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GI > Gallbladder & Biliary Tract Disorders > Flashcards

Gallbladder & Biliary Tract Disorders Flashcards

1
Q

Which hormone stimulates the gallbladder to release bile into the duodenum?

A

Cholecystokinin (CCK)

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2
Q

What is bile used for?

A

Emulsify fats

Assist with the excretion of cholesterol

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3
Q

Types of Biliary Tract Disorders

A 
Cholelithiasis
Choledocholithiasis
Acute cholecystitis
Cholangitis
Primary sclerosing cholangitis
Primary biliary cirrhosis
CA of the biliary tract
Hyperbilirubinemia
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4
Q

Define Cholelithiasis

A

Formation of gallstones which are solid concentrations of varying quantities of cholesterol, Ca, and bilirubin

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5
Q

What leads to the formation of cholesterol stones?

A

Supersaturation of bile with cholesterol and GB hypomotility

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6
Q

Types of Gallstones

A

Cholesterol (90%)

Pigmented (10%)

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7
Q

Types of Pigmented Gallstones

A

Black stones: contain Ca bilirubinate, associated with cirrhosis and hemolysis
Brown stones: associated with biliary tract stasis & infection

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8
Q

Major Risk Factors for the Development of Gallstones

A 
Age
Female
Genetic
Pregnancy
Obesity
Rapid weight loss
Cirrhosis
Hemolytic anemias
Hypertriglyceridemia
Medications: BC, clofibrate, ceftriaxone, octreotide
Terminal ileal resection
Gallbladder stasis
Reduced physical activity
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9
Q

The 4 F’s of Cholelithiasis

A

Fat
Fertile
Female
Forty

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10
Q

Signs/Symptoms of Cholelithiasis

A

Biliary colic
Steady RUQ pain radiates to back/R shoulder
Nausea
Pain after eating

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11
Q

Treatment of Cholelithiasis

A

Observation

Cholecystectomy

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12
Q

Consider Prophylactic Cholecystectomy in these Patients

A 
Diabetics
Porcelain gallbladder
Sickle cell disease
Hereditary spherocytosis
Gastric bypass
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13
Q

Define Porcelain Gallbladder

A

Blue discoloration & brittle consistency

Due to calcification from excessive gallstones

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14
Q

Gallstone Complications

A 
Gallstone ileus
Gallstone pancreatitis
Acute cholecystitis
Choledocholithiasis
Cholangitis
Bile duct injuries
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15
Q

Define Gallstone Ileus

A

Stone erodes through GB wall and develops a cholecystoenteric fistula leading to obstruction of narrowest segment of bowel causing ileus

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16
Q

Protective Factors of Cholelithiasis

A

Statins
Ascorbic acid
Coffee- caffeinated
Vegetable protein

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17
Q

Define Choledocholithiasis

A

Presence of gallstones within the common bile duct

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18
Q

Signs/Symptoms of Choledocholithiasis

A

RUQ/epigastric pain
N/V
LFT’s elevated
Bilirubin & alkaline phosphatase may be elevated

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19
Q

Choledocholithiasis Imaging

A

Transabdominal ultrasound
Abdominal CT
ERCP
Intraoperative cholangiography or ultrasonography
Magnetic resonance cholangiopancreatography (MRCP)

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20
Q

What is the gold standard for diagnosis of choledocholithiasis?

A

ERCP

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21
Q

Advantages of an ERCP

A

Therapeutic option
Stone retrieval
Sphincterotomy

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22
Q

Complications of an ERCP

A

Pancreatitis
Cholangitis
Perforation of duodenum or bile duct
Bleeding

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23
Q

Advantage of an MRCP

A

Detects choledocholithiasis, neoplasms, strictures, biliary dilations
High sensitivity & specificity
Minimally invasive

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24
Q

Disadvantages of an MRCP

A

Cannot sample bile, test cytology, remove stone

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25
Q

Contraindications for an MRCP

A

Pacemaker
Implants
Prosthetic valves

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26
Q

Indications for an MRCP

A

Cholangitis not severe

Risk of ERCP high

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27
Q

Treatment for Choledocholithiasis

A

Remove the stone via ERCP, lithotripsy, lap CBD exploration

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28
Q

Define Acute Cholecystitis

A

Syndrome of RUQ pain, fever, and leukocytosis associated with gallbladder inflammation usually caused by cystic duct obstruction

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29
Q

Important Findings on H&P

A 
RUQ/epigastric pain which radiates to right shoulder
Anorexia
N/V
Fever
 \+ Murphy's sign
Jaundice
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30
Q

Diagnostics of Acute Cholecystitis

A 
LFT's & bilirubin elevated
CBC: left shift
CRP elevated
US: stones/sludge, pericholecystic fluid, distended GB, thickened GB wall
HIDA scan: failure of GB filling
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31
Q

What is the imagining modality of choice for the gallbladder?

