Goljan Gallbladder and Biliary Tract disease Flashcards
Epidemiology of choledochal cyst
most common cyst in biliary tract in children < 10yo
clinical findings of choledochal cyst
abdominal pain w/ persistent or intermittent jaundice;
increased risk of cholelithiasis, cholangiocarcinoma, cirrhosis
Diagnosis of choledochal cyst
ultrasound is gold standard;
endoscopic retrograde cholangiopancreatography (ERCP => ID’s intra- and extrahepatic cysts along w/ sites of obstruction
Tx of choledochal cyst
surgery
Define Caroli disease
AD (adult) and AR (kids) types;
segmental dilatation of intrahepatic bile ducts;
portal tract fibrosis
clinical findings of Caroli disease
assoc w/ polycystic kidney disease;
increased risk of cholangioCA;
increased risk of intrahepatic cholelithiasis, cholangitis, hepatic abscesses, portal HTN
Tx of Caroli disease
surgical resection of involved lobe;
liver transplantation
MC malignancy of bile ducts
cholangioCA
causes of cholangioCA
primary sclerosing cholangitis;
Clonorchis sinensis (chinese liver fluke);
Thorotrast (thorium dioxide);
Choledochal cyst, Caroli disease
locations of cholangioCA
ampulla or common bile duct (MC);
junction of R/L hepatic duct => Klatskin tumor;
intrahepatic
clinical finding of cholangioCA
obstructive jaundice; palpable gallbladder (Courvoisier's sign); hepatomegaly
Diagnosis of cholangioCA
ultrasound;
ERCP
Tx for cholangioCA
surgery
Bile components
bile salts/acids (67%) phospholipid; protein; free CH; conjugated bilirubin; water, electrolytes, bicarbonate
What is the purpose of bile salts/acids?
hepatic product of CH metabolism;
water soluble;
detergent action renders CH soluble in bile
What does phospholipid serve as in bile?
mainly lecithin;
hydrophobic;
solubilizes CH in bile
What are the types of gallstones?
cholesterol stones (75%); pigment stones (black, brown)
Describe cholesterol stones
stones of mixed composition typically radiolucent;
stones contain CH, Ca+ carbonate, some bilirubin pigment => radiopaque if w/ CaHCO3;
What are black pigment stones a sign of?
chronic extravascular hemolytic anemia (sickle cell anemia, hereditary spherocytosis);
excess bilirubin in bile produces Ca+ bilirubinate
What are the brown pigment stones a sign of?
sign of infection in common bile duct (CBD);
commonly in Asians
pathogenesis of cholesterol stones
supersaturation of bile w/ cholesterol;
decreased bile salts/acids (normally solubilize cholesterol in bile)
Risk factors for cholesterol stones
female, OCP >40; obesity (cholesterol increased in bile); rapid weight loss; use of lipid lowering drugs; Native americans
complications assoc w/ stones
cholecystitis (MC);
CBD obstruction;
Gallbladder cancer;
acute pancreatitis
Epidemiology of acute cholecystitis
women > men
50-60 yo;
native americans;
assoc w/ gallstones in 95% of cases
describe stage 1 development of acute cholecystitis
stone lodges in cystic duct;
midepigastric colicky pain occurs from GB contraction against cystic duct;
N/V WITHOUT pain relief
How does a stone get lodged in cystic duct in acute cholecystitis?
stimulus of food causes gallbladder contraction => forces into cystic duct
describe stage 2 development of acute cholecystitis
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
describe stage 3 of acute cholecystitis
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
describe stage 4 of acute cholecystitis
perforation;
wall tension from GB distention compresses lumens of intramural vessels => gangrenous necrosis
What are diseases NOT associated w/ stones but may cause acute cholecystitis?
AIDS (CMV or cryptosporidium infection);
severe volume depletion
clinical findings in acute cholecystitis
fever; appropriate stage related findings; vomiting (75%); radiation of pain to right scapula/shoulder; Murphy sign; Jaundice (common bile duct stone); palpable gallbladder
Lab findings w/ acute cholecystitis
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)
What type of stone does estrogen cause?
Cholesterol
how does estrogen increase cholesterol stone formation?
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
What are the tests to identify stones?
ultrasound (gold standard);
Plain film (Xray);
hepatobiliary iminodiacetic acid radionuclide scan or HIDA scan
What is sensitive and not sensitive to find on ultrasound for stones?
stones > 12mm in diameter;
detects sludge;
evaluates GB wall thickness;
NOT effective in ID’ing CBD stones
what is the downside of Xray when looking for stones?
only 20% are radioopaque
Where is a HIDA scan good for finding stones?
stones in cystic duct=> no visualization of GB;
CBD stones => no tracer in duodenum
what are indications for CBD exploration?
jaundice;
CBD dilatation > 12mm
no stones in GB;
acute pancreatitis
Tx for acute cholecystitis
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
Epidemiology of chronic cholecystitis
most common symptomatic disorder of GB
pathogenesis for chronic cholecystitis
cholelithiasis w/ repeated attacks of minor inflammation; chemical inflammation (infection uncommon);
clinical findings in chronic cholecystitis
severe, persistent pain 12hr post-prandially in evening;
pain radiates into right scapular area;
recurrent epigastric distress, belching, bloating
Tx for chronic cholecystitis
laparoscopic cholecystectomy
define cholesterolosis and clinical significance
excess cholesterol in bile;
NO clinical significance
Why does cholesterolosis have a distinct gross appearance?
cholesterol deposits in macs which cause a yellow, speckled mucosal surface of gallbladder
define hydrops of gallbladder
chronic obstruction of cystic duct leading to GB distention w/ atrophy of mucosa/muscle => clear secretions
Tx for hydrops of gallbladder
surgery
epidemiology of gallbladder adenocarcinoma
elderly women;
poor Px
pathogenesis of gallbladder adenocarcinoma
cholelithiasis (95%);
porcelain gallbladder
describe a porcelain gallbladder assoc w/ gallbladder adenocarcinoma. What should be done?
gallbladder w/ dystrophic calcification;
immediate surgical removal due to 50% risk for cancer progression
Tx of gallbladder adenocarcinoma
surgery
Why is gallbladder adenocarcinoma Px so low?
most have locally invaded liver or porta hepatis at finding;
5yr survival rate < 2%
