Gastroenterology (Biliary) Flashcards
Gallstones
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)
RF of gallstones
4 Fs
- Fat, Fair, Female,Forty
summary of presentaiton of gallstones
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
Basic anatomy of the bile duct
- 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.
investigations for Gallstones
- LFTs
- US
- MRCP
- ERCP
- CT
liver function tests
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
US
- Can locate gallstone
- Limited by: pt weight, gaseosus bowel obstructing view and discomfort
*
MRCP
- Magnetic resonance cholangio-pancreatography (MRCP)
- MRI scan- detailed image of biliary system
ERCP
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
biliary colic pathophysiology
- 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
presentation of biliary colic
- 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
management of biliary colic
pain relief and removal
acute cholecystitis pathophysiology
Inflammation of gallbladder caused by full impaction of stone in cystic duct- preventing gallbladder draining
presentation of acute cholecystitis
- 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
management of acute cholecystitis
o pain relief and Ab
o Cholecystectomy
Gallbladder empyema
infected tissue and puss in gallbladder- IV antibiotics and surgery
Ascending cholangitis
Infection and inflammation in bile duct. High mortality rate due to sepsis.
Causes
- Gallstone in CBD or infection due to ERCP
- E.coli, klebsiella
presentation of ascending cholangitis
Charcots triad
- Inflammation
- RUQ pain,
- Jaundice (when stone reaches common bile duct)
management of ascending cholangitis
Primary biliary cholangitis (PBC)
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.
risk factor PBC
- female
- history of autoimmune disease
presentation of PBC
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
investigations for PBC
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
management of PBC
First line: Ursodeoxycholic acid
Others
* Cholestyramine for pruritus
* Liver transplant
complication of PBC
- Liver fibrosis and cirrhosis
- Hepatocellular carcinoma
- Malabsorption of fats and fat-soluble vitamins
- Hypercholesterolaemia
- The use of statins is safe in patients with PBC
primary sclerosing cholangitis
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.
PSC associated with
ulcerative colitis
- more common in men
presentation of PSC
Fatigue
Jaundice
Pruritus
Vague right upper quadrant pain
investigations of PSC
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
management of PSC
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.
