Gut Problems 3 (Clinical) (Ow) Flashcards
56 yo man presents with right upper quadrant (RUQ) pain for 24hr
- If RUQ pain is colicky (comes and goes, with periods of quite severe pain that subsides), typically indicates that there is a blockage to a lumen (e.g. biliary colic, renal colic))
On examination:
- Tender in RUQ with guarding
- Pain is particularly prominent when he is asked to take a deep breath with an examining hand just below the right costal margin (Murphy’s sign is hypersensitivity to deep palpation in subcostal area when a patient with gallbladder inflammation takes a deep breath)
His temperature is 38.2 C, white blood cell count elevated
Abdominal ultrasound showed gallstones, thickening of gallbladder wall, and fluid around the gallbladder
What Is Meant By The Term Guarding?
- Tensing of abdominal wall due to pain (can be voluntary or involuntary)
- Involuntary guarding indicates _peritonism (_percussion tenderness etc.)
- Voluntary guarding is usually due to anticipation of pain, cold hands etc.
Where does pain radiate for gallbladder pain?
Right back and/or shoulder blade
Describe the symptoms of gallstones
1) Strong pain
2) Comes and goes
- Sudden and rapidly intensifying pain in the upper right portion of your abdomen
- Sudden and rapidly intensifying pain in the center of your abdomen, just below your breastbone
- Back pain between your shoulder blades
- Pain in your right shoulder
- Nausea or vomiting
Involuntary guarding indicates ______
Involuntary guarding indicates peritonism
56 yo man presents with right upper quadrant (RUQ) pain for 24hr
- If RUQ pain is colicky (comes and goes, with periods of quite severe pain that subsides), typically indicates that there is a blockage to a lumen (e.g. biliary colic, renal colic))
On examination:
- Tender in RUQ with guarding
- Pain is particularly prominent when he is asked to take a deep breath with an examining hand just below the right costal margin (Murphy’s sign is hypersensitivity to deep palpation in subcostal area when a patient with gallbladder inflammation takes a deep breath)
His temperature is 38.2 C, white blood cell count elevated
Abdominal ultrasound showed gallstones, thickening of gallbladder wall, and fluid around the gallbladder
What Is Cause Of The Pain?
Because of inflammation -> distension, swelling, stretching of visceral organs
56 yo man presents with right upper quadrant (RUQ) pain for 24hr
- If RUQ pain is colicky (comes and goes, with periods of quite severe pain that subsides), typically indicates that there is a blockage to a lumen (e.g. biliary colic, renal colic))
On examination:
- Tender in RUQ with guarding
- Pain is particularly prominent when he is asked to take a deep breath with an examining hand just below the right costal margin (Murphy’s sign is hypersensitivity to deep palpation in subcostal area when a patient with gallbladder inflammation takes a deep breath)
His temperature is 38.2 C, white blood cell count elevated
Abdominal ultrasound showed gallstones, thickening of gallbladder wall, and fluid around the gallbladder
Diagnose
What would be the initiating event?
Cholecystitis
What Would Be Initiating Event?
Impaired bile flow or abnormal gallbladder contraction leading to a build-up of bile and bacteria due to stasis à infection à cholecystitis
Cholesterol Gallstones Form In The Gallbladder Not In The Bile Duct. Why?
- Cholesterol gallstones are the most common (80%) form of gallstone
- Cholesterol is part of the component of bile. When there is abnormal emptying or obstruction to flow, you get a _stasis of bil_e which causes the concentration of cholesterol -> formation of stones
- Other type called pigmented stone (bilirubin), tend to form in the bile duct
What Initiates Emptying Of Gallbladder? (hormone)
Cholecystokinin
What are the terms for gallstones in different areas of the Biliary tract?
- Biliary colic (not a diagnosis, just a descriptive term for pain people experience with gallstones (RUQ pain))
- Cholelithiasis (gallstones)
- Cholecystitis (inflammation of gallbladder)
- Choledocholithiasis (stone in bile duct)
- Cholangitis (infection in biliary tree; infected, blocked duct)
- Cholesterol stone (80%)
- Pigment stones
(stone in bile duct)
Choledocholithiasis
(inflammation of gallbladder)
Cholecystitis
(gallstones)
Cholelithiasis
(infection in biliary tree; infected, blocked duct)
Cholangitis
He is found to have an elevated GGT and ALP and bilirubin . Common bile duct is dilated on ultrasound. He develops a high fever and rigors.
