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Hepatobiliary and pancreatic disorders > Goljan Gallbladder and Biliary Tract disease > Flashcards

Goljan Gallbladder and Biliary Tract disease Flashcards

1
Q

Epidemiology of choledochal cyst

A

most common cyst in biliary tract in children < 10yo

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2
Q

clinical findings of choledochal cyst

A

abdominal pain w/ persistent or intermittent jaundice;

increased risk of cholelithiasis, cholangiocarcinoma, cirrhosis

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3
Q

Diagnosis of choledochal cyst

A

ultrasound is gold standard;

endoscopic retrograde cholangiopancreatography (ERCP => ID’s intra- and extrahepatic cysts along w/ sites of obstruction

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4
Q

Tx of choledochal cyst

A

surgery

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5
Q

Define Caroli disease

A

AD (adult) and AR (kids) types;
segmental dilatation of intrahepatic bile ducts;
portal tract fibrosis

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6
Q

clinical findings of Caroli disease

A

assoc w/ polycystic kidney disease;
increased risk of cholangioCA;
increased risk of intrahepatic cholelithiasis, cholangitis, hepatic abscesses, portal HTN

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7
Q

Tx of Caroli disease

A

surgical resection of involved lobe;

liver transplantation

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8
Q

MC malignancy of bile ducts

A

cholangioCA

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9
Q

causes of cholangioCA

A

primary sclerosing cholangitis;
Clonorchis sinensis (chinese liver fluke);
Thorotrast (thorium dioxide);
Choledochal cyst, Caroli disease

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10
Q

locations of cholangioCA

A

ampulla or common bile duct (MC);
junction of R/L hepatic duct => Klatskin tumor;
intrahepatic

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11
Q

clinical finding of cholangioCA

A 
obstructive jaundice;
palpable gallbladder (Courvoisier's sign);
hepatomegaly
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12
Q

Diagnosis of cholangioCA

A

ultrasound;

ERCP

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13
Q

Tx for cholangioCA

A

surgery

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14
Q

Bile components

A 
bile salts/acids (67%)
phospholipid;
protein;
free CH;
conjugated bilirubin;
water, electrolytes, bicarbonate
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15
Q

What is the purpose of bile salts/acids?

A

hepatic product of CH metabolism;
water soluble;
detergent action renders CH soluble in bile

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16
Q

What does phospholipid serve as in bile?

A

mainly lecithin;
hydrophobic;
solubilizes CH in bile

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17
Q

What are the types of gallstones?

A 
cholesterol stones (75%);
pigment stones (black, brown)
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18
Q

Describe cholesterol stones

A

stones of mixed composition typically radiolucent;

stones contain CH, Ca+ carbonate, some bilirubin pigment => radiopaque if w/ CaHCO3;

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19
Q

What are black pigment stones a sign of?

A

chronic extravascular hemolytic anemia (sickle cell anemia, hereditary spherocytosis);
excess bilirubin in bile produces Ca+ bilirubinate

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20
Q

What are the brown pigment stones a sign of?

A

sign of infection in common bile duct (CBD);

commonly in Asians

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21
Q

pathogenesis of cholesterol stones

A

supersaturation of bile w/ cholesterol;

decreased bile salts/acids (normally solubilize cholesterol in bile)

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22
Q

Risk factors for cholesterol stones

A 
female, OCP
>40;
obesity (cholesterol increased in bile);
rapid weight loss;
use of lipid lowering drugs;
Native americans
23
Q

complications assoc w/ stones

A

cholecystitis (MC);
CBD obstruction;
Gallbladder cancer;
acute pancreatitis

24
Q

Epidemiology of acute cholecystitis

A

women > men
50-60 yo;
native americans;
assoc w/ gallstones in 95% of cases

25
Q

describe stage 1 development of acute cholecystitis

A

stone lodges in cystic duct;
midepigastric colicky pain occurs from GB contraction against cystic duct;
N/V WITHOUT pain relief

26
Q

How does a stone get lodged in cystic duct in acute cholecystitis?

