Liver Flashcards
what is biliary colic
pain assosicated with the obstruction of the cystic or common bile duct by a gall stone
what is collicky pain
pain due to gallbladder constriction and duct spasms
- assos with fatty foods
charactersitics of abo pain caused by biliary colic
RUQ pain for less than 24hrs severe constant sudden onset crescendo character RADIATES to R shoulder/R subscapular hours after meal/laying flat/at night
other Cfs of biliary colic other than abdo pain (sever attacks)
N+V
anorexia
Complications of biliary colic
acute cholecystitis
Dx of biliary colic
bloods - LFT - increase in bilirubin or ALP in attack
abdo US - gall stones, distended ducts
Mx of biliary colic
alagesia (can pass on own) elective cholecystectomy (gallbladder removal)
what is cholecystitis
GB inflammation
what is cholangitis
bile duct inflam
what are gall stones
Solid stones inside gallbladder composed of bile components due to an imbalance of chemical constitutes
what are gall stones most commonly made up of
cholesterol (75%)
Rfs for gall stones
Fat (high cholesterol)
Female (linked to oestrogen - oral contraceptive pill)
Forty
Fertile
why do gall stones form
supersaturation
gall bladder stasis
not enough bile salts/acids/phospholipids to keep cholesterol in solution
what causes the release of bile into the duodenum
enteroendocrine cells in duodenum secrete CKK into the blood. CKK relaxes the sphincter of Oddi
bile released into the duodenum
what causes bilirubin stones
too much unconj bilirubin in the bile.
combines with Ca2+ to form CALCIUM BILIRUBINATE =
precipitates out as stones
Cx= increase in RBC breakdown secondary to liver cirrhosis, bil tract infection of blood conditions
are bilirubin stones radioopaque?
yes
what do brown stones signify
infection
what colour are bilirubin stones
black
what is the difference between brown stones and bilirubin stones
brown stones are a sign of infection and are made up of hydrolysed phospholipid also
(calcium + uncoj bilirubin + hydrolysed phospholipids)
bilirubin stones just calcium and uncoj bilirubin
are cholestrol gall stones seen on xray
no
what are causes of brown gall stones
E.coli
ascaris lumbricoides (round worm)
(the bacteria bring in the hydrolytic enzyme)
what colour are cholesterol gall stone
bilirubin gall stones
cholesterol stones = yellow / green
bilirubin = dark
Rfs for gall stones
female obesity high oestrogen - oral contraceptive rapid weight loss (decrease lipids = imbalance in bile) FAT FEMALE FORTY FERTILE
what makes up biliary tract diseases (in order)
biliary colic
cholecystitis
asc cholangitis
what is acute cholecystitis
Obstruction (95%=gall stone) stuck in gallbladder neck
causes inflammation
secondary to retained bile in the gall bladder
why does inflam occur in acute cholecystitis
impaction in neck of GB/cystic duct causes static bile.
mucose secretes mucus and inflam enzymes = inflammation
how does acute cholecystitis lead to peritonitis
bile retained - inflammation and pressure build up causing distension. BV supply to GB compromised = ischaemia.
