GI problems II - Ow Flashcards
What colour is jaundiced urine?
Tea without milk (dark)
What colour are jaundiced stools?
Clay like and yellow
can you still get stones if you’ve had your gall bladder removed?
yes because they can still form in the duct
What can happen if the stone gets stuck for too long?
Can get infected
What is cholydocolithiasis?
Stone stuck in the duct
What is cholangitis?
when you have choledocolithiasis and infection (fever and chills etc)
What does colic pain mean?
Pain that comes and goes
What is Murphy’s sign?
Patient takes a deep breath with an examining hand just below the right costal margin. Sign for cholycistitis
Guarding?
not always involuntary
e.g. if you have cold hands and you touch someones abdomen or if patient ticklish = voluntary
When in pain, specifically peritonisim (localised) Peritonitis is generalised = voluntary
Why is cholycistitis painful?
because of inflammation. distention, swelling of visceral organs
This is inflammation of the gall bladder
Cholycistitis - what could be the imitating event
impaired bile flow or abnormal gall bladder contraction, build up of bile and because of stasis can cause infection in the gall bladder.
What are the commonest gallstones? Why do they form in the gall bladder?
Cholesterol stones (80% of stones in the gall bladder) because cholesterol is stored in the GB, so when outflow of bile impeded, you get stasis and concentration of cholesterol --> stones. Other stones are generally made from bilirubin and other combos (pigmented stones) Bile duct tends to from pigment stones
What initiates emptying of the gall bladder?
Cholecystokinin (hormone)
What is biliary colic?
The description of the right upper quadrant pain (descriptive term, not a diagnosis)
Cholelithiasis?
Someone has uncomplicated stones in their gall bladder
Choledocolithiasos
When you have a gall stone in the bile duct
what is the cystic duct?
It joins the gall bladder to the common duct
What do elevated GGT, ALP and bilirubin indicate?
Cholestasis - there is a reduction of bile flow out of the liver.
elevated bilirubin means jaundice (just because someone doesn’t report jaundice doesn’t mean they don’t have biochemical jaundice, need quite high levels to look yellow)
What is a potential consequence of cholangitis?
If you have a stone that is stuck in the distal common bile duct, if the stone is not relived. can get pancreatitis, because this organ also cannot secrete its enzymes.
Other rarer causes of cholestasis?
Autoimmune disorders that cause inflammation in the bile ducts - primary biliary cirrhosis - Primary sclerosing cholangitis Drugs can also cause cholestasis and tumors
Sinful verses painless jaundice
Painful most commonly caused by gall stones, whereas painless has a long list of differentials
The difference between primary and secondary stones in the common duct
Primary stones form in the duct whereas secondary stones fall out of the gall bladder into the bile duct.
so people can get continuous problems even after they’ve had their gall bladder removed
Charcot’s Triad
Fever
Jaundice
RUQ pain
If you have these three you are very likely to have cholangitis. But there will also be many people with cholangitis who don’t fill the triad.
How would a history and examination suggest the duct obstruction was cause by cancer
acute presentation
weight loss
He had positive murphy sign and guarding which are signs of inflammation which you don’t typically get with cancer
would normally feel a mass in the area, or the patient could be wasted or cachexic
Why would the patient have an elevated prothrombin time but this is restored to normal after an injection of vitamin K
Fat malabsorption and therefore malabsorption of vitamin K which is fat soluble
What about a dilated common bile duct
Could still have stones in it, but might not be able to see under US
Better imaging than US?
MRCP = magnetic resonance cholangiopancreatography
Useful for accurate visualisation of biliary tree
Advantage: non-invasive
Disadvantage: non-therapeutic
ERCP
Endoscopic retrograde cholangiopancreatography
Diagnostic and therapeutic
Advantage: therapeutic
Disadvantage: risk of complications
They go in there with a wire basket and draw it out
ERCP not the final step?
for people who have had an ERCP for choledocholithiasos and elective cholecystectomy needs to be performed at a future date to remove source of the gallstones i.e. the gall bladder.
What feature on the ultrasound would have suggested that obstruction to the common bile duct was the diagnosis?
Given the absence of this finding where is the obstruction to bile flow?
Dilated bile duct
Obstruction to the biliary system either intrahepatic or extra hepatic.
One biliary condition only affects the ducts inside the liver, the other affects both intra and extra hepatic bile ducts
primary biliary cirrhosis (PBC)
affects the intrahepatic bile ducts, on scan probably wont see any abnormalities because it affects the small bile ducts. Not even visible on MRI.
Only diagnose through liver biopsy.
Strongly associated with particular antibody: anti-mitochondrial antibody. so for diagnosis is just blood test
Diagnosis requires 2 out of 3 of:
- High ALP
- Positive AMA
- Liver biopsy
You can have cirrhosis as a complication but the term itself doesn’t mean you need to have cirrhosis.
PSC: primary sclerosing cholangitis
on MRI or US see diffuse stricturing in the intra and extra hepatic bile ducts, often associated with inflammatory bowel disease. No good autoantibody tests for the condition, so sometimes diagnosed with imaging or liver biopsy
Immune mediated but antigen unknown
- Autoimmune
- May be triggered by chronic or recurrent bacteria
- Ischaemic damage
PBC: presentation
Approximately 50-60% are asymptomatic
Progressive disease
- Jaundice
- Liver cirrhosis and related complications
Early symptoms
- fatigue
- pruritius
- May have steatorrhoea (fat malabsorption and fat soluble vitamin deficiencies)
What is the description of fatty diarrhoea
Bulky, sticky, hard to flush, oil droplets in the pan as well.
Why does cholestasis cause fibrosis
Instead of being in the canaliculi there is back flow of bile into the hepatocytes, it is an irritant
First get fibrosis then cirrhosis and while this is going on have associated symptoms
PBC associated conditions
striking dyslipidaemia
- different from other lipid disorders: lipoprotein X elevated, HDL elevated
- no obvious risk of atherosclerotic complications: Unless risk factors for coronary artery disease
Associated with osteopenia/osteoporosis
- Not due to vit D malabsorption (from fat malabsorption)
- Mechanism not well understood
- Low bone formation
Hypothyroidism
- Autoimmune
PSC: presentation
Often associated with ulcerative colitis (if you have PSC very likely to have USC, but many people with UC don’t have PSC)
50% asymptomatic
if symptomatic
- pruritius
- Fatigue
- May have steatorrhea (advanced disease), Fat malabsorption, fat soluble vitamin deficiencies
progressive disease
- Jaundice
- Cholangitis
- Liver cirrhosis and related complications (including hepatocellular carcinoma)
Can get recurrent infections with PSC (because affects the large and small ducts) whereas with PBC, you don’t get.
Progresses far more rapidly than PBC
PSC: associated conditions
Associated with osteopenia / osteoporosis
- Not due to vit D malabsorption
- MOA unknown
- Low bone formation
PSC treatment
No medication to slow progression
If develops jaundice/ cholangitis and due to a dominant structure in a large bile duct could treat with ERCP and dilation/ stenting.
Tumors causing obstructive jaundice
Pancreatic cancer - Head of pancreas
Cholangiocarcinoma (cancer of the bile duct) (when found at the hilum known as a Klatskin tumour, see dilation of the right and left hepatic bile ducts but not the extra hepatic bile ducts)
Cancer of the duodenum in the ampulla
Symptoms and signs of tumours causing obstructive jaundice
Painless jaundice
Palpable epigastric mass
Palpable gal bladder - courvoisiers sign
- As obstruction occurs slowly, pressure also increases slowly an the gall bladder distends to compensate for this and reduce pressure in biliary system
