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Gastrointestinal 2 > Gallstones > Flashcards

Gallstones Flashcards

1
Q

What causes jaundice?

A

Excess accumulation of the pigment bilirubin <21μmol/L

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2
Q

What are the three classes of jaundice?

A

Pre-hepatic

Hepatic

Post-hepatic

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3
Q

What substances are tested in liver function tests?

A

ALP - Alkaline phosphatase

ALT and AST - Alanine amino transferase

Bilirubin

GGT - Gamma glutamyl transferase

Proteins

Serum albumin and serum bilirubin are tests of hepatic function.

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4
Q

What is the difference between ALT and AST?

A

ALT and AST are released in response to hepatocelluar injury.

ALT is more specific to hepatocytes but also present in kidney and muscle.

AST is also present in the heart, rbc’s and muscle.

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5
Q

ALP

A

Alkaline phosphotase, released by the liver and bone - so raised in children.

ALP is raised in canalicular obstruction.

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6
Q

GGT

A

GGT is present in the liver, pancreas and renal tubules - helps to tell if raised ALP is from bone or the liver.

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7
Q

Biliary tree Diagram

A
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8
Q

Explain the livers production and circulation of bile.

A
  1. RBC: Broken down as ααchain removed from globin to leave Heme. Heme is oxidized to bilivirdin, then reduced to bilirubin.
  2. At this stage Bilirubin is insoluble And must be protein bound = UNCONJUGATED.
  3. The liver “CONJUGATES” bilirubin To αα which makes it water soluble.
  4. Conjugated bilirubin is excreted from the liver With primary and secondary bile acids. This is called BILE.
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9
Q

What happens to the bilirubin in bile once it leaves the liver?

A

Conjugated bilirubin in bile is converted to UROBILOGEN by bacterial proteases, Then to stercobilinogen, which is excreted in the faeces.

Urobilinogen Excreted in kidney.

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10
Q

Summary of bilirubin metabolism:

A

Bile is excreted into the bowel, which after metabolism will form urobilinogen and stercobilin.

Stercobilin will give stool the “normal” brown colour and a small amount (approx. 5%) of urobilinogen will be renal excreted.

Overall the system is 80% efficient with both bilirubin and urobilinogen reabsorbed.

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11
Q

What are potential causes of pre-hepatic jaundice?

A

HAEMOGLOBINOPATHIES - sickle cell / thalassemia

CONGENTIAL - gilbert’s syndrome

(hyperbilirubinaemia’s)

TRANSFUSION

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12
Q

Thalassemia

A

Thalassemia is a blood disorder passed down through families (inherited) in which the body makes an abnormal form or inadequate amount of hemoglobin. Hemoglobin is the protein in red blood cells that carries oxygen. The disorder results in large numbers of red blood cells being destroyed, which leads to anemia.

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13
Q

What can detect pre-hepatic jaundice?

A

The direct Coombs test is used to test for autoimmune hemolytic anemia—that is, a condition where the immune system breaks down red blood cells, leading to anemia. The direct Coombs test is used to detect antibodies or complement proteins attached to the surface of red blood cells.

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14
Q

What do liver function tests show in cases of pre-hepatic jaundice?

A

Increased bilirubin

All other LFTs normal.

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15
Q

What are the causes of hepatic jaundice?

A

Drugs

Infection

Auto-immune

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16
Q

Summary of jaundice

A

Jaundice refers to a yellowing of the skin scleraeand mucosa from increased plasma bilirubin.

Jaundice is classified by the site of the problem - pre-hepatic, hepatic or post-hepatic, or by the type of circulating bilirubin - conjugated or unconjugated.

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17
Q

What’s the difference in conjugated vs unconjugated bilirubin?

What’s the significance of this?

A

Conjugated is water soluble where as unconjugated is water insoluble and must be protein bound.

Unconjugated bilirubin does not enter the urine resulting in unconjugated hyperbilirubinaemia.

Conjugated bilirubin is water soluble and so enters the urine making it dark, and the faeces making stools pale.

18
Q

What does dark urine and pale stools suggest?

A

Conjugated bilirubin in urine (bilirubinuria) gives urine an abnormally dark brown color. Thus, the presence of pale stool (stercobilin absent from feces) and dark urine (conjugated bilirubin present in urine) suggest an obstructive cause of jaundice.

19
Q

What can cause conjugated hyperbilirubinaemia?

