Pathophysiology of gallbladder and bile duct

Question 1

function of gallbladder

Answer 1

store/concentrate bile (fasting), contracts to deliver bile to duodenum (fed)

Question 2

function of sphincter of Oddi

Answer 2

conserve bile, prevention of biliary infection (cholangitis)

Question 3

manifestations of gallstones

Answer 3

most are asymptomatic. can lead to biliary colic, acute cholecystitis, obstructed common bile duct, pancreatitis

Question 4

most common gallstone. soft, greasy, white yellow

Answer 4

cholesterol stone

Question 5

black, hard, brittle stones. associated with bile stasis

Answer 5

pigment stones

Question 6

least common stones. associated with bacterial colonization

Answer 6

brown stones

Question 7

cholesterol lithogenesis

Answer 7

cholesterol supersaturation, phospholipid deficiency, stasis, inflammation, overabsorption of water in gallbladder

Question 8

chief constituent of pigment stones

Answer 8

calcium bilirubinate

Question 9

risk factors for pigment stones

Answer 9

bile duct obstruction, excess bilirubin excretion (hemolysis), east Asian ancestry, parasitic infection

Question 10

risk factors for gallstones

Answer 10

(5 F’s) fat, fertile, 40yo female with family history

Question 11

pain in epigastrium or RUQ, relapse/remit with food/fast

Answer 11

biliary colic

Question 12

management of biliary colic

Answer 12

cholecystectomy, nonlithogenic bile acid supplement (ursodeoxycholic acid)

Question 13

Presentation: severe RUQ, nausea, FEVER

stone impaction in cystic duct or gallbladder neck –> bacterial colonization (GNRs, enterococci)
transmural inflammation, distention, ischemia

Answer 13

acute calculous cholecystitis

Question 14

treatment of acute calculous cholecystitis

Answer 14

NPO (gallbladder rest), IV hydration, IV abx, cholecystectomy

Question 15

due to gallbladder ischemia. associated with sepsis, recent surgery, trauma/burns, hypotension

similar symptoms to acute calculous cholecystitis

Answer 15

acalcuous cholecystitis

Question 16

treatment of acalculous cholecystitis

Answer 16

percutaneous drainage of gallbladder, cholecystectomy

Question 17

Presentation: jaundice, dark urine, abd pain, acute pancreatitis

Answer 17

choledocholithiasis

Question 18

diagnosis of choledocholithiasis

Answer 18

liver chemistries, ultrasound, MRCP/ERCP

Question 19

Charcot’s triad: fever, RUQ pain, jaundice

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

complication of choledocholithiasis

Answer 19

ascending cholangitis

Question 20

treatment of ascending cholangitis

Answer 20

admit to hospital –> NPO, broad spec abx, IV fluids

Question 21

chronic, persistent sx (jaundice, dark urine, acholic stools, pruritus, RUQ pain, elevated LFTs), narrowing of bile duct

can be benign or malignant

Answer 21

biliary stricture

Question 22

Benign causes of biliary stricture

Answer 22

iatrogenic, surgery, chronic pancreatitis, primary sclerosing cholangitis, autoimmune pancreatitis

Question 23

malignant causes of biliary stricture

Answer 23

pancreatic cancer, cholangiocarcinoma, gallbladder cancer, ampullary cancer

Question 24

diagnosis of biliary stricture

Answer 24

US/CT (dilated ducts, stricture), MRCP/ERCP, cholangioscopy

Question 25

management of biliary stricture

Answer 25

biopsy (benign vs malignant), endoscopic dilation or stent, surgery

Question 26

associated with IBD (UC > Crohn’s), males

intra and extrahepatic fibrotic strictures

increased risk of cholangiocarcinoma

Answer 26

Primary sclerosing cholangitis

Question 27

PSC management

Answer 27

liver transplant, ERCP (jaundice), monitor for cholangiocarcinoma

Question 28

dysfunction of schincter of Oddi

Answer 28

females, 20-50, mimics choledocholithiasis

Question 29

diagnosis of sphincter of Oddi dysfunction

Answer 29

history, elevated LFTs associated with pain, sphincter of Oddi manometry (definitive)

Question 30

treatment of sphincter of Oddi dysfunction

Answer 30

endoscopic sphincterotomy

Question 31

abd ultrasound sensitivity/specificity

Answer 31

95% sensitive/specific for gallstones

90% accuracy for cholecystitis

50% sensitive for choledocholithiasis