What is the diagnosis now?
elevated GGT and ALP (cholestasis) and bilirubin (jaundice).
Cholangitis
What Is Another Potential Consequence Of Cholangitis?
- Cholangitis (infection in biliary tree; infected, blocked duct)
What Is Another Potential Consequence Of This Problem?
Risk of development into pancreatitis (commonest cause of pancreatitis is gallstone and pancreatitis)
- Therefore check for lipase and amylase too (pancreatic enzymes)
Describe Cholestasis
- lab tests
- causes
Cholestasis presents with elevated GGT and ALP. Common causes include:
- Stones
- Biliary disease (these conditions are autoimmune disease that cause inflammation of bile duct -> stricture -> restrict bile flow)
- Primary biliary cirrhosis (PBC)
- Primary sclerosing cholangitis (PSC)
- Drugs (important to take a medication history)
- Tumors
What is the significance of pain?
He is found to have an elevated GGT and ALP (cholestasis) and bilirubin (jaundice). Common bile duct is dilated on ultrasound. He develops a high fever and rigors.
Working through the differentials for jaundice, it is important to determine whether it is painful or painless jaundice
- Pain, esp. if it sounds like biliary colic (RUQ, might radiating to upper back), suggests gallstones
- But no pain does not mean it cannot be stones (wider range of differential diagnoses)1
Other causes (aside from gall stones) that cause cholestasis do not give significant pain
What are some causes of choledocholithiasis?
How do you treat this?
Most duct stones would have migrated from gallbladder (formed in gallbladder), i.e. secondary duct stones (usually cholesterol stones)
- Removing gallbladder would’ve treated vast majority of people with choledocholithiasis
Rarely, stones can form in duct i.e. primary duct stones (usually pigment stones) from infection/stasis
- Removing gallbladder does not treat this type of choledocholithiasis
*No gallbladder does not equate to no gallstones.
What are the common presenations of cholangitis?
Cholangitis is _complication of choledocholithiasi_s.
It presents with Charcot’s triad:
- Fever (infection)
- Jaundice (indicate obstructed bile duct)
- RUQ pain (biliary colic)
Not all cases of cholangitis will have the full triad!
What would the ultrasound show for people with gallstones?
1) Stones in bile duct/gallbladder
2) In addition to looking at the gallbladder, also measure the diameter of the duct
Sometimes, you may not see a stone on ultrasound but you may see a _dilated bile duc_t, may indicate choledocholithiasis
When is MRCP useful?
What are the advantages and disadvantages?
MRCP is useful for accurate visualization of the biliary tree
- Advantage: non-invasive
- Disadvantage: non-therapeutic
It is opposite to ultrasound. In MRCP, stone is black and duct is white, whereas in US, stone is white and
What is the therapeutic procedure for choledocholithiasis?
ERCP (Endoscopic Retrograde Cholangiopancreatography)
ERCP involves cannulation of the bile duct
- Advantage: diagnostic and therapeutic
- Disadvantage: risk of complication
ERCP Is Not Final Step…
In people who have had an ERCP for choledocholithiasis, an elective cholecystectomy needs to be performed at a future date to remove source of gallstones i.e. gallbladder
- >85% of common duct stones are secondary (i.e. migrated from the gallbladder).
- This means that remaining percentage is due to primary common duct stones (i.e. stones that form in the common bile duct). In this small amount of people, they may get future episodes of biliary obstruction even after cholecystectomy.
- So even if a patient has had cholecystectomy, they may still present in future with choledocholithiasis!
68 year old woman has been known to have abnormal LFT’s for more than 10 years
- She has had gradually increasing levels of GGT and ALP (cholestasis)
- Bilirubin level is normal
- Now presents with generalized itching
On examination, there was no jaundice. Widespread scratch marks. Liver was normal span upon percussion
The ultrasound scan of the liver was normal
increasing levels of GGT and ALP (cholestasis)
No pain = not likely to be gallstones
What Feature On Ultrasound Would Have Suggested That Obstruction To The Common Bile Duct Was The Diagnosis?
