Gallbladder and biliary disorders Flashcards
What is cholelithiasis
Hardened deposits of digestive fluid that form in the gallbladder
What are the complications with cholelithiasis
most disorders of the biliary tract
Who is at increased risk for cholelithiasis
those with crohns disease with ileum resection
What are common risk factors for cholelithiasis
Female
obesiry
increased age
pregnancy
western diet
American indian ethnicity
+fh
What are the 3 main pathways that gallstones can form
cholesterol supersaturation
Excessive bilirubin
impaired contractility
What is cholesterol supersaturation
liver produces more cholesterol than bile can dissolve and the excess cholesterol can crystallize
How does excess bilirubin lead to gallstones
liver makes too much bilirubin processing breakdown of hemoglobin
Why does gallbladder hypo motility lead to stones
gallbladder does not empty effectively causing bile to concentrate
What are the properties of black pigment gallstones
small, hard gallstones composed of calcium bilirubinate and inorganic salts
What are the risk factors for black pigmented gallstones
ETOH related liver disease, sickle cell, ill disease, chronic hemolysis
What are the properties of brown pigmented gallstones
soft and greasy, consisting of bilirubinate and fatty acids
What are the causes of brown pigmented gallstones
infection, inflammation, parasitic infection
What is the precursor to cholelithiasis
biliary sludge
When does biliary sludge develop
during gallbladder stasis (TPN)
What is the most common symptom of cholelithiasis
biliary colic
What is biliary colic
Temporary obstruction that cause sudden onset of RUQ pain, radiating to scapula (15min-hour) and will gradually resolve in 30-90min.
*generally a nocturnal issue
What is the first line and best imaging modality for cholelithiasis
US
If US of gallbladder is equivocal, what is the next line of imaging that can be done
nuc med cholescintigraphy scan (HIDA scan)
How do you treat asymptomatic gallstones
Diet changes to reduce the chance of recurrent episodes
refer to general surgeon for cholecystectomy
When can stone dissolution be preformed
small, radiolucent stones in functioning non-obstructed gallbladder
What can be used for stone dissolution
ursodeoxycholic
What is the treatment of choice for cholelithiasis
laparoscopic cholecystectomy
If a patient is at risk for cholelithiasis, what else are they at a risk for
cholecystitis
How will acute cholecystitis present
RUQ pain and tenderness
N/V
Fever / chills
What is the treatment for acute cholecystitis
antibiotics and cholecystectomy
What is the most common complication of cholelithiasis
acute cholecystitis
What is cute emphysematous cholecystitis
GB wall infected with gas forming organisms
When will Murphys sign be present
with acute cholecystitis
What is the best test to detect gallstones and evaluate GB disease
US
Which type of cholecystitis is a HIDA scan more useful to diagnose
acute acalculous cholecystitis
What is gallstone pancreatitis
stones pass into the biliary tract and block pancreatic duct
What is a cholecystoenteric fistula
large stone erodes GB wall, creating a fistula into the small bowel
may pass freely but could cause ileus
What is the classic mantra for cholecystitis
fat, forty, fertile, female, flatulent
What is a porcelain gallbladder
Extensive calcification due to fibrosis
What is the classic PE findings with chronic cholecystitis
+murphys sign
uncomfortable but not acutely ill
vitals WNL
What is the test of choice for chronic cholecystitis
US unless aclculous
What is the preferred treatment for chronic cholecystitis
laparoscopic cholecystectomy
What is choledocholithiasis
Stone in the CBD
What is the treatment for choledocholithiasis
ERCP
*possible cholecystectomy
What is the clinical presentation of choledocholithiasis
Colicky, RUQ pain, clay colored stools, episodic icterus (jaundice)
What is courvoisers sign
presence of palpable GB
What T.bili level is strongly associated with choledocholithiasis
> 3-4 mg/dL
What bloodwork should be drawn when working up choledocholithiasis
WBC, Hb/Hct, platelets, T. bili, D. bili, Alk phos, ALT, AST
What is the first test to be done if there is any suspicion of biliary disease
abdominal ultrasound
What is an ERCP
Endoscopic stone fragmentation may be considered for stones not easily removed
What is charcots triad
abd pain
jaundice
fever / chills
What is Reynolds pentad
confusion, hypotension, abdpain, jaundice, fever/chills
What is acute cholangitis
CBD obstruction allows bacteria to ascend from the duodenum
What are common organisms that cause cholangitis
E.coli
Enterobacter
Klebseilla
What is recurrent pyogenic cholangitis
oriental cholangiohepatitis
*intrahepatic brown stone formation that occurs in Southeast Asia
How do you treat acute cholangitis
agressive supportive care w/ urgent stone removal endoscopically or surgically
What is primary sclerosis cholangitis
chronic and progressive patchy inflammation, fibrosis, and strictures of bile ducts w/ no known cause
What do most people with primary sclerosing cholangitis already have
inflammatory bowel disease
*ulcerative colitis
How do you diagnose primary sclerosing cholangitis
ERCP
How do you treat advanced primary sclerosing cholangitis
liver transplant
What gender is at highest risk for primary sclerosing cholangitis
men
What are the different types of primary sclerosing cholangitis
classic
small-duct
association with autoimmune hepatitis
What is primary sclerosing cholangitis
progressive fibrosis around intrahepatic bile ducts that lead to concentric and circumferential lamination
*onion skin fibrosis
What will be seen on physical exam with primary sclerosing cholangitis
hepatomegaly
splenomegaly
jaundice
excoriations from pruritis
What is indicative of the terminal phase of primary sclerosing cholangitis
decompensated cirrhosis
portal HTN
ascites
liver failure
How do you diagnose primary sclerosing cholangitis
cholangiography showing multiple strictures and dilations in intrahepatic and extra hepatic bile ducts
What is the only treatment that improves life expectancy with primary sclerosing cholangitis
liver transplant
If a patient has +PSC and IBD, what are they at an increased risk for
colorectal cancer
What is a TIPS procedure
Transjugular Intrahepatic portosystemic shunt
