Pathophys of Gallbladder and biliary tree

Question 1

Gallbladder fxn (2)

Answer 1

1) Store and concentrate bile (fasting)

2) Contract to deliver bile to duodenum (fed)

Question 2

Bile Duct Fxn (3)

Answer 2

1) Conduit
2) Route of bile flow for digestion
3) Route of excretion for cholesterol, minerals, and certain drugs

Question 3

Bile Composition (3)

Answer 3

1) Cholesterol
2) Bile acids
3) Bilirubin

Question 4

Gallstones: Where do they cause problems?

Answer 4

1) almost always develop w/in gallbladder
a) Biliary colic
b) Acute cholecystitis
2) May spill into bile duct
a) Obstruct CBD
b) Pancreatitis

Question 5

Gallstone Types (3)

Answer 5

1) Cholesterol (most common-white)
2) Brown - bx infxn
3) Pigment - bile stasis

Question 6

Cholesterol stone mechanism (2)

Answer 6

1) Cholesterol supersaturation

2) Bile acid deficiency

Question 7

Pathophysiology of Stone Formation (5)

Answer 7

1) Gallbladder stasis
2) Gallbladder inflamm
3) Cholesterol hyper-secretion by liver (genetic)
4) Over-absorption of H2O w/in gallbladder (genetic)
5) Mucin plug or FBO

Question 8

Pigment Stone Chief constituent

Answer 8

Calcium bilirubinate

Question 9

Pigment Stone Risk Factors (4)

Answer 9

1) Biliary obstruction
2) Excess bilirubin excretion
3) Asian
4) May develop in gallbladder or bile duct

Question 10

LO4: Gallstone Risk factors 5 F’s

Answer 10

1) Fat
2) Female
3) Fertile
4) Forty
5) FMH

Question 11

LO1: Gallstone complications (5)

Answer 11

1) Biliary Colic
2) Acute Cholecystitis
3) Ascending cholangitis
4) Gallstone pancreatitis
5) Gallbladder carcinoma

Question 12

Biliary Colic (4)- Stuck in neck of gallbladder and falls back in

Answer 12

1) Intermittent pn in epigastrium or RUQ
2) After fatty meals
3) Peaks in 1 hr, remits 3-8 hrs later
4) Caused by movement of stone into cystic duct or gallbladder neck

Question 13

LO2: Biliary Colic Management

Answer 13

1) Laparascopic cholecystectomy is curative

2) non-lithogenic acid supplement (ursodeoxycholic acid) in special cases

Question 14

Acute (calculous) cholecystitis (2 where, 2 what, 3 complications)

Answer 14

1) Stone in cystic duct or gallbladder neck
2) Bx colonization (GNRs, enterococci)
3) Transmural inflamm
4) GB perforation, sepsis or death may result if untreated

Question 15

Acute Calculous Cholecystitis Presentation (3)

Answer 15

1) Severe RUQ pn
2) Nausea
3) Fever

Question 16

LO2: Acute Calculous Cholecystitis Tx (5)

Answer 16

1) NPO
2) IV fluids
3) IV antibiotics
4) Cholecystectomy when stable
5) Percutaneous drainage in pts too ill for surgery

Question 17

Acalculous cholecystitis (what, 2; Risks, 1; associations, 1; Sx, 1; Tx, 1)

Answer 17

1) Nonobstructive cholecystitis
2) Usually from gallbladder ischemia
3) Risks-sepsis, recent surgery, trauma/burns, hypotension
4) Associated w/ vasculitis
5) Sx- similiar to ACC
6) Tx: drain gallbladder or cholecystectomy

Question 18

LO2: Choledocholithiasis (what 2, Sx 1, Complication 1)

Answer 18

1) Stones in bile duct
2) Majority migrate from gallbladder
3) Jaundice, dark urine, abd pn
4) May cause acute pancreatitis

Question 19

LO2: Choledocholithiasis Dx (3)

Answer 19

1) Liver chemistries
2) US
3) MRCP or ERCP

Question 20

LO2: Choledocholithiasis management (2)

Answer 20

1) ERCP w/ extraction and/or lithotripsy

2) Surgery if refractory

Question 21

LO5: Ascending cholangitis (3) -

Answer 21

1) Bx infxn of bile duct
2) Often a complication of choledocholithiasis
3) Sepsis or death may occur if untreated

Question 22

LO5: Ascending Cholangitis Sx-Charcot’s Triad

Answer 22

1) Fever
2) RUQ pn
3) Jaundice

Question 23

Reynold’s Pentad (sepsis in ascending cholangitis)

Answer 23

1) Fever
2) RUQ pn
3) Jaundice
4) Hypotension
5) AMS

Question 24

LO2: Ascending Cholangitis Initial Management (4)

Answer 24

1) Hospital admit
2) NPO
3) Broad spectrum IV abx
4) IV fluids

Question 25

Ascending cholangitis Dx (4)

Answer 25

1) Hx
2) Labs
3) US
4) Definitive - Urgent ERCP

Question 26

Biliary stricture (5)-what, where, cause, sx

Answer 26

1) Fixed narrowing or blockage
2) Intra- or extrahepatic
3) intrinsic or extrinsic
4) Benign-Iatrogenic, PSC, chronic pancreatitis-autoimmune pancreatitis or malignant
5) Sx more chronic and persistent than stones

Question 27

Biliary Stricture Presentation (3)

Answer 27

1) RUQ pn
2) Cholestasis-jaundice, dark urine, acholic stools, pruritis
3) LFTS elevated in cholestatic pattern - Alk Phos/GGT, bilirubin» ALT/AST

Question 28

Biliary Stricture Dx (3)

Answer 28

1) US or CT -dilated ducts
2) MRCP or ERCP for confirm
3) Biopsy to differentiate benign vs. malignant

Question 29

Biliary Stricture Management (3)

Answer 29

1) ERCP w/ dilation or stenting
2) biopsy to r/o malignancy
3) surgery if refractory or malignant

Question 30

Primary Sclerosing Cholangitis (PSC)-

Association, Sx (3), Increased risks (2)

Answer 30

1) Associate w/ IBD (UC)
2) RUQ pn, jaundice, fever
3) Most get liver cirrhosis
4) increased risk of cholangiosarcoma

Question 31

PSC Dx (3) Tx (2) Surveillance (1)

Answer 31

1) ALk Phos/GGT> AST/ALT
2) Bili rises late
3) MRCP or ERCP
4) Liver transplant is only effective tx
5) biliary stent if jaundiced
6) Close surveillance for CholangioCA

Question 32

LO3: SOD Dysfxn

Answer 32

1) Motility disorder of SOD
2) Intermittent
3) Sx, labs, and imaging may mimc choledocholithiasis
4) Types I-III depending on severity. I -worst

Question 33

LO3: SOD Presentation (3)

Answer 33

1) Recurrent RUQ Pn
2) Dynamically elevated ALT/AST/alk phos
3) Dilated bile duct on US

Question 34

LO3: SOD Dx

Answer 34

ERCP w/ SOD manometry

Question 35

SOD Tx

Answer 35

Biliary sphincterotomy;

complication-bile reflux

Question 36

LO6: Abd US-Pros + cons (4)

Answer 36

1) Cheap, safe, available
2) Sensitive and specific for gallstones
3) 80% accurate for cholecystitis
4) 50% sensitive for choledocholithiasis

Question 37

EUS

Answer 37

Find bile duct stone not seen on US

Question 38

MRI/MRCP

Answer 38

MRCP-diagnostic, but not procedural

Question 39

ERCP

Answer 39

Diagnostic and procedural