WBCs
* Liver enzymes will be normal
Imaging of acute cholecystitis may show _
Imaging of acute cholecystitis may show stones, gallbladder wall thickening and pericholecystic fluid
We treat acute cholecystitis with _
We treat acute cholecystitis with urgent cholecystectomy
Of the gallstone pathologies, _ and _ are most certain to elevate liver enzymes
Of the gallstone pathologies, choledocholithiasis and cholangitis are most certain to elevate liver enzymes
* Gallstone pancreatitis (stone at the ampulla of vater) may or may not have elevated LFTs
Choledocholithiasis and ascending cholangitis are treated with _
Choledocholithiasis and ascending cholangitis are treated with urgent ERCP, then cholecystectomy
Autoimmune hepatitis is often positive for…
- Positive anti-nuclear antibody (ANA)
- Positive anti-smooth muscle antibody
- Positive anti-liver-kidney microsomal Ab
- Elevated IgG
Autoimmune hepatitis will reveal _ on histology
Autoimmune hepatitis will reveal plasma cells and mononuclear infiltrates around the portal triad on histology
(ALP/GGT) comes from liver and bones
ALP comes from liver and bones
* GGT only comes from hepatocytes
Differential for elevated ALP and GGT
Differential for elevated ALP and GGT:
* Biliary obstruction (stone, tumor)
* Biliary disease (PSC, PBC)
* Infiltrative disease invading bile duct (sarcoidosis, lymphoma)
* Medications
(PBC/PSC) is associated with intense pruritus
PBC is associated with intense pruritus
(PBC/PSC) is associated with recurrent biliary obstructions/infections (cholangitis)
PSC is associated with recurrent biliary obstructions/infections (cholangitis)
(PBC/ PSC) will have positive ANA
PBC will have positive ANA
We can treat PBC with _ , a medication which changes the composition of bile
We can treat PBC with ursodeoxycholic acid , a medication which changes the composition of bile
PBC
(PBC/PSC) has granulomas
PBC has granulomas
* Spillage of bile –> macrophages try to contain
PSC
PSC