A

Hepatocellular dysfunction: - anything that can cause damage to hepatocytes.

Impaired hepatic excretion (cholestasis): primary biliary cholangitis, common bile duct gall stones, Mirrizzi syndrome.

20
Q

What are potential causes of unconjugated hyperbilirubinaemia?

A
  1. Overproduction of bilirubin due to haemolysis.
  2. Impaired hepatic uptake: Drugs / Ischaemic hepatitis.
  3. Impaired conjugation: Gilbert’s syndrome.
  4. Neonatal jaundice cause by the above combined.
21
Q

Gilbert’s syndrome

A

Gilbert’s syndrome is an inherited condition where the liver in unable to process a substance called bilirubin properly.

22
Q

Pale stools + dark urine ≈

A

≈ cholestatic jaundice

23
Q

Bilirubin metabolism summary

A
24
Q

Mirizzi syndrome

A

Mirizzi syndrome is defined as common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Patients with Mirizzi syndrome can present with jaundice, fever, and right upper quadrant pain.

25
Q

Biliary colic

  • presentation?
  • treatment?
A

Gallstones are symptomatic with cystic duct obstruction or if passed into the common bile duct.

Presentation: RUQ pain which radiates to back with or without jaundice.

Treatment: Analgesia + rehyrdrate, elective laproscopic cholecystectomy.

26
Q

What is acute cholecystitis and how does it present?

A

Stone impaction on the neck of the bladder which may cause continuous epigrastric / RUQ pain, referred pain to the right shoulder, vomiting, fever, local peritonitis.

Note: Main difference from biliary colic is the inflammatory component e.g local perotonitis and fever.

27
Q

Murphy’s test

A

Causes pain on inspiration as inflamed gall bladder presses on fingers.

28
Q

Cholangitis

A

Bile duct infection - Causes RUQ pain, jaundice and rigors.

29
Q

Post-hepatic jaundice is conjugated or unconjugated?

A

Conjugated

30
Q

The presence of bilirubin in the urine guarantees what diagnosis?

A

Obstructive jaundice.

31
Q

What information do ultrasounds give?

A

Ultrasounds show biliary dilation, can also show gallstones can also show liver metastases and indicate cirrhosis.

32
Q

Investigation of jaundice when there is no hepatic or bile duct dilation.

A
33
Q

MRCP

A

MRCP stands for magnetic resonance cholangiopancreatography. MRCP produces detailed images of your liver, gallbladder, bile ducts, pancreas and pancreatic duct.

34
Q

What is the treatment in cases of diagnosed obstructive jaundice?

A
  • Are there bile duct stones
  • ERCP and endoscopic sphincterotomy (ES). Cholecystectomy
35
Q

Choledochal cyst

A

A choledochal cyst is a congenital anomaly of the duct (tube) that transports bile from the liver to the gall bladder and small intestine.

30x increased risk of cholangiocarcinoma.

36
Q

Sclerosing cholangitis and Biliary cirrhosis:

A
37
Q

Cholangiocarcinoma

A
38
Q

How do gallstones form?

A

Gallstones are thought to develop because of an imbalance in the chemical make-up of bile inside the gallbladder. In most cases the levels of cholesterol in bile become too high and the excess cholesterol forms into stones.

39
Q

Break down of how gall stones can cause:

  1. Acute pancreatitis
  2. Cholangitis
  3. Mirizzi syndrome
  4. Gallstone ileus
A
  1. Actue pancreatitis - stones in the bile duct can block the ampulla causing acute pancreatitis.
  2. Cholangitis - stone in the bile duct causing stagnation of bile in the gallbladder can lead to infection - cholangitis. Presents with Charcot’s triad.
  3. Mirizzi syndrome - stone in GB compresses common bile duct causing it to narrow.
  4. Gall stone ileus - Stone erodes through GB into the duodenum.
40
Q

Charcot’s triad

A

RUQ pain

Jaundice

Rigors

41
Q

Gallstone endoscopy

A
42
Q

Primary biliary cholangitis (PBC) is what and caused by what?

A

Primary biliary cholangitis (PBC), previously known as primary biliary cirrhosis, is an autoimmune disease of the liver. It results from a slow, progressive destruction of the small bile ducts of the liver, causing bile and other toxins to build up in the liver, a condition called cholestasis.

Gastrointestinal 2 (24 decks)

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