GI test 2: Gallbladder disorders Flashcards
What is cholelithiasis? Most stones result from what?
presence of one or more calculi, most d/o’s of teh biliary tract result from gallstones
Prevalence and RF’s of cholelithiasis?
prevalence: developed countries: 10% of adults & 20% ppl >65 yo have gallstones
RFs: 5 F’s: female, fat, fertile, forty, family hx; female, obesity, western diet, american indian ethnicity
Pathophys of cholelithiasis. Types of stones?
biliary sludge= precursor to gallstones develop during GB stasis
- cholesterol stones: >85% in western world, bile supersaturated w/chol usu from excessive chol secretion (diabetes, obesity)
- black pigment stones: small & hard, Ca2+ bilirubinate & inorganic salt
- brown pigment stones: soft & greasy, bilirubinate & FA’s, form during infxn, inflam & parasitic infxns
Ssxs of cholelithiasis?
80% asx, biliary colic, RUQ pain that may radiate into back or down R arm, pain beings suddenly, intense in 15 mins-1 hr, steady for up to 12 hrs, gradually disappears leaving dull ache, N/V common w/attacks, fever UNCOMMON
W/u cholelithiasis
labs usu unrevealing
abd US diagnostic
What is cholecystitis?
inflam of GB, acute or chronic
What is acute cholecystitis? cause? prevalence? complication of what?
inflam of GB, develops over hrs usu dt gallstone obstructing cystic duct
most common complication of cholelithiasis, >95% who have also have cholelithiasis
Ssxs of cholecystitis?
pain similar in quality & location to biliary colic but lasts >6 hrs
begins to subside in 2-3 d, resolves in 1 wk in most, vomiting common
PE of cholecystitis?
R subcostal tenderness, + Murphy’s, FEVER
W/u for cholecystitis?
abd US, cholescintigraphy if US equivocal, abd CT can help identify complications (GB performation–> peritonitis, pancreatitis)
What is chronic cholecystitis? range of damage?
longstanding GB inflam, almost always dt stones
damage ranges from modest infiltrate to fibrotic, shrunken GB
extensive calcification= PORCELAIN GB
Ssxs of chronic cholecystitis
recurrent biliary colic
PE of chronic cholecysitis
upper abdominal tenderness, afebrile
W/u for chronic cholecystitis
abd US, gallstones & mb shrunken, fibrotic GB
What is acalculous biliary pain? when would you suspect?
biliary colic w/o gallstones, dt structural or functional d/o’s, suspected in pts w/biliary colic & DI can’t detect gallstones
Causes of acalulous biliary pain?
microscopic stones abn GB emptying overly sensitive biliary tract sphincter of Odi dysfxn hypersensitivity of adjacent duodenum possibly gallstones that have passed
W/u of acalculous biliary pain
labs may reveal abn biliary tract (elevated alk phos, bilirubin, AST, ALT) or pancreatic abn (elevated lipase)
abd US, endoscopic ultrasonography, ERCP w/biliary manometry may reveal sphincter of Odi dysfxn
What is postcholecystectomy syndrome?
occurrence of abd sxs after cholecystectomy
Causes of postcholecystectomy syndrome? Consequences?
alterations in bile flow dt loss of reservoir fxn of GB
consequences: increased bile flow into upper GI (esophagitis & gastritis) or lower GI (diarrhea, colicky lower abd pain)
Other contributing factors of postcholecystectomy syndrome?
papillary stenosis (rare), retained bile duct stone, pancreatitis, GERD
Prevalence of postcholecystectomy syndrome?
5-40% of post-op pts
Ssxs of postcholecystectomy syndrome?
dyspepsia, non-specific biliary sxs rather than true biliary colic, persistent abd pain
W/u of postcholecystectomy syndrome?
biliary manometry during ERCP (ERCP has increased risk of inducing pancreatitis): shows increased P in biliary tract w/pain, slowed hepatic hilum-duodenal transit time suggests sphincter of Odi dysfxn
What is choledocholithiasis?
presence of stones in bile ducts causing biliary colic, obstruction & gallstone pancreatitis or cholangitis
Types of choledocholithiasis
primary stones: usu brown stones, form in bile duct
secondary stones: usu chol, form in GB & migrate to bile ducts, developed countries >85% are these
residual stones: missed at time of cholecystectomy (>3 yrs later)
recurrent stones: recur >3 yrs post-op
Ssxs of choledocholithiasis
stones may pass into duodenum= asx, biliary colic when duct partially obstructed
course of choledocholelithiasis
more complete obstruction causes: dust dilation, jaundice, eventually cholangitis (bac infxn), stones that obstruct Ampulla of Vater can cause gallstone pancreatitis
What is cholangitis? 3 types?
bile duct infxn & inflm, can lead to strictures, stasis & choledocholithiasis
acute cholangitis= EMERGENCY
recurrent pyogenic cholangitis
sclerosing cholangitis
What is acute cholangitis? Common causes?
