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My DEMS I > Pathophsyiology of gall bladder and biliary tree > Flashcards

Pathophsyiology of gall bladder and biliary tree Flashcards

1
Q

Main function of bile

A

bile acids are active ingredient

–lipid digestion

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2
Q

Bile synthesized by ___

secreted into ____

A

hepatocytes

cannaliculi, which drain into the peripheral intrahepatic bile ducts –> R, L hepatic ducts–> common bile duct

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3
Q

Gallbladder general function

A

Stores and concentrates bile (fasting)

Contracts to deliver bile to duodenum (fed)

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4
Q

Bile ducts

A

Conduit for bile

Excretion for cholesterol, minerals, certain drugs

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5
Q

Sphincter of Oddi

A

Conserves bile acids
Prevention of biliary infection (cholangitis)

During fasting state, vagal tone and CCK levels are low. Sphincter of Oddi remains closed. Bile flows into GB.

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6
Q

Gallstones

A 
Genetic and acquired risk factors (lithogenic bile, nucleation (mucin plug), biliary stasis)
Multiple causes in same patient
Usually develop within the gallbladder 
-Biliary colic
-Acute cholecystitis

May spill into bile duct

  • Obstruction of CBD
  • Pancreatitis

Most are asymptomatic

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7
Q

Types of gallstones

A 
Cholesterol:
most common
soft, greasy, white-yellow
always start in GB
chol/bile salt supersaturation

Pigment:
black, hard, brittle
associated with bile stasis
calcium bilirubinate salts coalesce around mucin nidus

Brown:
least common
assoc w/ bacterial colonizaiton

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8
Q

Cholesterol lithogenesis

A

-cholesterol supersaturation
-phospholipid deficiency
-Occurs w/:
Gallbladder stasis
Chronic gallbladder inflammation
Cholesterol hyper-secretion by liver
Over-absorption of water in gallbladder

Mucin plug or foreign body nidus

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9
Q

Pigment stone lithogenesis

A

Chief constituent = calcium bilirubinate

Risk factors:
Bile duct obstruction
Excess bilirubin excretion (hemolysis)
East Asian ancestry
Parasitic infection
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10
Q

Gallstone RFs

A 
Age > 30 
Obesity
Female gender
Family history
Pregnancy or estrogens
Latin American or Native American ethnicity
Rapid weight loss
Biliary obstruction

“fat, female, forty, FH, from latin america”

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11
Q

Gallstone complications

A 
Biliary colic
Acute cholecystitis
ascending cholangitis
Gallstone pancreatitis
Gallbladder carcinoma
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12
Q

Biliary colic

A

Intermittent pain in epigastrium or RUQ
After meals, particularly fatty foods
Builds over an hour, remits 3-8 hrs later
Occurs w movement of stone into cystic duct or gallbladder neck

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13
Q

Management of biliary colic

A
  • may persist mo to yrs
  • (Lap) cholecystectomy is curative
  • Nonlithogenic bile acid supplement (ursodeoxycholic acid) may be considered
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14
Q

Acute calculous cholecystitis

A

Stone impaction in cystic duct or gallbladder neck
Bacteria colonization (GNRs, enterococci)
Transmural inflammation
Distension and ischemia
-GB perforation, sepsis or death may result if untreated

Presentation:
Severe RUQ pain, nausea, fever

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15
Q

Tx of acute calculous cholecystitis

A

NPO (gallbladder rest)
IV hydration
IV antibiotics
Surgical removal of the gallbladder (cholecystectomy)
Percutaneous or endoscopic drainage if too ill for surgery

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16
Q

Acalculous cholecystitis

A 
Less common than calculous
Usually from gallbladder ischemia
Risk factors = sepsis, recent surgery, trauma/burns, hypotension
Vasculitis
Symptoms otherwise similar to ACC

Treatment:
Percutaneous drainage of gallbladder
Cholecystectomy if fit for surgery

17
Q

Choledocholithiasis

A

Definition = stones in bile duct/s
Majority migrate from gallbladder
~ 10% form de novo in CBD

Presentation:
Jaundice, dark urine, and abdominal pain
Acute pancreatitis

18
Q

Dx and management of choledocholithiasis

A

Diagnosis
Liver chemistries
Ultrasound
MRCP or ERCP

Management
ERCP with extraction and/or lithotripsy
Surgery for refractory cases

19
Q

Ascending cholangitis

A

Bacterial infection of bile duct
Usually a complication of choledocholithiasis

Symptoms (Charcot’s triad)
Fever
RUQ pain
Jaundice

Sepsis or death may occur if untreated!

Reynold’s pentad: Charcot’s triad + hypotension + altered mental status

20
Q

Dx and mgmt of Ascending cholangitis

A

Diagnosis:
History, labs, US

Initial management:
Admit to hospital
NPO
Broad spectrum IV abx
IV fluids

Definitive diagnosis/ management–> Urgent ERCP!!

21
Q

Gallstone (biliary) pancreatitis

A

1 cause of acute pancreatitis in US

Clues :
Risk factors for gallstones (“5Fs”)
Gallstones seen on imaging
Dilated bile duct 
Elevated liver chemistries 
Absence of other risk factors for pancreatitis
22
Q

Biliary stricture

A 
Narrowing (stenosis) of bile duct
Intra- or extrahepatic
Intrinsic or extrinsic
Benign or malignant
Symptoms more chronic and persistent than stones
23
Q

Presentation of biliary stricture

A 
Cholestasis:
Jaundice
Dark urine (choluria)
Acholic stools
Pruritus
RUQ pain
LFTs elevated in cholestatic pattern:
Alk phos/GGT, bilirubin >> ALT/AST
24
Q

Benign causes of biliary stricture

A 
Iatrogenic - surgery, radiation
Chronic pancreatitis
Primary sclerosing cholangitis (PSC)
Autoimmune pancreatitis
Choledocolithiasis
25
Q

Malignant causes of biliary stricture

A

Pancreatic cancer
Cholangiocarcinoma
Gallbladder cancer (adenocarcinoma– RFs gallstones and chronic cholecystitis; 5 yr

26
Q

Dx of biliary stricture

A

Ultrasound or CT:
Dilated ducts
Stricture

MRCP or ERCP for confirmation

Cholangioscopy if uncertain

27
Q

Management of biliary stricture

A

Biopsy to differentiate benign vs. malignant
(onion skinning around bile ducts in liver biopsy may be seen)

Endoscopic dilation or stenting

Surgery:

  • Refractory to stenting
  • Malignancy
28
Q

Primary Sclerosing Cholangitis

A

Intra- and extrahepatic fibrotic strictures
Males > females, ages 30-50
Ass’d with IBD, *UC > Crohns
Risk of liver cirrhosis

Disease course independent of IBD

Increased risk of cholangiocarcinoma

29
Q

Management of PSC

A

Liver transplant is only effective therapy
ERCP with stent if jaundiced
Close surveillance for cholangiocarcinoma:
LFTs
MRCP or ERCP
CA 19-9

30
Q

Sphincter of Oddi dysfunction (SOD)

A 
Dysfunctional contraction of SO
Females >> males
Ages 20-50
May lead to episodic RUQ pain
Mimics choledocholithiasis
31
Q

Dx/Tx of SOD

A 
Dx:
History
Elevated LFTs during pain
\+/- dilated bile duct on US
Sphincter of Oddi manometry is definitive

Treatment = endoscopic sphincterotomy

32
Q

Abdominal US

A

Cheap, safe, readily available
95% sensitive and specific for gallbladder stones
> 90% accuracy for cholecystitis
50% sensitive for choledocholithiasis

My DEMS I (26 decks)

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