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GI > 17. Biliary Tract: Gallbladder and Biliary Disease > Flashcards

17. Biliary Tract: Gallbladder and Biliary Disease Flashcards

1
Q

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

A

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

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2
Q

What is cholecystitis?

A

Galbladder inflammation

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3
Q

What does acute choecystitis present with?

A

RUQ pain
Fever
Leukocytosis
Gallbladder inflammation

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4
Q

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

A

Acalculous

**calculus and xanthogranulomatous are associated with gallstones

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5
Q

Chronic cholecystitis is almost always associated with:

A

Gallstones

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6
Q

What happens in chronic cholecystitis?

A

Mechanical irritation or recurrent acute cholecystitis –> fibrosis

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7
Q

What is the pathogenesis of acute cholecystitis?

A

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

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8
Q

What are the clinical manifestations of acute cholecystitis?

A
  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
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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

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10
Q

Is there elevated bilibrubin and ALP with acute cholecystitis?

A

No

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11
Q

What imaging is done for acute cholecystitis?

A

Abdominal ultrasound
HIDA scan
CT

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12
Q

What abdominal ultrasound findings suggest acute chol?

A

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

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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

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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

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15
Q

What is the most common complication of acute cholecystitis?

A

Gangrene

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16
Q

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

A

Perforation; localized, resulting in abscess

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17
Q

4 complications of acute chol?

A

Gangrene
Perforation
Cholecystoenteric fistula
Emphysematous cholecystitis

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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)

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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

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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
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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

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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
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23
Q

What happens in acalculous cholecystitis (pathogenesis)?

A

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

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24
Q

Who typically gets acalculous cholecystitis?

A

Hospitalized, critically ill patients

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25
Q

What is the clinical presentation of acalculous chol?

A

Similar to calculous–fever, leukocytosis, abdominal pain

**non-specific liver enzyme tests

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26
Q

Diagnosis of acalculous chol

A

Abdominal ultrasound: no cholelithiasis, wall thickening over 3 mm, sonographic Murphy’s sign, percholecystic fluid
HIDA scan: lack of gallbladder visualization
CT

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27
Q

Three components of tx for acalculous cholecystitis?

A
  1. Antibiotics
  2. Percutaneous cholecystostomy
  3. Cholecystectomy
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28
Q

What is the prognosis of acalculous cholecystitis?

A

High mortality with delayed tx 75%

Overall mortality of 30%

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29
Q

What is xanthogranulomatous cholecystitis?

A

Extravastion of bile into the gallbladder wall –>
Inflammatory reaction (fibroblasts and PMNs phagocytose biliary lipids in bile) –>
Xanthoma cells
**gallstones present in all patients

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30
Q

What is the clinical presentation of xanthogranulomatous cholecystitis?

A

Hx suggestive of acute cholecystitis
Can mimic gallbladder cancer
High rate of complications–perforation, fistulas, abscess

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31
Q

Diagnosis of xanthogranulomatous cholecystitis

A

Abdominal ultrasound: hypoechoic nodules or bands in the gallbladder wall most characteristic
CT: intramural hypodense nodules

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32
Q

Tx for xanthogranulomatous cholecystitis

A

Cholecystectomy

Preop cholangiogram to exclude bile duct cancer

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33
Q

What is porcelain gallbladder?

A

Chronic cholecystitis with intramural calcification of the gallbladder wall

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34
Q

Possible causes of porcelain gallbladder

A
  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
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35
Q

Prevalence of porcelain gallbladder
M/F
Increased risk for:

A

Uncommon 0.06-0.08
Females 5:1
Gallbladder cancer; incomplete calcificaiton more risky than complete

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36
Q

Possible clinical presentations of porcelain gallbladder

A

Asymptomatic
Biliary type pain
Palpable gallbladder

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37
Q

Diagnosis of porcelain gallbladder

A

Plain x-ray
CT
Abdominal ultrasound

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38
Q

Tx for porcelain gallbladder

A

Cholecystectomy for incomplete calc or symptomatic complete calc

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39
Q

What are the four classes of benign gallbladder polyps *found in 1.5-4.5% of patients undergoing gallbladder ultrasonography

A

Cholesterol
Adenomyomas
Inflammatory
Adenoma

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40
Q

What are cholesterol gallbladder polyps

A

Abnormal deposits of triglycerides, cholesterol precursors, and cholesterol esters into the gallbladder mucosa

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41
Q

What is a adenomyomatosis? (gallbladder polyp)

A

Overgrowth of the mucosa, thickening of the muscle wall, and intramural diverticula
**associated with cholelithiasis

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42
Q

M/F in adenomyomatosis? Cancer?

A

More common in women

No conclusive evidence of increased risk of gallbladder cancer

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43
Q

What are inflammatory gallbladder polyps?

A

Granulation and fibrous tissue with plasma cells and lymphocytes

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44
Q

What are adenomas (gallbladder polyps)?

A

Benign glandular tumors with the potential for malignancy

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45
Q

What is the relationship between likelihood of adenoma malignant transformation to size?

A

Larger has more risk of transforming

46
Q

What is the clinical presentation of gallbladder polyps?

A

Asymptomatic usually
BIliary pain
possible association of dyspepsia with cholestrolosis and adenomyomatosis

47
Q

Diagnosis of gallbladder cancer

A

Transabdominal ultrasound
Endoscopic ultrasound
CT–most useful in gallbladder cancer

48
Q

When should you do a cholecystectomy for gallbladder polyps?