AN EMERGENCY!!!
bile duct obstruction & subsequent bac ascend from duodenum
most from common bile duct stones but bild duct obstruction can also occur from tumors & other conditions
common bugs: gram-neg bac, less commonly gram pos & mixed anaerobes
Ssxs of acute cholangitis?
CHARCOT’S TRIAD: abd pain, jaundice, fever or chills
PE for acute cholangitis?
Morbidity rate?
RUQ abd tenderness, hepatomegaly and tenderness, often containing abscesses, confusion & hypoTN predict ~50% of mortality rate
HIGH MORBIDITY
What is recurrent pyogenic cholangitis?
intrahepatic brown stones lead to cycles of obstruction, infxn & inflam
What type of stones form in recurrent pyogenic cholangitis? Where are they? Prevalence? Causes/RFs?
brown stones: sludge & bac debris in the bile ducts
prevalence: occurs in SE asia
causes: undernutrition & parasitic infxn increases susceptibility
When should you suspect a common duct stone? When would you suspect acute cholangitis?
common duct stone: in pt w/jaundice, biliary colic
acute cholangitis: jaundice, biliary colic and FEVER and leukocytosis present
W/u for choledocholithiasis and cholangitis? (labs & procedure)
labs: suggesting stone/extrahepatic obstruction= elev bilirubin, alk phos, ALT, GGT
suggesting acute cholangitis: leukocytosis, AST & ALT elevated suggest hepatic necrosis dt microabscesses
procedure: abd US
What is sclerosing cholangitis? 2 subclasses? Causes in each subclass?
chronic choleastatic syndromes w/patchy inflam, fibrosis & strictures of intrahepatic & extrahepatic bile ducts mb primary (no known cause) or secondary (immune deficiencies, congenital in children, acquired in adults (AIDS)) which leads to inflam & fibrosis of bile ducts
What is primary sclerosing cholangitis? prevalence? RF’s?
most common form
no known cause
80% have IBD, usu ulcerative colitis
Ssxs of sclerosing cholangitis?
progressive fatigue then pruritis, jaundice later, steatorrhea & deficiencies of fat sol vits, syptomatic gallstones & choledocholithitasis develop in ~75%, some asx until late in course & present w/hepatosplenomegaly or cirrhosis
W/u (labs & imaging) for sclerosing cholangitis?
labs: elev alk phos, GGT, gamma globulin & IgM; antimito ab negative
imaging: 1st US to exclude extrahepatic biliary obstruction, MRCP: multiple strictures in intrahepatic & extrahepatic bile ducts
ERCP: 2nd choice b/c invasive
liver bx not needed for dx but will show bile duct proliferation, periductal fibrosis, inflam & loss of bile ducts
Complications of sclerosing cholangitis?
cholangiocarcinoma develops in 10-15% of pts
what is AIDS cholangiopathy?
biliary obstruction secondary to biliary tract strictures dt various opportunistic infxns
before antiretroviral tx, cholangiopathy occurred in about 25% of AIDS pts, esp those w/low CD4 counts
Ssxs of AIDS cholangiopathy?
RUQ & epigastric pain, severe pain= papillary stones, milder pain- sclerosing cholangitis; diarrhea, few have fever & jaundice
W/u of AIDS cholangiopathy?
labs: elev alk phos, GGT
imaging: ERCP & US
What are the types of tumors of the GB & bile ducts? What can they cause?
Can cause extrahepatic biliary obstruction
cholangiocarcinoma
GB carcinoma
GB polyps
Prevalence of cholangiocarcinoma? Most likely to occur? RF’s? Ssxs? PE?
rare occurrence but usu malignant, usu in extrahepatic bile duct
RF’s: primary sclerosing cholangitis, older, infestation w/liver flukes, choledochal cyst
Ssxs: pruritis, painless obstructive jaundice, abd pain, anorexia & wt loss
PE: non-tender palpable mass (courvoisier’s sign), hepatomegaly
GB carcinoma prevalence, RF’s, Ssxs, prognosis
uncommon
RF’s: native american, large gall stones, GB calcification dt chronic cholecystitis (porcelain GB), nearly all have gallstones (70-90%)
Ssxs: varies w/course of dz, asx–> biliary pn–> advanced dz: wt loss, constant pn, abd mass, obstructive jaundice
prognosis: median survival 3 mo., cure possible if found early
What are GB polyps?
usu asx benign mucosal projections in lumen of GB, most sm., usu found on US, require no tx