A

US

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32
Q

Advantages of an Abdominal US

A

Fast
Real-time
Non-invasive
No radiation

33
Q

Indications for a HIDA Scan

A

Functional assessment of the hepatobiliary system
Evaluation of acute cholecystitis, chronic biliary tract disorders, CBD obstruction, congenital abnormalities
Detection of bile extravasation

34
Q

Requirements for HIDA Scan

A

Patient prep: fast 2-4 hours

35
Q

Other Important Information for a HIDA Scan

A 
Hx previous surgeries
Time of most recent meal
Current meds: opioids (4 hours after last dose)
Bilirubin & liver enzyme levels
Results of US
36
Q

Treatment of Acute Cholecystitis

A

Admit: supportive care, NPO, IV fluids, analgesia, vitals, urinary output
Antibiotics: cipro, levo, flagyl, cefuroxime
Lap chole: PREFERED
Percutaneous cholecystotomy tube

37
Q

Complications of Acute Cholecystitis

A 
Emphysematous cholecystitis
Gangrenous cholecystitis
Pericholecystic abscess formation
Sepsis
Peritonitis
Ascending cholangitis
Cholecystoenteric fistula
Perforation
38
Q

What to look for with complications in acute cholecystitis?

A 
Fever
Shaking chills
High WBC
Increased abdominal pain
Persistent symptoms
39
Q

Chronic Cholecystitis

A

Repeated episodes of mild attacks
Due to presence of stones
Mild inflammation can lead to shrinking, scarring, thickened walls, mucosal atrophy, & fibrosis of GB wall

40
Q

Signs/Symptoms of Chronic Cholecystitis

A

Transient RUQ pain: precipitated by fatty meal

N/V

41
Q

Treatment of Chronic Cholecystitis

A

Cholecystectomy
Look for choledocholithiasis
Prevent future complications

42
Q

Define Porcelain Gallbladder

A

Extensive calcium encrustation of the gallbladder wall

43
Q

What is a porcelain gallbladder a risk for?

A

GB adenocarcinoma

44
Q

Treatment of Porcelain Gallbladder

45
Q

Define Acute Cholangitis

A

Inflammation or infection of the bile duct system

46
Q

What is the most important predisposing factor for acute cholangitis?

A

Biliary obstruction & stasis secondary to biliary calculi or benign stricture

47
Q

Define Charcot’s Triad

A

RUQ Pain
Jaundice
Fever/Chills

48
Q

Define Renold’s Pentad

A 
RUQ pain
Jaundice
Fever/Chills
Hypotension
Altered mental status
49
Q

What is the mortality rate for patients with septic cholangitis?

50
Q

Diagnstics of Cholangitis

A 
Leukocytosis
Elevated LFTs, CRP
Blood cultures: gram negative
ABGs: metabolic acidosis
Elevated BUN & creatinine
US: dilated bile duct, CBD stones
ERCP: bile duct stone/obstruction or stricture
51
Q

Treatment of Cholangitis

A

Admit
Treat infection
Remove stones (ERCP)
Biliary drainage

52
Q

Define Primary Sclerosing Cholangitis

A

Chronic inflammatory cholestatic disease characterized by diffuse inflammation of the biliary tract

53
Q

Having primary sclerosing cholangitis increases your risk of what?

