Gallbladder and bile duct Flashcards
Cholesterol stones - mechanisms
Cholesterol supersaturation
Bile acid deficiency
Occurs when there is: Gallbladder stasis Gallbladder inflammation Cholesterol hyper-secretion by liver Over-absorption of water in gallbladder Nidus such as mucin plug or foreign body
Pigment stone lithogenesis (what it’s made of and risk factors)
Chief constituent = calcium bilirubinate
Risk factors: Biliary obstruction Excess bilirubin excretion (hemolysis) Asian ancestry May develop in gallbladder or bile duct
Gallstones – risk factors
Obesity Female gender Age > 30 Family history Estrogen use
Latin American or Native American ethnicity
Rapid weight loss
Biliary obstruction
Gallstone complications
Billiary colic
Acute cholecystitis
Ascending cholangitis
Gallstone pancreatitis
Gallbladder carcinoma
Billiary colic
Intermittent pain in epigastrium or RUQ
After meals, particularly fatty foods
Peaks within an hour, remits 3-8 hours later
Caused by movement of stone into cystic duct or gallbladder neck
Billiary colic- management
May persist for months or years
Laparoscopic cholecystectomy is curative
Non-lithogenic bile acid supplement (ursodeoxycholic acid) may be considered in special cases
Acute (calculous) cholecystitis
Stone impaction in cystic duct or gallbladder neck
Bacteria colonization (GNRs, enterococci)
Transmural inflammation
Distention and ischemia
GB, perforation, sepsis or death may result if untreated
Presentation of acute cholecystitis
Severe RUQ pain, nausea, fever
Treatment of acute cholecystitis
NPO (gallbladder rest)
IV hydration
IV antibiotics
Surgical removal of the gallbladder (cholecystectomy) when stable
Percutaneous drainage of gallbadder in patients too ill for surgery
Acalculous cholecystitis (most common cause, risk factors, symptoms, treatment)
Less common than calculous
Usually from ischemia of gallbladder
Risk factors = sepsis, recent surgery, trauma/burns, hypotension
Vasculitis
Symptoms: disease otherwise similar to ACC
Treatment: percutaneous drainage of gallbladder or cholecystectomy if fit for surgery
Choledocholithiasis (definition, how they develop, and presentation)
Stones in bile duct/s
Majority migrate from gallbladder
~ 10% form de novo in CBD
Presentation: Jaundice, dark urine, and abdominal pain; May also cause acute pancreatitis
Choledocholithiasis (diagnosis and treatment)
Diagnosis:
Liver chemistries
Ultrasound
MRCP or ERCP
Management:
ERCP with extraction and/or lithotripsy
Surgery if refractory
Ascending cholangitis (what is it, what causes it, symptoms, and what happens if untreated)?
Bacterial infection of bile duct
Almost always a complication of choledocholithiasis
Symptoms = Charcot’s triad (Fever, RUQ pain, Jaundice)
Sepsis or death may occur if untreated
Diagnosis and management of ascending cholangitis
Initial management: Admit to hospital NPO Broad spectrum IV abx IV fluids
Diagnosis:
History, labs, US are usually suggestive
Definitive diagnosis and management
Urgent ERCP!
Biliary stricture
Fixed narrowing or blockage of bile duct
Intra- or extrahepatic
Intrinsic or extrinsic
Benign or malignant
Symptoms are more chronic and persistent than stones
Biliary stricture - presentation
RUQ pain
Cholestasis: Jaundice, Dark urine (choluria), Acholic stools, pruritus
LFTs elevated in cholestatic pattern:
Alk phos/GGT, bilirubin»_space; ALT/AST
Causes of biliary stricture
Benign: Iatrogenic - surgery, radiation Primary sclerosing cholangitis (PSC) Chronic pancreatitis Autoimmune pancreatitis
Malignant: Pancreatic cancer Cholangiocarcinoma Gallbladder cancer Ampullary cancer
Diagnosis of biliary stricture
Ultrasound or CT → dilated ducts
MRCP or ERCP for confirmation
Biopsy to differentiate benign vs. malignant
Management of biliary stricture
Biopsy to rule out malignancy, if applicable
ERCP with dilation or stenting
Surgery if refractory or malignant
Primary sclerosing cholangitis (PSC): What is it, who gets it, progression of disease, and symptoms
Intra- and extrahepatic fibrotic strictures
males>females, ages 30-50
Association with inflammatory bowel disease (UC > Crohns)
Risk of liver cirrhosis
Disease course independent of colitis
Increased risk of cholangiocarcinoma
Symptoms: RUQ pain, jaundice, fevers -> cirrhosis of liver
Diagnosis and management of PSC
Alk phos/GGT > AST/ALT
Bilirubin rises late
No effective treatment, except liver transplant
ERCP with stent if jaundiced
Close surveillance for cholangiocarcinoma is essential
Calcifications seen in the pancreas on x-ray are diagnostic for what?
chronic pancreatitis
Sphincter of Oddi dysfunction (SOD)
Motility disorder of Sphincter of Oddi
Young females (20-50)
Typically intermittent
Symptoms, labs, imaging may mimic choledocholithiasis
Types I, II, III depending on severity
Presentation, diagnosis, and treatment of Sphincter of Oddi dysfunction
Presentation:
Recurrent RUQ pain
Dynamically elevated ALT/AST/alk phos
Dilated bile duct on US
Diagnosis: History Elevated LFTs during pain \+/= dilated bile duct on US Sphincter of Oddi manometry is definitive
Treatment: biliary sphincterotomy
Abdominal ultrasound
95% sensitive and specific for gallbladder stones
> 90% accuracy for cholecystitis
50% sensitive for choledocholithiasis
Cheap, safe, readily available
Are most gallbladder stones symptomatic?
No
