17. Biliary Tract: Gallbladder and Biliary Disease Flashcards
(110 cards)
1
Q
What are the three main problems of the gallbladder that were discussed?
A
Cholecystitis: calculous cholecystitis, acalculous, xanthogranulomatous
Porcelain gallbladder
Gallbladder polyps
2
Q
What is cholecystitis?
A
Galbladder inflammation
3
Q
What does acute choecystitis present with?
A
RUQ pain
Fever
Leukocytosis
Gallbladder inflammation
4
Q
What is the term for when cholecystitis is NOT associated with a gallstone?
A
Acalculous
**calculus and xanthogranulomatous are associated with gallstones
5
Q
Chronic cholecystitis is almost always associated with:
A
Gallstones
6
Q
What happens in chronic cholecystitis?
A
Mechanical irritation or recurrent acute cholecystitis –> fibrosis
7
Q
What is the pathogenesis of acute cholecystitis?
A
Cystic duct obstruction in addition to irritant (lysolecithin) –> Release of inflammatory mediators (prostaglandins)
8
Q
What are the clinical manifestations of acute cholecystitis?
A
- Prolonged (over 4-6 hr) RUQ/epigastric pain with radiation to the shoulder or back
- Fever
- Abdominal guarding: local parietal peritoneal inflammation
- Murphy’s sign
- Leukocytosis
9
Q
What is murphy’s sign for acute cholecystitis?
A
Increased discomfort when the patient takes a deep breath in while the examiner palpates RUQ
10
Q
Is there elevated bilibrubin and ALP with acute cholecystitis?
A
No
11
Q
What imaging is done for acute cholecystitis?
A
Abdominal ultrasound
HIDA scan
CT
12
Q
What abdominal ultrasound findings suggest acute chol?
A
Cholelithiasis, wall thickening over 4-5 mm or edema, sonographic Murphy’s sign
13
Q
What happens in cholescintigraphy/99mTc-hepatic imindiacetic acid (HIDA) scans?
A
Labelled HIDA injected IV
Taken up by hepatocytes
Excreted in the bile
**no visualization of the gallbladder due to cystic duct obstruction
14
Q
What will a CT show with acute chol?
A
Gallbladder wall edema
Pericholecystic stranding and fluid
High-attenuation bile
**not a good modality to detect gallstones
15
Q
What is the most common complication of acute cholecystitis?
A
Gangrene
16
Q
What can happen after the development of gangrene from acute chol?
A
Perforation; localized, resulting in abscess
17
Q
4 complications of acute chol?
A
Gangrene
Perforation
Cholecystoenteric fistula
Emphysematous cholecystitis
18
Q
What happens in a cholecystoenteric fistula from acute chol?
A
Fistula into duodenum or jejunum allows passage of gallstone, mechanical bowel obstruction, usually in the terminal ileum (gallstone ileus)
19
Q
What is emphysematous cholecystitis? (complication of acute chol)
A
Secondary infection of the gallbladder wall with gas forming organisms
–usually leads to gangrene and perforation
20
Q
Tx of acute cholecystitis
A
May abate in 7-10 days if not treated Antibiotics Pain control: NSAIDs and opioids Gallbladder drainage (percutaneous, endoscopic) Surgery
21
Q
When is immidiate surgery advised for acute chol? Delayed cholecystectomy?
A
Patients with complications or low risk
High risk patients: severe chronic illness, low-risk patients with sepsis
22
Q
Prognosis of acute cholecystitis?
A
Mortality of approximately 3%
- less than 1% in young healthy patients
- up to 10% in high-risk patients or those with complications
23
Q
What happens in acalculous cholecystitis (pathogenesis)?
A
Gallbladder stasis and ischemia ->
Local inflammatory response ->
Secondary infection
24
Q
Who typically gets acalculous cholecystitis?
A
Hospitalized, critically ill patients
25
What is the clinical presentation of acalculous chol?
Similar to calculous--fever, leukocytosis, abdominal pain
| **non-specific liver enzyme tests
26
Diagnosis of acalculous chol
Abdominal ultrasound: no cholelithiasis, wall thickening over 3 mm, sonographic Murphy's sign, percholecystic fluid
HIDA scan: lack of gallbladder visualization
CT
27
Three components of tx for acalculous cholecystitis?