A

stimulus of food causes gallbladder contraction => forces into cystic duct

27
Q

describe stage 2 development of acute cholecystitis

A

stone becomes impacted in cystic duct;
mucus accumulates behind obstruction;
chemical irritation of mucosa;
bacterial overgrowth (no invasion) of E. coli;
pain shifts to RUQ => dull, continuous aching pain => pain radiation to right scapular/shoulder

28
Q

describe stage 3 of acute cholecystitis

A

bacterial invasion of GB wall;
localized peritonitis w/ rebound tenderness;
positive Murphy sign;
absolute neutrophilic leukocytosis;
attack subsides if stone falls out of cystic duct

29
Q

describe stage 4 of acute cholecystitis

A

perforation;

wall tension from GB distention compresses lumens of intramural vessels => gangrenous necrosis

30
Q

What are diseases NOT associated w/ stones but may cause acute cholecystitis?

A

AIDS (CMV or cryptosporidium infection);

severe volume depletion

31
Q

clinical findings in acute cholecystitis

A 
fever;
appropriate stage related findings;
vomiting (75%);
radiation of pain to right scapula/shoulder;
Murphy sign;
Jaundice (common bile duct stone);
palpable gallbladder
32
Q

Lab findings w/ acute cholecystitis

A

absolute neutrophilic leukocytosis w/ L shift and WBC > 12,000 cells/mm^3;
increased AST/ALP;
increased serum amylase and lipase assoc w/ pancreatitis;
increased serum bilirubin > 4mg/dL (CBD stone)

33
Q

What type of stone does estrogen cause?

A

Cholesterol

34
Q

how does estrogen increase cholesterol stone formation?

A

increases HDL synthesis which transports cholesterol from peripheral tissue to liver for excretion in bile;
upregulates LDL receptor synthesis in hepatocytes and increases HMG-CoA reductase activity which is rate-limiting enzyme in CH synthesis

35
Q

What are the tests to identify stones?

A

ultrasound (gold standard);
Plain film (Xray);
hepatobiliary iminodiacetic acid radionuclide scan or HIDA scan

36
Q

What is sensitive and not sensitive to find on ultrasound for stones?

A

stones > 12mm in diameter;
detects sludge;
evaluates GB wall thickness;
NOT effective in ID’ing CBD stones

37
Q

what is the downside of Xray when looking for stones?

A

only 20% are radioopaque

38
Q

Where is a HIDA scan good for finding stones?

A

stones in cystic duct=> no visualization of GB;

CBD stones => no tracer in duodenum

39
Q

what are indications for CBD exploration?

A

jaundice;
CBD dilatation > 12mm
no stones in GB;
acute pancreatitis

40
Q

Tx for acute cholecystitis

A

cholecystectomy;
ERCP w/ sphincterotomy to extract CBD stone
Meperidine for pain => NO morphine as will cause sphincter of Oddi to contract and worsen pain;
piperacillin-tazobactam

41
Q

Epidemiology of chronic cholecystitis

A

most common symptomatic disorder of GB

42
Q

pathogenesis for chronic cholecystitis

A 
cholelithiasis w/ repeated attacks of minor inflammation;
chemical inflammation (infection uncommon);
43
Q

clinical findings in chronic cholecystitis

A

severe, persistent pain 12hr post-prandially in evening;
pain radiates into right scapular area;
recurrent epigastric distress, belching, bloating

44
Q

Tx for chronic cholecystitis

A

laparoscopic cholecystectomy

45
Q

define cholesterolosis and clinical significance

A

excess cholesterol in bile;

NO clinical significance

46
Q

Why does cholesterolosis have a distinct gross appearance?

A

cholesterol deposits in macs which cause a yellow, speckled mucosal surface of gallbladder

47
Q

define hydrops of gallbladder

A

chronic obstruction of cystic duct leading to GB distention w/ atrophy of mucosa/muscle => clear secretions

48
Q

Tx for hydrops of gallbladder

A

surgery

49
Q

epidemiology of gallbladder adenocarcinoma

A

elderly women;

poor Px

50
Q

pathogenesis of gallbladder adenocarcinoma

A

cholelithiasis (95%);

porcelain gallbladder

51
Q

describe a porcelain gallbladder assoc w/ gallbladder adenocarcinoma. What should be done?

A

gallbladder w/ dystrophic calcification;

immediate surgical removal due to 50% risk for cancer progression

52
Q

Tx of gallbladder adenocarcinoma

A

surgery

53
Q

Why is gallbladder adenocarcinoma Px so low?

A

most have locally invaded liver or porta hepatis at finding;

5yr survival rate < 2%

Hepatobiliary and pancreatic disorders (7 decks)

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