Liver and Gallbladder Flashcards

1
Q

Discuss the anatomy of the biliary system

A

Bile leaves the cystic duct to enter the common bile duct -> joins the pancreatic duct at the hepatopancreatic ampulla of Vater -> sphincter of Oddi surrounding the ampulla regulates flow of bile and pancreatic juice

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2
Q

List the functions of bile

A
  • secrete bile salts that aid in digestion and reabsorption of fat
  • excretory route of cholesterol
  • excretory route for bilirubin
  • excretory route for detoxified hydrophobic endogenous metabolites
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3
Q

Discuss the enterohepatic circulation of bile

A

Bile salts synthesized in the liver and stored in gallbladder where electrolytes and fluids are reabsorbed increasing the concentration -> with meal CCK is released causing contraction of gallbladder and relaxation of sphincter of Oddi -> duodenum have digestion and absorption of fat -> terminal ileum will have reabsorption and return via portal circulation (if not reabsorbed lead to secretory diarrhea)

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4
Q

Discuss differences in primary and secondary bile salts

A

Primary (conjugated)
- include cholic and chenodeoxycholic acid
- HMG CoA reductase is rate limiting step for formation of primary bile salt
- active reabsorption through Na cotransporter
Secondary (uncojugated)
- include deoxycholic and lithocholic acid
- bacteria convert to secondary
- passive reabsorption in terminal ileum

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5
Q

Discuss the presentation and management of biliary colic, cholecystitis, choledocholithiasis, and cholangitis

A

Presentation:
- Biliary Colic: RUQ pain, radiation to right shoulder, worse with food intake
- Cholecystitis: biliary colic, fever/chills
- Choledocholithiasis: biliary colic, jaundice
- Ascending cholangitis: Charcot’s triad (RUQ pain, jaundice, fever) + confusion and hypotension (Reynold’s pentad)
Investigations:
- Leukocytosis in cholecystitis and cholangitis
- Elevated conjugated bilirubin in choledocholithiasis and cholangitis
- Elevated Alk Phosph and GGT in choledocholiathiasis and cholangitis
- Ultrasound
Treatment:
- Biliary colic: cholecystectomy
- Cholecystitis: admit, IV fluid resuscitation, urgent surgical cholecystectomy
- Choledocholithiasis: admit, IV fluid resuscitation, ERCP and cholecystectomy
- Cholangitis, admit, IV fluids resuscitation, antibiotics (ceftriaxone and metronidazole), ERCP and cholecystecomy

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6
Q

List that mechanism of biliary colic, cholecystitis, choledocholithiasis, cholangitis

A

Biliary colic:
- Stone obstructs cystic duct leading to pain
Cholecystitis:
- obstructing stone leads to inflammation of the gallbladder
Choledocholithiasis:
- obstruction of the common bile duct
Cholangitis:
- obstruction of the common bile duct leading to stasis of bile and infection
- KEEPS: Kliebsella, E coli, Enterococcus, Enterbacter, Pseudomonas, Proteus, Serratia, B fragillis

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7
Q

Discuss the risk factors for gallstone disease

A
Female
Fair skin
Fat
Fertile 
Fourty
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8
Q

Discuss the presentation and management of acute pancreatitis

A
Presentation
- nausea, vomiting
- severe epigastric pain that radiates to back
- hypoxemia due to ARDS
- jaundice, scleral icterus
- Grey-Turner (bruising around flanks) and Cullen (bruising around umbilicus) signs
Investigations
- Lipase (>3x upper limit of normal)
- elevated ALP, GGT, bilirubin if obstructed
- abdominal ultrasound 
- abdominal CT
Management
- based off admission risk
- aggressive rehydration
- NPO
- pain management
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9
Q

Discuss the admission risk profile for acute pancreatitis

A

GA LAW

  • Glucose >10mmol/L
  • Age >55
  • LDH >350
  • AST >250
  • WBC >16

After 2 days of Admission C HOBBS

  • Ca <2
  • HCT fall >10%
  • Oxygen requirement
  • Base deficit >4
  • BUN increase by >1.8
  • Sequestration of fluid >6
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10
Q

List some of the complications from acute pancreatitis

A
Pancreatic necrosis
Pancreatic pseudocyst
- collection of pancreatic fluid surrounded by granulation tissue
- occur 4 weeks following episode 
Thrombosis
Fistula
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11
Q

List the causes of chronic pancreatitis

A
  • Chronic alcohol use is most common
  • hypercalcemia, hyperlipidemia, hypertriglyceridemia
  • Cystic fibrosis
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12
Q

List the complications from chronic pancreatitis

A
  • recurrent acute pancreatitis
  • pseudocyst
  • pancreatic cancer
  • diabetes
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13
Q

Discuss the presentation and management of chronic pancreatitis

A

Presentation
- chronic epigastric pain that radiates to the back, worse after meals
- steatorrhea
- weight loss
Investigations
- lipase may be normal or only mildly elevated
- secretin/CCK stimulation with direct enzyme test
- fecal chymotrypsin concentration or fecal elastase ELISA
Management
- discontinuation of alcohol and small, low fat meals
- pain management
- pancreatic enzymes with PPI

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14
Q

List the risk factors for pancreatic cancer

A
  • black
  • age >45
  • chronic pancreatitis
  • alcohol
  • smoking
  • diabetes
  • diet high in fat and meat
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15
Q

Discuss the pathophysiology of pancreatic cancer

A
  • most are located in the head of the pancreas

- most are exocrine adenocarcinoma (ductal, neuroendocrine (Islet cells), and acinar)

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16
Q

Discuss the presentation and management of pancreatic cancer

A
Presentation:
- obstructive, painless jaundice
- weight loss
- palpable mass in epigastrium 
- Virchow's node
Investigation
- CA-19-9 >37
- high ALP, GGT, bilirubin 
- CT with contrast
Management
- Whipple procedure (pancreatcoduodenectomy - head of pancreas, first two parts of duodenum, common bile duct and antrum of stomach removed)
- Chemotherapy: gemcitabine, folfirinox
17
Q

List the risk factors for gallbladder cancer

A
  • > 50yr
  • past history of gallstone disease
  • female, obesity
  • polyp >1cm
  • porcelain gallblader
  • infection with salmonella typhi
18
Q

List the risk factors for cholangiocarcinoma

A
  • male
  • primary sclerosing cholangitis
  • Southeast Asian due to infection with O Viverrini and C Sinensis
  • smoking
19
Q

Discuss the presentation and management of bile duct cancer

A
Presentation
- jaundice
- clay colored stool
- tea-colored urine
- pruritis
- vague RUQ pain
- palpable tumor
Investigation
- CA 19-9 >180 for cholangiocarcinoma
- CT with contrast
Management
- laparoscopic cholcystectomy
- if upper or middle third lesion than biliary duct excision with Roux-en-Y. Lower third get Whipple