A dilated bile duct
What can block the bile duct?
1) Gall stones
2) Bile duct diseases
3) Tumours
Given Absence Of a dilated bile duct Where Is The Obstruction To Bile Flow?
Intrahepatic Bile Duct Disease. (Obstructive jaundice is a condition in which there is blockage of flow of bile out of liver, it can be categorized into intrahepatic and extrahepatic.)
Can be caused by
-
Primary Biliary Cirrhosis (PBC)
- Primary biliary cirrhosis (PBC) is a disease caused by damage to bile ducts in the liver.
-
Primary Sclerosing Cholangitis (PSC)
- Primary sclerosing cholangitis (PSC) is a long-term progressive disease of the liver and gallbladder characterized by inflammation and scarring of the bile ducts which normally allow bile to drain from the gallbladder.
Describe Primary Biliary Cirrhosis (PBC)
-Cause
-Diagnosis
-Where it affects
She had positive mitochondrial antibodies, which suggested a diagnosis of primary biliary cirrhosis.
Primary biliary cirrhosis is autoimmune chronic cholestatic liver disease that affects small intra-hepatic bile ducts.
- Bile duct abnormality in PBC is not detectable on imaging.
- Detected by liver biopsy (showed destruction of bile ductules by an autoimmune process)
- Diagnosed by positive anti-mitochondrial antibody (AMA)
Diagnosis requires 2 out of the following 3 criteria
- high ALP,
- positive AMA,
- liver biopsy
What are the difference between PBC and PSC? **
8:42
Describe PBC presentation
In PBC, ~50-60% are asymptomatic
- Usually diagnosed when patient has LFTs done for something else
- ALP tends to go up first
Early symptoms include:
- Fatigue
- Pruritus (severe itching) (even without jaundice) (due to the accumulation of bile salts in the skin)
- May have steatorrhea (pale, floating, bulky, oily, sticky)
- Fat malabsorption
- Fat-soluble vitamin deficiencies as well (e.g. Vitamin D and K)
It is progressive disease:
- Jaundice
-
Liver cirrhosis and related complications (including hepatocellular carcinoma)
- Bile duct is damaged by the antibodies, but the bile leaks into the adjacent liver cells and damage the liver.
What are the PBC associated conditions?
PBC Associated Conditions
Associated with striking dyslipidaemia
- Different from other lipid disorders
- Lipoprotein X elevated, HDL elevated
- No obvious increased risk of atherosclerotic complications, unless risk factors for CHD
Associated with osteopenia/osteoporosis
- Not due to vitamin D malabsorption, mechanism not well understood
- Low bone formation
Associated with hypothyroidism (autoimmune)
What is the PBC Treatment?
Ursodeoxycholic acid (UDCA) is not toxic and is hydrophilic bile acid
- Improves blood tests
- Delays the need for liver transplantation
- Does NOT cure the disease but slow progression
- Endogenous bile acids are hydrophobic and toxic to hepatocytes/cholangiocytes
- Competes against endogenous bile acids for absorption in the terminal ileum
Mechanism unclear but likely multifactorial:
- Increases the rate of bile flow from the hepatocytes, thereby combating cholestasis and diluting toxic bile acids in bile
- Inhibits production of toxic bile acids, thereby preventing further injury to the hepatocytes
- Inhibits apoptosis, thereby preventing hepatocytes from dying.
- Mildly inhibits the immune response in the liver, thereby possibly reducing immunological injury to the bile ducts and liver.
Describe PSC
Primary sclerosing cholangitis is _chronic cholestatic liver disease t_hat affects both intra and extrahepatic bile ducts
- It causes distinctive stricturing of bile ducts (typical abnormality on imaging)
-
Immune mediated but antigen unknown
- Autoimmune
- May be triggered by chronic or recurrent bacteria
- Ischemic damage
- No good autoantibody tests for this condition (usually diagnosed with imaging, sometimes liver biopsy)
Diagnosis is usually radiological, occasionally requires liver biopsy
What are the PSC presentations?
