Pathophysiology of gallbladder and bile duct Flashcards
function of gallbladder
store/concentrate bile (fasting), contracts to deliver bile to duodenum (fed)
function of sphincter of Oddi
conserve bile, prevention of biliary infection (cholangitis)
manifestations of gallstones
most are asymptomatic. can lead to biliary colic, acute cholecystitis, obstructed common bile duct, pancreatitis
most common gallstone. soft, greasy, white yellow
cholesterol stone
black, hard, brittle stones. associated with bile stasis
pigment stones
least common stones. associated with bacterial colonization
brown stones
cholesterol lithogenesis
cholesterol supersaturation, phospholipid deficiency, stasis, inflammation, overabsorption of water in gallbladder
chief constituent of pigment stones
calcium bilirubinate
risk factors for pigment stones
bile duct obstruction, excess bilirubin excretion (hemolysis), east Asian ancestry, parasitic infection
risk factors for gallstones
(5 F’s) fat, fertile, 40yo female with family history
pain in epigastrium or RUQ, relapse/remit with food/fast
biliary colic
management of biliary colic
cholecystectomy, nonlithogenic bile acid supplement (ursodeoxycholic acid)
Presentation: severe RUQ, nausea, FEVER
stone impaction in cystic duct or gallbladder neck –> bacterial colonization (GNRs, enterococci)
transmural inflammation, distention, ischemia
acute calculous cholecystitis
treatment of acute calculous cholecystitis
NPO (gallbladder rest), IV hydration, IV abx, cholecystectomy
due to gallbladder ischemia. associated with sepsis, recent surgery, trauma/burns, hypotension
similar symptoms to acute calculous cholecystitis
acalcuous cholecystitis
treatment of acalculous cholecystitis
percutaneous drainage of gallbladder, cholecystectomy
Presentation: jaundice, dark urine, abd pain, acute pancreatitis
choledocholithiasis
diagnosis of choledocholithiasis
liver chemistries, ultrasound, MRCP/ERCP
Charcot’s triad: fever, RUQ pain, jaundice
Reynolds’ pentad: Charcot’s triad + hypotension + altered mental status
complication of choledocholithiasis
ascending cholangitis
treatment of ascending cholangitis
admit to hospital –> NPO, broad spec abx, IV fluids
chronic, persistent sx (jaundice, dark urine, acholic stools, pruritus, RUQ pain, elevated LFTs), narrowing of bile duct
can be benign or malignant
biliary stricture
Benign causes of biliary stricture
iatrogenic, surgery, chronic pancreatitis, primary sclerosing cholangitis, autoimmune pancreatitis
malignant causes of biliary stricture
pancreatic cancer, cholangiocarcinoma, gallbladder cancer, ampullary cancer
diagnosis of biliary stricture
US/CT (dilated ducts, stricture), MRCP/ERCP, cholangioscopy
management of biliary stricture
biopsy (benign vs malignant), endoscopic dilation or stent, surgery
associated with IBD (UC > Crohn’s), males
intra and extrahepatic fibrotic strictures
increased risk of cholangiocarcinoma
Primary sclerosing cholangitis
PSC management
liver transplant, ERCP (jaundice), monitor for cholangiocarcinoma
dysfunction of schincter of Oddi
females, 20-50, mimics choledocholithiasis
diagnosis of sphincter of Oddi dysfunction
history, elevated LFTs associated with pain, sphincter of Oddi manometry (definitive)
treatment of sphincter of Oddi dysfunction
endoscopic sphincterotomy
abd ultrasound sensitivity/specificity
95% sensitive/specific for gallstones
90% accuracy for cholecystitis
50% sensitive for choledocholithiasis
