Gallbladder and bile duct

Question 1

Cholesterol stones - mechanisms

Answer 1

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

Question 2

Pigment stone lithogenesis (what it’s made of and risk factors)

Answer 2

Chief constituent = calcium bilirubinate

Risk factors:
Biliary obstruction
Excess bilirubin excretion (hemolysis)
Asian ancestry
May develop in gallbladder or bile duct

Question 3

Gallstones – risk factors

Answer 3

Obesity
Female gender
Age > 30
Family history
Estrogen use

Latin American or Native American ethnicity
Rapid weight loss
Biliary obstruction

Question 4

Gallstone complications

Answer 4

Billiary colic
Acute cholecystitis
Ascending cholangitis
Gallstone pancreatitis

Gallbladder carcinoma

Question 5

Billiary colic

Answer 5

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

Question 6

Billiary colic- management

Answer 6

May persist for months or years

Laparoscopic cholecystectomy is curative

Non-lithogenic bile acid supplement (ursodeoxycholic acid) may be considered in special cases

Question 7

Acute (calculous) cholecystitis

Answer 7

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

Question 8

Presentation of acute cholecystitis

Answer 8

Severe RUQ pain, nausea, fever

Question 9

Treatment of acute cholecystitis

Answer 9

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

Question 10

Acalculous cholecystitis (most common cause, risk factors, symptoms, treatment)

Answer 10

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

Question 11

Choledocholithiasis (definition, how they develop, and presentation)

Answer 11

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

Question 12

Choledocholithiasis (diagnosis and treatment)

Answer 12

Diagnosis:
Liver chemistries
Ultrasound
MRCP or ERCP

Management:
ERCP with extraction and/or lithotripsy
Surgery if refractory

Question 13

Ascending cholangitis (what is it, what causes it, symptoms, and what happens if untreated)?

Answer 13

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

Question 14

Diagnosis and management of ascending cholangitis

Answer 14

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!

Question 15

Biliary stricture

Answer 15

Fixed narrowing or blockage of bile duct

Intra- or extrahepatic

Intrinsic or extrinsic

Benign or malignant

Symptoms are more chronic and persistent than stones

Question 16

Biliary stricture - presentation

Answer 16

RUQ pain

Cholestasis: Jaundice, Dark urine (choluria), Acholic stools, pruritus

LFTs elevated in cholestatic pattern:
Alk phos/GGT, bilirubin&raquo_space; ALT/AST

Question 17

Causes of biliary stricture

Answer 17

Benign:
Iatrogenic - surgery, radiation
Primary sclerosing cholangitis (PSC)
Chronic pancreatitis
Autoimmune pancreatitis

Malignant:
Pancreatic cancer
Cholangiocarcinoma
Gallbladder cancer
Ampullary cancer

Question 18

Diagnosis of biliary stricture

Answer 18

Ultrasound or CT → dilated ducts
MRCP or ERCP for confirmation
Biopsy to differentiate benign vs. malignant

Question 19

Management of biliary stricture

Answer 19

Biopsy to rule out malignancy, if applicable

ERCP with dilation or stenting

Surgery if refractory or malignant

Question 20

Primary sclerosing cholangitis (PSC): What is it, who gets it, progression of disease, and symptoms

Answer 20

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

Question 21

Diagnosis and management of PSC

Answer 21

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

Question 22

Calcifications seen in the pancreas on x-ray are diagnostic for what?

Answer 22

chronic pancreatitis

Question 23

Sphincter of Oddi dysfunction (SOD)

Answer 23

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

Question 24

Presentation, diagnosis, and treatment of Sphincter of Oddi dysfunction

Answer 24

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

Question 25

Abdominal ultrasound

Answer 25

95% sensitive and specific for gallbladder stones

> 90% accuracy for cholecystitis

50% sensitive for choledocholithiasis

Cheap, safe, readily available

Question 26

Are most gallbladder stones symptomatic?

Answer 26

No