Often associated with ulcerative colitis (IBD)
- If you have PSC, you most likely will have UC
- But people with UC don’t normally have PSC
Asymptomatic ~50%
- Diagnosed when patients have LFTs done for something else
- Cholestatic with predominant ALP elevation
Symptomatic (~50%) include:
- Pruritus
- Fatigue
- May have steatorrhea (advanced disease) (fat malabsorption + fat-soluble vitamin deficiencies)
Progressive disease:
- Jaundice
- Cholangitis (not seen in PBC) (because PSC also affects extrahepatic ducts which can lead to recurrent infections when they become strictured)
- Liver cirrhosis and related complications (including hepatocellular carcinoma)
What are the PSC associated conditions?
PSC Associated Conditions
Associated with osteopenia/osteoporosis
- Not due to vitamin D malabsorption
- Mechanism not well understood
- Low bone formation
What is the PSC treatment?
No medication to slow down medication, far more rapidly progressing than PBC (people diagnosed with PSC at a young age are likely to require a liver transplant at some stage)
- If develops jaundice/cholangitis and due to a dominant stricture in a large bile duct, could treat with ERCP and dilatation/stenting
- If stricture in smaller ducts, not treatable.
Eventually cirrhosis + fibrosis -> liver failure
Describe the Tumours causing obstructive Jaundice
-
Pancreatic cancer
- Cancer on head of pancreas, leads to obstruction of the bile duct
-
Cholangiocarcinoma
- Cancer of bile duct (primary bile duct cancer), can occur anywhere in the bile ducts
- When found at hilum (point where left and right hepatic ducts meet), also known as Klatskin tumour (presents with dilated left and right intrahepatic bile ducts, but normal extrahepatic bile ducts)
- Duodenal cancer at the ampulla can also cause obstructive jaundice
Describe the presentation of Tumours causing Jaundice
- Painless jaundice
- Palpable epigastric mass
-
Palpable gallbladder (Courvoisier’s sign)
- As obstruction occurs slowly, pressure also increases slowly and the gallbladder distends to compensate for this and reduced pressure in the biliary system
Compare and contrast the diff between PBC and PSC
1) Affects where?
2) Causes
3) Presentation
4) Ass. Conditions
5) Treatment
80 year old man
1 week of feeling unwell
Shivery coming and going
Sore tummy for 5 days - band around the upper belly. Acute epsiodes that are intense
Dark and concentrated urine
Eyes look a little yellow
1) What are the differentials?
1) Gallstone disease
2) Hepatitis
3) Cholengitis
- 80 year old man
- 1 week of feeling unwell
- Shivery coming and going
- Sore tummy for 5 days - band around the upper belly. Acute epsiodes that are intense
- Dark and concentrated urine
- Eyes look a little yellow
Blood test
- Bilirubin increased x2
- GGT increased x2
- ALP increased x2
- AST increased
- ALT increased
1) Describe these findings
2) Differential diagnoses
3) What other tests should you do?
1)
- Jaundiced
- Mixed picture with predominantly cholestasis
2)
- Cholecystisis- does not cause jaundice
- Hepatitis- unlikely
- Choledocholithiasis - likely (obstruction)
- Tumour- short history, systemic symptoms and pain- so unlikely.
- Cholangitis - likely
3)
- Ultrasound - dilatations
- MRCP
44 year old woman
Cold
Muscle aches
Yellow eyes
Hasn’t travelled
No tummy pain
Problem with liver functiont tests in the past?
No IBD
Drugs- took some pandaol but only 4 a day.
No new sexual partners
Intravascular drug use
Ethnic group?
Family history of Hep B?
Blood transfusions? (prior to 1990s?)
Alcohol history
Blood test
- Bilirubin +
- GGT +
- ALP normal
- AST ++
- ALT ++
What ar ethe tests you would do?
Have hepatitis with mild jaundice (no cholestasis)
1)
- Viral studies
- Iron studies
- Autoimmune (not PSC or PBC)
