Liver and Gallbladder Flashcards
Discuss the anatomy of the biliary system
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
List the functions of bile
- 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
Discuss the enterohepatic circulation of bile
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)
Discuss differences in primary and secondary bile salts
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
Discuss the presentation and management of biliary colic, cholecystitis, choledocholithiasis, and cholangitis
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
List that mechanism of biliary colic, cholecystitis, choledocholithiasis, cholangitis
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
Discuss the risk factors for gallstone disease
Female Fair skin Fat Fertile Fourty
Discuss the presentation and management of acute pancreatitis
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
Discuss the admission risk profile for acute pancreatitis
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
List some of the complications from acute pancreatitis
Pancreatic necrosis Pancreatic pseudocyst - collection of pancreatic fluid surrounded by granulation tissue - occur 4 weeks following episode Thrombosis Fistula
List the causes of chronic pancreatitis
- Chronic alcohol use is most common
- hypercalcemia, hyperlipidemia, hypertriglyceridemia
- Cystic fibrosis
List the complications from chronic pancreatitis
- recurrent acute pancreatitis
- pseudocyst
- pancreatic cancer
- diabetes
Discuss the presentation and management of chronic pancreatitis
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
List the risk factors for pancreatic cancer
- black
- age >45
- chronic pancreatitis
- alcohol
- smoking
- diabetes
- diet high in fat and meat
Discuss the pathophysiology of pancreatic cancer
- most are located in the head of the pancreas
- most are exocrine adenocarcinoma (ductal, neuroendocrine (Islet cells), and acinar)