17. Biliary Tract: Gallbladder and Biliary Disease Flashcards Preview

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Flashcards in 17. Biliary Tract: Gallbladder and Biliary Disease Deck (110):
1

What are the three main problems of the gallbladder that were discussed?

Cholecystitis: calculous cholecystitis, acalculous, xanthogranulomatous
Porcelain gallbladder
Gallbladder polyps

2

What is cholecystitis?

Galbladder inflammation

3

What does acute choecystitis present with?

RUQ pain
Fever
Leukocytosis
Gallbladder inflammation

4

What is the term for when cholecystitis is NOT associated with a gallstone?

Acalculous
**calculus and xanthogranulomatous are associated with gallstones

5

Chronic cholecystitis is almost always associated with:

Gallstones

6

What happens in chronic cholecystitis?

Mechanical irritation or recurrent acute cholecystitis --> fibrosis

7

What is the pathogenesis of acute cholecystitis?

Cystic duct obstruction in addition to irritant (lysolecithin) --> Release of inflammatory mediators (prostaglandins)

8

What are the clinical manifestations of acute cholecystitis?

1. Prolonged (over 4-6 hr) RUQ/epigastric pain with radiation to the shoulder or back
2. Fever
3. Abdominal guarding: local parietal peritoneal inflammation
4. Murphy's sign
5. Leukocytosis

9

What is murphy's sign for acute cholecystitis?

Increased discomfort when the patient takes a deep breath in while the examiner palpates RUQ

10

Is there elevated bilibrubin and ALP with acute cholecystitis?

No

11

What imaging is done for acute cholecystitis?

Abdominal ultrasound
HIDA scan
CT

12

What abdominal ultrasound findings suggest acute chol?

Cholelithiasis, wall thickening over 4-5 mm or edema, sonographic Murphy's sign

13

What happens in cholescintigraphy/99mTc-hepatic imindiacetic acid (HIDA) scans?

Labelled HIDA injected IV
Taken up by hepatocytes
Excreted in the bile
**no visualization of the gallbladder due to cystic duct obstruction

14

What will a CT show with acute chol?

Gallbladder wall edema
Pericholecystic stranding and fluid
High-attenuation bile
**not a good modality to detect gallstones

15

What is the most common complication of acute cholecystitis?

Gangrene

16

What can happen after the development of gangrene from acute chol?

Perforation; localized, resulting in abscess

17

4 complications of acute chol?

Gangrene
Perforation
Cholecystoenteric fistula
Emphysematous cholecystitis

18

What happens in a cholecystoenteric fistula from acute chol?

Fistula into duodenum or jejunum allows passage of gallstone, mechanical bowel obstruction, usually in the terminal ileum (gallstone ileus)

19

What is emphysematous cholecystitis? (complication of acute chol)

Secondary infection of the gallbladder wall with gas forming organisms
--usually leads to gangrene and perforation

20

Tx of acute cholecystitis

May abate in 7-10 days if not treated
Antibiotics
Pain control: NSAIDs and opioids
Gallbladder drainage (percutaneous, endoscopic)
Surgery

21

When is immidiate surgery advised for acute chol? Delayed cholecystectomy?

Patients with complications or low risk
High risk patients: severe chronic illness, low-risk patients with sepsis

22

Prognosis of acute cholecystitis?

Mortality of approximately 3%
- less than 1% in young healthy patients
- up to 10% in high-risk patients or those with complications

23

What happens in acalculous cholecystitis (pathogenesis)?

Gallbladder stasis and ischemia ->
Local inflammatory response ->
Secondary infection

24

Who typically gets acalculous cholecystitis?

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