bacterial growth in static bile (E.coli, klebsiella) - invades GB wall and causes inflam of peritoneum (PERITONITIS)
how does acute cholecystitis lead to sepsis
gall stone blockage -> inflam and pressure build up –> distension –> compromises blood supply to GB –> ischaemia –> gangerous cell death weakening wall –> ruptures and bacteria into blood = SEPSIS (bacteria build up due to static bile)
Cfs of acute cholecystitis
RUQ pain radiates to R shoulder (epigastric if peritonitis) fever N+V Murpheys sign guarding REBOUND TENDERNESS
what is Murpheys sign
pressure to r side of abdo so abdo contents dont move = deep breathe = diahragm down onto gallbladder = pain
Mx of acute cholecystitis
cholecystectomy
analgesia
what is ascending cholangitis
bacterial infection due to gallstone blocking the cystic bile duct resulting in inflammation
what occurs in ascending cholangitis that is normally prevented by bile flow
bacterial migration up the biliary tree
Cx of ascending cholangitis
E.coli
Enterococcus (D strep)
Klebsiella
why does bacterial migration occur in ascending cholangitis
gall stone blocks bile flow and pancreatic juices
what is a complication of asc cholangitis
SEPTIC SHOCK
how does septic shock occur in asc cholangitis
blcokage by gall stone of the cystic bile duct - increases pressure in GB and so spaces betweeen cells lining the bile duct increase and bacteria enters blood stream = SEPTIC SHOCK
why do patients get confused as a result of ascending cholangitis
septic shock - hypotension due to leaky blood vessels - less blood to the brain - confusion (RAYNAUDS PENTAD)
what is reynauds pentad in asc cholangitis
charcots + (fever+jaundice+RUQ pain)
hypOtension
confusion
when does reynauds pentad occur in asc cholangitis
as a result of septic shock due to bacteria from increased p. in GB entering the blood stream
HYPOTENSION
CONFUSION
what is charcots triad assos with
asc cholangitis
what is charcots triad
fever
RUQ pain
jaundice
what causes jaundice in asc cholangitis
bile in the blood stream ( GB increased pressure, spaces between cell lining widen = leaks out)
what are syptoms of asc cholangitis
fever RUQ pain Rigors Pruritus (jaundice) dark urine pale stools
signs of asc cholangitis
jaundice RUQ tenderness confusion hypotension guarding and tenderness
Dx of asc cholangitis
bloods - jaundice signs (increase serum bilirubin), shock, infection (increased neutrophils)
US - dilated common bile duct
CT - exl carcinoma of pancreas
Mx of asc cholangitis
IV fluid and ABX (cefotaxime + metronidazole)
analgesia
relieve obstruction (ERCP/stenting)
cholecystectomy
what does ERCP stand for and what is it used for
endoscopic retrograde cholangio pancreatography
what causes RUQ pain in biliary disorders
biliary colic
acute cholecystitis
cholangitis
what causes fever/increased WCC out of the biliary disorders
acute cholecystitis
asc cholangitis
NOT billiary colic
which biliary tract diseases cause jaundice
asc cholangitis ONLY
what is primary biliary cholangitis (PBC)
autoimmune destruction of interlobular bile ducts- leakage of bile and toxins into liver parenchyma and blood.
cholestasis - fibrosis - cirrhosis
3 As of Primary biliary cholangitis
AI (autoimmune)
AMA positive
ALP increased
Cfs of PBC
asympt fatigue hepatosplenomegaly pruritis xanthomas xanthelasma
Dx buzz word in blood of PBC
AMA postive
= antimitochondrial antibodies
Dx of PBC
bloods - Anitmitochondrial antibodies LFTs - increased GGT and ALP increased PTT as decreased albumin Biopsy = granulomas lymphocytes and plasma cells in the portal tracts
complications of PBC
autoimmune (Sjogrens, Rheumatoid arthritis)
osteoporosis
ascites
epidem of PBC
female x9
Mx of PBC
early = ursodeoxycholic acid (UDCA) to decrease cholestasis (Weight gain = SE) supportive - itch = colestyramine cirrhosis complications vit suppl (as fat malabsorb) ADEK liver transpl
what is primary sclerosing cholangitis
immune mediated chronic cholestatic liver disease characterised by the fibrosing infam destruction of both intra and extra hepatic bile ducts
what is PSC assoc with
Ulcerative collitis (75%) or crohns
Cfs of PSC
jaundice - itching, fatigue, yellow skin,
hepatosplenomegaly
abdo pain
what often precedes primary sclerosing cholangitis
Ulcerative colitis
epidem of primary sclerosing cholangitis
M more than F (70%)
pathology of primary sclerosing cholangitis
inflam of intrahepatic bile ducts and assos scar tissue = onion skin fibrosis (peri ductal oedema)
minor inflam –> cirrhosis
leads to strictures impeding bile flow to small intestines
causes ductopenia
pANCA increased
complications of primary sclerosing cholangitis
firosis builds up round bile ducts near portal veins - portal HTN - fluid backs up -
hepatosplenomegaly
cirrhosis
(BILE DUCT DAMAGE INCREASES RISK OF CHOLANGIOCARCINOMA)
CFs of primary sclerosing cholangitis
fluctuating pruritis jaundice cholangitis fatigue yellow skin abdo pain hepatosplenomegaly
Dx of primary sclerosing cholangitis bloods
increased conj bilirubin in serum increased ALP and gamma GGT enzymes AMA -ve ANCA +ve bilirubinuria - no urobilinogen as bile flow obstructed
Dx of primary sclerosing cholangitis (not bloods)
ERCP - endoscopy into bile ducts
cholioangiogram for irregular ducts - strictures
BEADED appearance due to fibrosis