A 
Cholangiocarcinoma
Gallbladder CA
Colon CA
Ulcerative colitis
Hepatocellular CA
54
Q

Presentation of Primary Sclerosing Cholangitis

A 
Progressive, obstructive jaundice
Malaise
Fatigue
Pruritus
Anorexia
Dyspepsia
Symptoms of cirrhosis
Symptoms of portal HTN
Elevated alkaline phosphatase, ALT, AST
55
Q

Diagnosis of Primary Sclerosing Cholangitis

A

ERCP
ANCA (Anti-neutrophil cytoplasmic antibodies)
MRCP alternative to ERCP

56
Q

Treatment of Primary Sclerosing Cholangitis

A

Balloon dilation or stenting

Liver transplantation

57
Q

Define Primary Biliary Cirrhosis (PBC)

A

Slowly progressive autoimmune liver disease

58
Q

Epidemiology of Primary Biliary Cirrhosis (PBC)

A 
Females >> Males
Peak in 40s
Portal inflammation & autoimmune destruction of bile ducts
Leads to cirrhosis & liver failure
Antimitochondrial antibody (AMA)
59
Q

Clinical Features of Primary Biliary Cirrhosis (PBC)

A 
Fatigue
Pruritus
Skin hyperpigmentation
Rheumatic symptoms
Musculoskeletal complaints
Hyperlipidemia
Hypothyroidism
Osteopenia
Autoimmune disease
Portal HTN
Liver failure
60
Q

PE in Primary Biliary Cirrhosis (PBC)

A 
Hyper pigmented skin
Excoriations
Xanthelasmas
Hepatomegaly
Spider nevi
Jaundice
Muscle wasting
Ascites
Edema
61
Q

Diagnosis Criteria of Primary Biliary Cirrhosis

A

2 of 3 criteria
Positive AMA
Abnormal LFT: alkaline phosphatase & GGTP
Compatible biopsy shows destruction of interlobular bile ducts

62
Q

Treatment of Primary Biliary Cirrhosis

A 
UDCA (ursodiol)
Colchicine (severe inflammation)
Methotrexate (severe inflammation)
Budesonide (severe inflammation)
Liver tranplant
63
Q

What does UDCA (ursodiol) do for primary biliary cirrhosis?

A

Reduces bilirubin, LFTs, cholesterol, IgM
Delays fibrosis & varices
Reduce risk of need for liver transplant & death over 4 years

64
Q

Known Risk Factors for Cholangiocarcinoma

A

Primary Sclerosing cholangitis
Congenital liver malformations
Infection with parasitic liver flukes
Exposure to Thorotrast (thorium dioxide)

65
Q

Diagnostic Testing for Cholangiocarcinoma

A

US: tumor & spread, dilation of GB & ducts
CT: tumor & spread, dilation of GB & ducts, enlarged lymph nodes
MRI: bile ducts & blood vessels
Cholangiography via ERCP: access to biliary tree

66
Q

Treatment of Cholangiocarcinoma

A

Palliative chemo +/- radiation

Resect if possible

67
Q

What is the prognosis of cholangiocarcnoma?

A

Resectable: 5% in 5 years

Non-resectable: 0% in 5 years

68
Q

Epidemiology of Gallbladder CA

A

Women > Men

Found incidentally

69
Q

Risk Factors for Gallbladder CA

A 
Gallstones
Gallbladder Polyps
Chornic salmonella infection
Abnormal pancreaticobiliary duct junction
Porcelain gallbladder
DM
Obesity
70
Q

Presentations for Gallbladder CA

A

During/after lap chole for benign disease
Diagnostic eval: found on imaging
Advanced stage at presentation

71
Q

Surgical Management of Gallbladder Disease if Resectable

A

Simple chole
Radical chole
Radical whole with anatomic liver resection
Radical whole with Whipple

72
Q

Clinical Features of Ampulla of Vater CA

A 
Obstructive jaundice
Weight loss
Anorexia
Fatigue
Abdominal
Occult GI bleeding
Positive FOBT
73
Q

Imaging for Ampulla of Vater CA

A 
US
CT
ERCP
EUS
MRCP
74
Q

Treatment of Ampulla of Vater CA

A

Whipple procedure

75
Q

Define Bilirubin

A

Yellow pigment formed by breakdown of heme present in hemoglobin

76
Q

Causes of Hyperbilirubinemia

A

Increased production of bilirubin

Decreased clearance of bilirubin

77
Q

What is Gilbert’s Syndrome caused by?

A

Reduction in the glucuronidation activity of the UGT1A1 enzyme

78
Q

Lab Results of Gilbert’s Syndrome

A

Elevated unconjugated bilirubin

Normal conjugated bilirubin

GI (20 decks)

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