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Medicine (Year 5) > Gastroenterology (Biliary) > Flashcards

Gastroenterology (Biliary) Flashcards

1
Q

Gallstones

A

Stones form in the gallbladder and are made from concentrate bile from the bile duct (mostly cholesterol). Leads to complications such as:

  • Biliary colic
  • Acute cholecystitis
  • Acute cholangitis
  • Acute pancreatitis (when stones block the pancreatic duct)
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2
Q

RF of gallstones

A

4 Fs
- Fat, Fair, Female,Forty

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3
Q

summary of presentaiton of gallstones

A

1) Asymptomatic (sometimes)

2) Biliary colic

  • After meal
  • RUQ pain/ N+V
  • 3-8 hours

3) Acute cholecystitis

  • Positive murphy’s sign

4) Ascending cholangitis

  • Charcots triad-jaundice
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4
Q

Basic anatomy of the bile duct

A
  • The right hepatic duct and left hepatic duct leave the liver and join together to become the common hepatic duct.
  • The cystic duct from the gallbladder joins the common hepatic duct halfway along.
  • The pancreatic duct from the pancreas joins with the common bile duct further along.
  • When the common bile duct and the pancreatic duct join they become the ampulla of Vater, which then opens into the duodenum.
  • The sphincter of Oddi is a ring of muscle surrounding the ampulla of Vater that controls the flow of bile and pancreatic secretions into the duodenum.
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5
Q

investigations for Gallstones

A
  • LFTs
  • US
  • MRCP
  • ERCP
  • CT
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6
Q

liver function tests

A

Bilirubin

  • Raised bilirubin (jaundice) due to blockage in the in common bile ducts
  • Pale stool and dark urine
  • Causes: gallstones, chlangiocarcinoma or tumour of pancreas

Alkaline phosphatase

  • Biliary obstruction
  • Also- liver or bone problems and pregnancy
  • Gamma-glutamyl transferase GTT to check biliary problem

Alanine aminotransferase (ALT) and Aspartate aminotransferase (AST)

  • Hepatocellular injury
  • ALT better
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7
Q

US

A
  • Can locate gallstone
  • Limited by: pt weight, gaseosus bowel obstructing view and discomfort
    *
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8
Q

MRCP

A
  • Magnetic resonance cholangio-pancreatography (MRCP)
  • MRI scan- detailed image of biliary system
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9
Q

ERCP

A

Endoscopic retrograde cholangio- pancreatography

Involves inserting endoscope down oesophagus, past stomach and into the sphincter of oddi up into common bile duct

  • Main indication: clear stones in bile duct

Allows operator to:

  • Inject contrast and take x-rays
  • Clear stones
  • Insert stents
  • Biopsy of tumour

Complications
* Excessive bleeding
* Cholangitis (infection)
* Pancreatitis

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10
Q

biliary colic pathophysiology

A
  • Due to cholecystokinin (CCK) release after meal, which causes the gall bladder contract and push a gallstone up against the neck of the gall bladder- temporary obstruction of biliary duct
  • Gall stones happily sitting within gall bladder, but can cause sudden onset of RUQ pain typically a few hours after eating a fatty meal
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11
Q

presentation of biliary colic

A
  • Severe, colicky epigastric or right upper quadrant pain
  • Radiates to back
  • Often triggered by meals (particularly high fat meals)
  • Lasting between 30 minutes and 8 hours
  • May be associated with nausea and vomiting
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12
Q

management of biliary colic

A

pain relief and removal

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13
Q

acute cholecystitis pathophysiology

A

Inflammation of gallbladder caused by full impaction of stone in cystic duct- preventing gallbladder draining

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14
Q

presentation of acute cholecystitis

A
  • RUQ pain
  • Fever, N and V
  • Tachycardia
  • Raised CRP
  • Positive Murphy sign ->place a hand on right side of the patients stomach and ask them to take a deep breathe in- will push gall bladder down and cause them to take a sharp breathe in pain (wont happen on left hand side)
  • Pain which radiates to shoulder
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15
Q

management of acute cholecystitis

A

o pain relief and Ab
o Cholecystectomy

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16
Q

Gallbladder empyema

A

infected tissue and puss in gallbladder- IV antibiotics and surgery

17
Q

Ascending cholangitis

A

Infection and inflammation in bile duct. High mortality rate due to sepsis.

Causes
- Gallstone in CBD or infection due to ERCP
- E.coli, klebsiella

18
Q

presentation of ascending cholangitis

A

Charcots triad

  • Inflammation
  • RUQ pain,
  • Jaundice (when stone reaches common bile duct)
19
Q

management of ascending cholangitis

A
  • acute management of sepsis and acute abdomen (BUFALO)
  • imaging to diagnose CBD stone and cholangitis
    o most sensitive MRCP or endoscopic ultrasound
  • ERCP required for stone removal
  • Percutaneous transhepatic cholangiogram
20
Q

Primary biliary cholangitis (PBC)

A

is an autoimmune liver disease characterised by the destruction of the small bile ducts of the liver, leading to cholestasis (the stopping of bile flow). Eventually, the damage leads to scarring, fibrosis, and eventually cirrhosis in its late stages.

21
Q

risk factor PBC

A
  • female
  • history of autoimmune disease
22
Q

presentation of PBC

A

Patients tend to be asymptomatic or have very vague symptoms, typically itching and fatigue. Other features include:

  • Jaundice – this is not commonly seen in PBC
  • Raised ALP despite no symptoms
  • Hepatomegaly
23
Q

investigations for PBC

A

LFTs:

  • Show cholestatic results, i.e. ALP and gamma-GT are more significantly increased compared to AST and ALT, which may be normal/slightly increased

Autoantibodies:

  • Elevated IgM
  • Anti-mitochondrial antibodies are present in up to 95% of patients
  • Anti-nuclear antibodies are present in around 30% of patients

Abdominal ultrasound:

  • Rules out obstruction

Magnetic resonance cholangiopancreatography (MRCP):

  • Rules out obstruction, which must be excluded
24
Q

management of PBC

A

First line: Ursodeoxycholic acid

Others
* Cholestyramine for pruritus
* Liver transplant

25
Q

complication of PBC

A
  • Liver fibrosis and cirrhosis
  • Hepatocellular carcinoma
  • Malabsorption of fats and fat-soluble vitamins
  • Hypercholesterolaemia
  • The use of statins is safe in patients with PBC
26
Q

primary sclerosing cholangitis

A

Primary sclerosing cholangitis (PSC) is characterised by inflammation and scarring of the bile ducts. Its pathophysiology is not understood as despite the presence of autoantibodies and the association with other autoimmune diseases, PSC does not behave similarly to other autoimmune diseases and does not respond to immunosuppressants.

27
Q

PSC associated with

A

ulcerative colitis

  • more common in men
28
Q

presentation of PSC

A

Fatigue
Jaundice
Pruritus
Vague right upper quadrant pain

29
Q

investigations of PSC

A

LFTs:

  • Show cholestatic results, i.e. ALP and gamma-GT are more significantly increased compared to AST and ALT, which may be normal/slightly increased

Autoantibodies:

  • Perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) may be positive, but is not specific to PSC

Abdominal ultrasound:

  • An initial test to rule out obstruction

Magnetic resonance cholangiopancreatography (MRCP):

  • Diagnostic test which shows intra- and/or extrahepatic structures
30
Q

management of PSC

A

No effective medical treatment is available.

Treatment is mainly symptomatic and a liver transplant is the only option available for advanced disease.

Cholestyramine may help with pruritus.

31
Q
A

Medicine (Year 5) (34 decks)

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