1. Antibiotics
2. Percutaneous cholecystostomy
3. Cholecystectomy
28
What is the prognosis of acalculous cholecystitis?
High mortality with delayed tx 75%
| Overall mortality of 30%
29
What is xanthogranulomatous cholecystitis?
Extravastion of bile into the gallbladder wall -->
Inflammatory reaction (fibroblasts and PMNs phagocytose biliary lipids in bile) -->
Xanthoma cells
**gallstones present in all patients
30
What is the clinical presentation of xanthogranulomatous cholecystitis?
Hx suggestive of acute cholecystitis
Can mimic gallbladder cancer
High rate of complications--perforation, fistulas, abscess
31
Diagnosis of xanthogranulomatous cholecystitis
Abdominal ultrasound: hypoechoic nodules or bands in the gallbladder wall most characteristic
CT: intramural hypodense nodules
32
Tx for xanthogranulomatous cholecystitis
Cholecystectomy
| Preop cholangiogram to exclude bile duct cancer
33
What is porcelain gallbladder?
Chronic cholecystitis with intramural calcification of the gallbladder wall
34
Possible causes of porcelain gallbladder
1. Gallbladder wall injury from stone irritation
2. Bile stagnation and mucosal precipitation of calcium carbonate salts
3. Deposition of lime salts from chronic inflammation
35
Prevalence of porcelain gallbladder
M/F
Increased risk for:
Uncommon 0.06-0.08
Females 5:1
Gallbladder cancer; incomplete calcificaiton more risky than complete
36
Possible clinical presentations of porcelain gallbladder
Asymptomatic
Biliary type pain
Palpable gallbladder
37
Diagnosis of porcelain gallbladder
Plain x-ray
CT
Abdominal ultrasound
38
Tx for porcelain gallbladder
Cholecystectomy for incomplete calc or symptomatic complete calc
39
What are the four classes of benign gallbladder polyps *found in 1.5-4.5% of patients undergoing gallbladder ultrasonography
Cholesterol
Adenomyomas
Inflammatory
Adenoma
40
What are cholesterol gallbladder polyps
Abnormal deposits of triglycerides, cholesterol precursors, and cholesterol esters into the gallbladder mucosa
41
What is a adenomyomatosis? (gallbladder polyp)
Overgrowth of the mucosa, thickening of the muscle wall, and intramural diverticula
**associated with cholelithiasis
42
M/F in adenomyomatosis? Cancer?
More common in women
| No conclusive evidence of increased risk of gallbladder cancer
43
What are inflammatory gallbladder polyps?
Granulation and fibrous tissue with plasma cells and lymphocytes
44
What are adenomas (gallbladder polyps)?
Benign glandular tumors with the potential for malignancy
45
What is the relationship between likelihood of adenoma malignant transformation to size?
Larger has more risk of transforming
46
What is the clinical presentation of gallbladder polyps?
Asymptomatic usually
BIliary pain
possible association of dyspepsia with cholestrolosis and adenomyomatosis
47
Diagnosis of gallbladder cancer
Transabdominal ultrasound
Endoscopic ultrasound
CT--most useful in gallbladder cancer
48
When should you do a cholecystectomy for gallbladder polyps?
1. With cholelithiasis
2. With primary sclerosing cholangitis
3. Biliary colic or pancreatitis
4. Polyps > 10 mm
49
What is acute (ascending) cholangitis
Fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract
50
What is the pathogenesis of acute cholangitis?
Bacteria enter from the small intestine or protal system
- disruption of the sphincter of oddi
- nidus for bacterial colonization
51
WHat are the more common bacteria involved in acute cholangitis?
E. coli (25-50%) > Klebsiella (15-20%) > Enterococcus (10-20%) > Enterobacter species (5-10%)
52
What is Charcot's triad?
Fever
Abdominal pain
Jaundice
**associated with acute cholangitis 50-75% of the time
53
What is Reynolds' pentad?
Confusion and hypotension witht Charcot's triad
| **high morbidity and mortality, assoicated with acute cholangitis
54
How is acute cholangitis diagnosed?
