Pathophys gall bladder and biliary tree

Question 1

Understand the pathophysiology of gallstone formation

Answer 1

Cholesterol supersaturation
Bile acid deficiency

Gallbladder stasis
Gallbladder inflammation
Cholesterol hyper-secretion by liver
Over-absorption of water within the gallbladder
Nidus such as mucin plug or foreign body

Question 2

Understand the tests used to diagnose gallstone complications

Answer 2

1. abdominal ultrasound
   - cheap available safe
2. HIDA scans
   - gallbladder stuff
3. endoscopic ultrasound
4. ERCP
5. MRCP

Question 3

1. Recognize the complications of gallstones

Answer 3

complications

• Biliary colic
• Acute cholecystitis
• Ascending cholangitis
• Gallstone pancreatitis
• Gallbladder carcinoma

Question 4

2. Recognize the causes, mechanism, tests, and treatment of acute calculous and acalculous cholecystitis.

Answer 4

acute calculous
-More common than acalculous variety
-Stone in cystic duct or gallbladder neck
-Bacteria colonization (GNRs, enterococci)
-Transmural inflammation
-GB, perforation, sepsis or death may result if untreated
Presentation:
-Severe pain in RUQ, nausea, fever
Treatment
-NPO (gallbladder rest)
-IV hydration
-IV antibiotics (focus on GNR)
-Surgical removal of the gallbladder (cholecystectomy) -when stable
-Percutaneous drainage of gallbadder in patients too ill for -surgery

Question 5

3. Recognize the causes, presentation, diagnostic tests, and treatments for biliary strictures.

Answer 5

Fixed narrowing or blockage of bile duct
Intra- or extrahepatic
Intrinsic or extrinsic

Symptoms- more chronic and persistent than stones
-RUQ pain, Cholestasis, Jaundice, Dark urine (choluria), -Acholic stools, pruritus, LFTs elevated in cholestatic -pattern, Alk phos/GGT, bilirubin >> ALT/AST
Benign
-Iatrogenic - surgery, radiation
-Primary sclerosing cholangitis (PSC)
-Chronic pancreatitis
-Autoimmune pancreatitis
Malignant
-Pancreatic cancer
-Cholangiocarcinoma
-Gallbladder cancer
-Ampullary cancer
Diagnosis
-Ultrasound or CT → dilated ducts
-MRCP or ERCP for confirmation
-Biopsy to differentiate benign vs. malignant

Question 6

4. Recognize the presentation, diagnosis, and management of sphincter of Oddi dysfunction.

Answer 6

young females
Motility disorder of Sphincter of Oddi
Typically intermittent
symptoms, labs, imaging may mimic choledocholithiasis
Types I, II, III depending on severity
Presentation
-Recurrent RUQ pain
-Dynamically elevated ALT/AST/alk phos
-Dilated bile duct on US
Diagnosis
-ERCP with sphincter of Oddi manometry

Question 7

what are the most common gall stones

Answer 7

cholesterol stones

Question 8

pigment stones

Answer 8

Chief constituent = calcium bilirubinate

Risk factors:
Biliary obstruction
Excess bilirubin excretion (hemolysis) (sickle cell)
Asian ancestry
May develop in gallbladder or bile duct

Question 9

risk factors for gall stones

Answer 9

fat, over forty, female, fertile, family Hx,

Question 10

Biliary colic

Answer 10

Intermittent pain in epigastrium or RUQ
After meals, particularly fatty foods
Peaks within an hour, remits 3-8 hours later
Caused by movement of stone into cystic duct or gallbladder neck

Tx-May persist for months or years
Laparoscopic cholecystectomy is curative
(non-surgical)- Non-lithogenic bile acid supplement (ursodeoxycholic acid) may be considered in special cases

Question 11

Recognize the causes, mechanism, tests, and treatment of acalculous cholecystitis.

Answer 11

Usually from ischemia of gallbladder
Risk factors =
-sepsis, recent surgery, trauma/burns, hypotension
-Vasculitis- Polyarteritis Nodosa
Symptoms, disease otherwise similar to ACC
Treatment: drainage of gallbladder or cholecystectomy

Question 12

Choledocolithiasis

Answer 12

Stones in bile duct/s
Majority migrate from gallbladder
~ 10% form de novo in CBD
Jaundice, dark urine, and abdominal pain
May also cause acute pancreatitis 
Diagnosis
-Liver chemistries (ALT, ALK Phos, Bili)
-Ultrasound
-MRCP or ERCP
Management
-ERCP with extraction and/or lithotripsy
-Surgery if refractory

Question 13

Ascending Cholangitis

Answer 13

Bacterial infection of bile duct

Almost always a complication of choledocholithiasis
Symptoms = Charcot’s triad,Fever, RUQ pain, Jaundice
-Sepsis or death may occur if untreated
Initial management
-Admit to hospital, NPO, Broad spectrum IV abx, IV fluids
Diagnosis:
-History, labs, US are usually suggestive
-Definitive diagnosis and management
-Urgent ERCP!

Question 14

Reynolds pentad

Answer 14

charcots triad + hypotension and mental confusion

Question 15

Gallstone Pancreatitis

Answer 15

#1 cause of pancreatitits is america
Clues. stone at the ampulla, retrogade pile in pancreatic duct
-5 F's, Gallstone seen on imaging, dilated bile duct, -elevated liver chemistry, absence of other risk factors

Question 16

primary sclerosing cholangitis is related to what disease-

Answer 16

UC, only effective treatment is liver transplant, associted with bile duct cancer

Question 17

are most gallstones symptomatic or asymptomatic?

Answer 17

asymptomatic