gallbladder pathophysiology Flashcards
components of bile
water, bile acids (active ingredient), cholesterol, phospholipids, lecithn, electrolytes
Function of gallbladder and bile duct
gallbladder stores and concentrates bile when fasting, then contracts to deliver bile to duodenum. Ducts are route for excretion of cholesterol, minerals, drugs
compare bile in the liver vs gallbladder
Bile is much more concentrated in gallbladder
Control of gallbladder release
During fasting, PSNS vagal tone and CCK levels are decreased so sphincter of Oddi is closed. During eating, CCK and vagal tone increase, gallbladder and bile duct peristalsis, transport into duodenum
Causes of gallstones
Too much cholesterol in bile, too little water, or both. Caused by gallbladder/bile duct dysmotility, hereditary mutations in cholesterol chain structure, or inflammation in the gallbladder.
Types of gallstones
Cholesterol (white or yellow), brown (bacterial), or pigment stones (black and hard bile stasis)
What causes cholesterol gallstones
genetic mutations in cholesterol side chains, bile acid hypersecretion, gallbladder stasis, or a combination
What causes pigment stones
develop in patients with increased concentrations of bilirubin in the bile, especially those with hemolytic states such as sickle cell anemia. Also as result of stasis. More common in asians. Can develop in gallbladder or bile duct
Chief component of pigment stones
calcium bilirubinate
gallstones risk factors
5 Fs: obesity, female, age >30, family history, estrogen use, rapid weight loss, biliary obstruction
Diagnosis of gallstones
abd ultrasound, or CT if cause of abd pain is unclear. For stones in bile duct, MRI of biliary tree (MRCP: magnetic resonance cholangiopancreatography) or endoscopic retrograde cholangiopancreatography (ERCP).
gallstone treatment
endoscopic retrograde cholangiopancreatography (ERCP)
Gallstone complications
biliary colic, acute cholecystitis, ascending cholangitis, gallstone pancreatitis, gallbladder carcinoma
What is biliary colic
•Caused by movement of stone into cystic duct or gallbladder neck
biliary colic symptoms
•Intermittent pain in epigastrium or RUQ. After meals, particularly fatty foods. Peaks in an hour, remits 3-8 hrs later
biliary colic management
•Laparoscopic cholecystectomy is curative.
Acute calculus cholecystitis
•Stone in cystic duct or gallbladder neck. Bacteria colonization, transmural inflammation. GB, perforation, sepsis or death may result if untreated
Acute calculus cholecystitis presentation
–Severe pain in RUQ, nausea, fever. Murphys sign (pt stops exhaling on palpation of RUQ)
Acute calculus cholecystitis treatment
NPO (rest), IV hydration, IV antibiotics, surgical removal of gallbladder, percutaneous drainage if too ill for surgery
Acalculous cholecystitis
Usually from ischemia of gallbladder. Risk factors = sepsis, recent surgery, trauma/burns, hypotension.
Choledocholithiasis
stones in bile ducts, most migrate from gallbladder.
Choledocholithiasis symptoms
jaundice, dark urine, abd pain, acute pancreatitis
Choledocholithiasis diagnosis and management
liver chemistries, ultrasound, MRCP or ERCP. Treatment: ERCP with extraction and/or lithotripsy, surgery if refractory
Ascending cholangitis
Bacterial infection of bile duct. Almost always a complication of choledocholithiasis
Ascending cholangitis symptoms
Charcots triad: fever, RUQ pain and jaundice. Sepsis or death may occur if untreated
Ascending cholangitis management and diagnosis
history, labs, US are suggestive, but ERCP is definitive for diagnosis and management. Hospital admit NPO, broad spectrum IV Abx, IV fluids.
Causes of benign biliary stricture
surgery, radiation, Primary sclerosing cholangitis (PSC), chronic pancreatitis, autoimmune pancreatitis, chronic choledocholithiasis
Causes of malignant biliary stricture
Pancreatic cancer, Cholangiocarcinoma, Gallbladder cancer, Ampullary cancer
Biliary stricture presentation
RUQ pain, cholestasis (jaundice, dark urine, acholic stools, pruritus),
Biliary stricture labs
liver function tests elevated. Alk phos/GGT, bilirubin»_space; ALT/AST
Biliary stricture diagnosis
ultrasound or CT showing dilated ducts. MRCP or ERCP for confirmation. Biopsy to differentiate benign vs malignant
Biliary stricture management
ERCP with dilation or stenting. Biopsy to rule out malignancy. Surgery if refractory or malignant
Primary sclerosing cholangitis (PSC)
an idiopathic, intra- and extrahepatic inflammatory disorder causing numerous Benign biliary strictures throughout the biliary tree. association with IBD (UC > crohns)
Primary sclerosing cholangitis (PSC) symptoms and labs
RUQ pain, jaundice, fevers all due to cirrhosis of liver. Alk phos/GGT > AST/ALT. Bilirubin rises late.
Primary sclerosing cholangitis (PSC) therapy
none effective except liver transplant. ERCP with stent if jaundiced.
What is sphincter of Oddi dysfunction
motility disorder- intermittent.
sphincter of Oddi dysfunction presentation and diagnosis
–Recurrent RUQ pain. ALT/AST/Alk phos elevations. Dilated bile duct on US. ERCP with sphincter of Oddi manometry
Sphincter of Oddi dysfunction treatment
biliary sphincterotomy