Clinical signs
| Imaging: dilated biliary system, cholegocholithiasis
55
How is acute cholangitis treated?
Antibiotics
| Biliary drainage: ERCP, percutaneous transhepatic cholangiography (PTC), and surgery
56
What is biliary atresia?
Progressive, idiopathic, fibroobliterative disease of the extrahepatic biliary tree
57
How does biliary atresia present?
WIth biliary obstruction exclusively in the neonatal period
Infants born at full term with normal birth weight
Jaundice birth to 8 weeks with acholic stools and dark urine
58
What are the two types of biliary atresia?
1. Biliary atresia 70-85%
2. Biliary atresia splenic malformation (BASM) 10-15%
3. BIliary atresia in association with other congenital malformations
59
What are the findings in biliary atresia splenic malformation?
```
Situs inversus
Asplenia or polysplenia
Malrotation
Interrupted IVC
Cardiac anomalies
```
60
What is associated in 'biliary atresia in association with other congenital malfromations'?
Intestinal atresia
Imperforate anus
Kidney anomalies
Heart malformations
61
Possible pathogenesis of biliary atresia
Viral
Toxic
Genetic--possibly BASM subtype
Immune dysregulation
62
Dx of biliary atresia
1. Abdominal ultrasound
2. Lier biopsy
3. Cholangiogram: intraoperative, PTC, endoscopic (ERCP)
63
Treatment of biliary atresia
```
Kasai procedure: surgical reconstruction of the extrahepatic biliary tract. Not curative, buys time for--
Liver transplantation (want to wait till weight is over 10 kg)
```
64
What are biliary cysts?
Cystic dilations that may occur singly or multiply thoughout the biliary tree
65
What are 70% of biliary cysts associated with?
Abnormal pancreaticobiliary junction (APBJ): pancreatic and bile duct join outside the duodenal wall
**associated with increased risk of gallbladder cancer independent of biliary cysts
66
Who gets biliary cysts
More common in asian populations
Women 4:1
Equal numbers in children and adults
67
What are the types of biliary cysts?
Type I: 50-80%--> extrahepatic only
TYpe IV: 15-35%--> multiple cysts, extrahepatic +/- intrahepatic
Type V: 20% --> intrahepatic only, Caroli's disease
68
Pathogenesis of biliary cysts
Genetic or environmental predisposition
Associated with developmental anomalies
Congenital or acquired (from APBJ)
69
The majority of biliary cysts present before the age of
10
70
Infants with biliary cysts present with:
| Patients over 2 with biliary cysts present with:
Jaundice, FTT, abdominal mass
| Chronic intermittant abdominal pain, pancreatitis, intermittant jaundice, cholangitis
71
How are biliary cysts diagnosed?
Abdominal ultrasound
Cholangiography: ERCP, PTC, intraoperative, MRCP
CT
72
What do biliary cysts increase the risk for?
20-30 fold increased risk for cholangiocarcinoma
| **most occur with types I and IV cysts
73
What is primary sclerosing cholangitis
Progressive inflammation, fibrosis, and stricture of the intrahepatic and extrahepatic bile ducts
74
What causes secondary sclerosing cholangitis?
Recurrent pyogenic cholangitis, choledocholithiasis, cholangitis, AIDS cholangiopathy
75
What does PSC have a strong association with?
IBD
Ulcerative colitis > crohns
**up to 90% of patients with PSC have UC
76
Who gets PSC?
70% men
| Mean age of dx 40 yo **women dx later
77
What is the pathogenesis of PSC?
Immune activation
Genetic factors--CFTR mutations
?Bacterial infections
?Ischemia duct injury
78
What are the clinical manifestations of PSC?
```
Asymptomatic (50%)
Elevated liver tests in a cholestatic pattern
Fatique
Pruritus
Jaundice
```
79
What are the lab manifestations of PSC?
Hypergammaglobulinemia
Increased immunoglobulin
Atypical p-ANCA
80
What are the subtypes of classic PSC?
Intrehepatic and extrahepatic
Intrahepatic alone
Extrahepatic alone
81
What is the presentation of small-duct PSC?
Normal cholangiogram
| Involves small caliber bile ducts
82
Diagnosis of PSC?
