HPB Flashcards
Gallstone pathophysiology
Bile is formed from cholesterol, phospholipids and bile pigments
Form as a result of supersaturation of bile:
1) Cholesterol stones – excess cholesterol production
2) Pigment stones – excess bile pigment production (commonly seen in those with known haemolytic anaemia)
3) Mixed stones – cholesterol and bile pigments
Gallstone risk factors
Fat
Female
Forty
Fertile
Family history
Pregnancy, oral contraceptives, haemolytic anaemia & malabsorption
Biliary colic
Gallbladder neck is impacted by a gallstone
No inflammatory response, but contraction of the gallbladder against the occluded neck will result in pain
Pain – sudden, dull & colicky, focused in the RUQ but may radiate to the epigastrium/back, may be precipitated by fatty foods
Acute cholecystitis
Constant pain in RUQ or epigastrium, associated with signs of inflammation
Tender in the RUQ & may demonstrate a positive Murphy’s sign
Gallstone and acute cholecystitis investigations
Lab test
* FBC & CRP
* LFTs
* Amylase
Imaging – trans-abdominal ultrasound is first line
* MRCP is gold standard if US scans are inconclusive
Biliary colic management
Should be prescribed analgesia
Patient should be advised about lifestyle factors
Elective laparoscopic cholecystectomy is warranted & should be offered within 6 weeks of first presentation
Acute cholecystitis management
Should be started on appropriate IV abx (co-amoxiclav +/- metronidazole)
Laparoscopic cholecystectomy is indicated within 1 week of presentation, ideally within 72 hours of presentation
For those not fit for surgery & not responding to antibiotics, a percutaneous cholecystostomy can be performed to drain the infection
Mirizzi syndrome
Stone located in Hartmanns pouch/cystic duct itself can cause compression of the adjacent hepatic duct
Results in obstructive jaundice
Diagnosis is confirmed by MRCP & management is usually with laparoscopic cholecystectomy
Gallbladder empyema
Gallbladder becomes filled with pus
Patients will become unwell, often septic, presenting with a similar clinical picture to acute cholecystitis
Condition is diagnosed by either US scan/CT scan
Treatment – via laparoscopic cholecystectomy/percutaneous cholecystostomy (if unsuitable for surgery)
Chronic cholecystitis
Typically have a history of recurrent/untreated cholecystitis -> led to persistent inflammation of the gallbladder wall
Patients present with ongoing RUQ/epigastric pain with associated N&V
Diagnosed typically by CT imaging
Management – uncomplicated cases is via elective cholecystectomy
Main complications – gallbladder carcinoma & biliary-enteric fistula
Bouveret’s syndrome and gallstone ileus
Inflammation of the gallbladder can cause a fistula to form (cholecystoduodenal fistula) allowing gallstones to pass directly into the small bowel
Bouveret’s syndrome – stone impacts in the proximal duodenum, causing a gastric outlet obstruction
Gallstone ileus – a stone impacts at the terminal ileum, causing small bowel obstruction
Pre-hepatic jaundice
Excessive red cell breakdown -> overwhelms the liver’s ability to conjugate bilirubin
Causes an unconjugated hyperbilirubinemia (remains in the blood steam to cause jaundice)
E.g. haemolytic anaemia, Gilbert’s syndrome
Hepatocellular jaundice
Dysfunction of the hepatic cells
Loses the ability to conjugate bilirubin & also causes where it may become cirrhotic -> compresses the intra-hepatic portions of the biliary tree to cause a degree of obstruction
Both unconjugated and conjugated bilirubin
e.g. alcoholic liver disease, viral hepatitis, hereditary haemochromatosis
Post-hepatic jaundice
Obstruction of biliary drainage
Conjugated hyperbilirubinemia
e.g. gallstones, cholangiocarcinoma, strictures, pancreatic cancer
Cholangiocarcinoma risk factors
Primary sclerosing cholangitis
Congenital – Caroli’s disease, choledochal cyst
Intraductal gallstone formation
Infective – liver flukes, hepatitis
Toxins – chemicals in rubber & aircraft industry
Liver cirrhosis
Cholangiocarcinoma clinical features
Intrahepatic – generally asymptomatic until a late stage in the disease
Extrahepatic – typically present early
Jaundice, pruritus, steatorrhea, non-specific abdominal pain, dark urine
Courvoisier’s law
In the presence of jaundice and an enlarged/palpable gallbladder, malignancy of the biliary tree/pancreas should be strongly suspected as the cause is unlikely to be gallstones
Cholangiocarcinoma investigations
Bloods – elevated bilirubin, ALP & yGT
Tumour markers – CEA and CA19-9 may also be elevated
MRCP – gold standard imaging modality
CT, ERCP/PTC (obtain tissue brushings for cytological diagnosis)
Triple phase CT imaging/contrast-enhanced MRI of the liver – staging of the disease
Cholangiocarcinoma management
Definitive cure – complete surgical resection (only 10-15% patients are suitable)
Both chemotherapy and radiotherapy may be used in some cases as adjuvant treatments after surgery
Palliative
1) Stenting – relieve obstructive symptoms
2) Surgery – bypass procedures if obstruction cannot be relieved by stenting
3) Medical – palliative radiotherapy/chemotherapy
Cholangitis
Infection of the biliary tract
Caused by a combination of biliary outflow obstruction & biliary infection
During an obstruction, stasis of fluid allows bacterial colonisation of the biliary tree to become pathological
Cholangitis causes
(any condition that causes occlusion of the biliary tree)
Gallstones
ERCP
Cholangiocarcinoma
Most common infective causes – E coli, Klebsiella species & enterococcus
Cholangitis clinical presentation
Charcot’s triad – jaundice, fever, RUQ pain
Reynold’s pentad – jaundice, fever, RUQ pain, hypotension & confusion
Cholangitis investigations
Routine bloods – esp, FBC & LFTs
Blood cultures – should always be taken in suspected cases
Imaging – biliary tract USS, ERCP is gold standard as it is both diagnostic & therapeutic
Cholangitis management
Immediate – IV access, fluid resus, routine bloods, blood cultures, broad spectrum IV abx (co-amoxiclav & metronidazole)
Definitive – endoscopic biliary decompression, ERCP should clear any obstruction (PTC is second line for patients too unwell)
