Hepato-biliary: Gallbladder and Biliary tree Disease Flashcards
What is primary sclerosing cholangitis?
Chronic progressive cholestatic liver disease, characterised by inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts, resulting in diffuse, multi-focal stricture formation
What is primary sclerosing cholangitis associated with?
- IBD
- HLA-A1; B8, DR3
- Male
What is the main pathophysiological process going on in primary sclerosing cholangitis?
Inflammation and injury of the medium- and large-sized bile ducts leading to fibrosis and multi-focal stricturing of the ducts.
Obstruction of the medium- and large-sized bile ducts leads to progressive fibrosis and ultimately obliteration of the smaller ducts (ductopenia) and bile stasis (cholestasis)
What cancers are associated with primary sclerosing cholangitis?
- Cholangiocarcinoma - bile duct, gallbladder
- Colon cancer
- Liver cancer
What autoantibody can be found in the serum of those with primary sclerosing cholangitis?
pANCA - 60%
What are symptoms of primary sclerosing cholangitis?
- Pruritus + Fatigue
- Can have RUQ/epigastric pain
- Features of jaundice
What are signs of primary sclerosing cholangitis?
- Excoriations (from pruritus)
- Weight loss - from fat malabsorption/active IBD/ advanced liver disease
- Jaundice
- Splenomegaly
- Ascites
- Encephalopathy
- Oesophageal variceal bleeding
What sex does primary sclerosing cholangitis most commonly occur in?
Male
What tests would you consider doing in someone suspected to have primary sclerosing cholangitis?
- Bloods - LFTs, serum albumin, FBC, PT, ANCA, ANA
- MRCP
- Consider ERCP
- Abdo US
- Consider iver biopsy
What might you find on LFT in someone with primary sclerosing cholangitis?
- Elevated GGT
- Elevated ALP
- Moderately elevated AST/ALT
- Hyperbilirubinaemia - conjugated
In someone with PSC, what is the predominating type of bilirubin present if they have hyperbilirubinaemia?
Conjugated bilirubin
What might you find when assessing serum albumin in someone with PSC?
Normal in early disease, low in advanced liver disease
What might you find on FBC in someone with PSC?
Indication of liver synthetic dysfunction due to advanced liver disease
- Normal, or
- Thrombocytopaenia +/- anaemia, leukopenia
Why would you perform PT in someone with PSC?
Assess liver synthetic function - can be prolonged in someone with lvier failure
What investigations reveal duct anatomy?
- MRCP
- ERCP
- CT Abdo
What might you find on liver biopsy in someone with PSC?
Fibrous, obliterative cholangitis
How would you manage someone with PSC?
- Supportive - pruritis relief, lifestyle change
- Consider immunosuppression
- Consider bisphosphonates - if osteopenic/porotic
- End stage disease - liver transplantation
What are complications that can arise in PSC?
- Liver failure/cirrhosis
- Cancer - hepatocellular, cholangiocarcinoma, colon, gallbladder
- Dominant biliary stricture
- Bacterial cholangitis
- Choledocholithiasis
What is primary biliary cirrhosis/cholangitis?
Primary biliary cholangitis (PBC) is a chronic disease of the small intrahepatic bile ducts that is characterised by progressive bile duct damage (and eventual loss) occurring in the context of chronic portal tract inflammation.
Fibrosis develops as a consequence of the original insult and the secondary effects of toxic bile acids retained in the liver, resulting ultimately in cirrhosis
What is the difference between PBC and PSC in terms of where it affects the biliary tree?
- PBC - intrahepatic ducts
- PSC - intra- and extrahepatic bile ducts