CT, abdominal ultrasound
Cholangiography
Liver biopsy (not needed if the cholangiogram is diagnostic, consider for small-duct PSC
**will see onion skin pattern around bile ducts
83
Complications of PSC
Cirrhosis and portal HTN due to hepatic fibrosis
Steatorrhea and fat-soluble vitamin malabsorption from decreased bile acids
Osteoporosis
Dominant biliary structures
Acute cholangitis
Choletlithiasis
Hepatobiliary cancers--cholangiocarcinoma
Colon cancer
84
Treatment of PSC
Medical therapy NOT recommended
ERCP for dominant extrahepatic strictures
Surgery: biliary reconstruction or liver transplant
85
What is AIDS cholangiopathy?
Biliary obstruction resulting from infection related strictures of the biliary tract
Classically cryptosporidium parvum
86
Who gets AIDS cholangiopathy?
Seen in AIDs patients with CD4 count <100/mm3
87
What is the presentation of AIDS cholangiopathy?
RUQ pain
Epigastric pain
Diarrhea
88
Diagnosis of AIDS cholangiopathy?
Elevation of cholestatic liver enzymes
Transabdominal ultrasounds
MRCP
ERCP
89
Treatment of AIDS cholangiopathy
BIliary sphincterotomy during ERCP
Stending of dominant extrahepatic strictures
Sometimes ursodeoxycholic acid
**NOT antimicrobials
90
What parasites are involved in biliary parasitosis?
```
Ascaris lumbricoides (roundworm)*
Echinococcus granulosus (tapeworm)*
Clonorchis sinensis
Opithorchiasis
Fasciola hepatica (sheep liver fluke)*
```
91
What is the roundworm that is found worldwide and inhabits human small intestine?
Ascaris lumbricoides
92
What will be seen on ultrasound with ascarid lumbricoides?
Long, linear, parallel echogenic structures without acoustic shadowing
93
Dx and tx of ascaris lumbricoides?
ERCP of dx and removal
| Tx with anti-helminthic therapy
94
What is the tapeworm that has a dog as a host and is found in S. america, middle east, e. mediterranian, china, etc
Echinococcus granulousus
95
What happens with echinococcus granulosus?
Rupture of hepatic cyst into biliary system causing jaundice and hepatomegaly
96
Tx of echinococcus granulosus related cyst?
Surgical resection or percutaneous injection of scolicidal agents as well as anti-helminth therapy
97
What is a liver fluke found in the far east and russie, with dog and cat reservoir?
Clonorchis sinensis
98
What does clonorchis sinensis cause?
Chronic infection associated with cholangiocarcinoma
99
Dx and tx of clonorchis sinensis
ERCP for acute cholangitis
| Tx with anti-helminth therapy
100
What is a liver fluke of cates in SE asia and central and eastern europe with a similar presentation as clonorchis sinensis?
Opisthorchiasis
101
What is a sheep liver fluke that causes human infection when eating raw veggies infected with metacercariae?
Fasciola hepatica
102
What happens upon fasciola hepatica infection?
Penetrate duodenal wall
Migrate across peritoneum
Enter the biliary system
103
Tx for Fasciola hepatica
ERCP for acute cholangitis
| Tx with anti-helminthic therapy
104
What is recurrent pyogenic cholangitis?
Pigment stone formation in the intrahepatic biliary system resulting in intrahepatic stricturing and biliary obstruction with recurrent bouts or acute cholangitis
105
Who gets recurrent pyogenic cholangitis?
Patients from SE Asia
106
What causes recurrent pyogenic cholangitis?
Biliary parasitosis
Bacterial infection
Stasis
107
What is the key clinical manifestation of recurrent pyogenic cholangitis?
Acute cholangitis
108
Dx of recurrent pyogenic cholangitis
```
Abdomenal ultrasound
MRI
CT
PTC
ERCP
```
109
Tx of recurrent pyogenic cholangitis
Treat acute cholangitis
Stone clearance--ERCP, PTC, surgical
Consider ursodeoxycholic acid
Hepatic resection and reanastomosis
110
Possible SEs of recurrent pyogenic cholangitis?
Cirrhosis from seconday sclerosing cholangitis
| INCREASED RISK FOR CHOLANGIOCARCINOMA