A
  1. With cholelithiasis
  2. With primary sclerosing cholangitis
  3. Biliary colic or pancreatitis
  4. Polyps > 10 mm
49
Q

What is acute (ascending) cholangitis

A

Fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract

50
Q

What is the pathogenesis of acute cholangitis?

A

Bacteria enter from the small intestine or protal system

  • disruption of the sphincter of oddi
  • nidus for bacterial colonization
51
Q

WHat are the more common bacteria involved in acute cholangitis?

A

E. coli (25-50%) > Klebsiella (15-20%) > Enterococcus (10-20%) > Enterobacter species (5-10%)

52
Q

What is Charcot’s triad?

A

Fever
Abdominal pain
Jaundice
**associated with acute cholangitis 50-75% of the time

53
Q

What is Reynolds’ pentad?

A

Confusion and hypotension witht Charcot’s triad

**high morbidity and mortality, assoicated with acute cholangitis

54
Q

How is acute cholangitis diagnosed?

A

Clinical signs

Imaging: dilated biliary system, cholegocholithiasis

55
Q

How is acute cholangitis treated?

A

Antibiotics

Biliary drainage: ERCP, percutaneous transhepatic cholangiography (PTC), and surgery

56
Q

What is biliary atresia?

A

Progressive, idiopathic, fibroobliterative disease of the extrahepatic biliary tree

57
Q

How does biliary atresia present?

A

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
Q

What are the two types of biliary atresia?

A
  1. Biliary atresia 70-85%
  2. Biliary atresia splenic malformation (BASM) 10-15%
  3. BIliary atresia in association with other congenital malformations
59
Q

What are the findings in biliary atresia splenic malformation?

A 
Situs inversus
Asplenia or polysplenia
Malrotation
Interrupted IVC
Cardiac anomalies
60
Q

What is associated in ‘biliary atresia in association with other congenital malfromations’?

A

Intestinal atresia
Imperforate anus
Kidney anomalies
Heart malformations

61
Q

Possible pathogenesis of biliary atresia

A

Viral
Toxic
Genetic–possibly BASM subtype
Immune dysregulation

62
Q

Dx of biliary atresia

A
  1. Abdominal ultrasound
  2. Lier biopsy
  3. Cholangiogram: intraoperative, PTC, endoscopic (ERCP)
63
Q

Treatment of biliary atresia

A 
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
Q

What are biliary cysts?

A

Cystic dilations that may occur singly or multiply thoughout the biliary tree

65
Q

What are 70% of biliary cysts associated with?

A

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
Q

Who gets biliary cysts

A

More common in asian populations
Women 4:1
Equal numbers in children and adults

67
Q

What are the types of biliary cysts?

A

Type I: 50-80%–> extrahepatic only
TYpe IV: 15-35%–> multiple cysts, extrahepatic +/- intrahepatic
Type V: 20% –> intrahepatic only, Caroli’s disease

68
Q

Pathogenesis of biliary cysts

A

Genetic or environmental predisposition
Associated with developmental anomalies
Congenital or acquired (from APBJ)

69
Q

The majority of biliary cysts present before the age of

A

10

70
Q

Infants with biliary cysts present with:

Patients over 2 with biliary cysts present with:

A

Jaundice, FTT, abdominal mass

Chronic intermittant abdominal pain, pancreatitis, intermittant jaundice, cholangitis

71
Q

How are biliary cysts diagnosed?

A

Abdominal ultrasound
Cholangiography: ERCP, PTC, intraoperative, MRCP
CT

72
Q

What do biliary cysts increase the risk for?

A

20-30 fold increased risk for cholangiocarcinoma

**most occur with types I and IV cysts

73
Q

What is primary sclerosing cholangitis

A

Progressive inflammation, fibrosis, and stricture of the intrahepatic and extrahepatic bile ducts

74
Q

What causes secondary sclerosing cholangitis?

A

Recurrent pyogenic cholangitis, choledocholithiasis, cholangitis, AIDS cholangiopathy

75
Q

What does PSC have a strong association with?

A

IBD
Ulcerative colitis > crohns
**up to 90% of patients with PSC have UC

76
Q

Who gets PSC?

A

70% men

Mean age of dx 40 yo **women dx later

77
Q

What is the pathogenesis of PSC?

A

Immune activation
Genetic factors–CFTR mutations
?Bacterial infections
?Ischemia duct injury

78
Q

What are the clinical manifestations of PSC?

A 
Asymptomatic (50%)
Elevated liver tests in a cholestatic pattern
Fatique 
Pruritus
Jaundice
79
Q

What are the lab manifestations of PSC?

A

Hypergammaglobulinemia
Increased immunoglobulin
Atypical p-ANCA

80
Q

What are the subtypes of classic PSC?

A

Intrehepatic and extrahepatic
Intrahepatic alone
Extrahepatic alone

81
Q

What is the presentation of small-duct PSC?

A

Normal cholangiogram

Involves small caliber bile ducts

82
Q

Diagnosis of PSC?

A

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
Q

Complications of PSC

A

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
Q

Treatment of PSC

A

Medical therapy NOT recommended
ERCP for dominant extrahepatic strictures
Surgery: biliary reconstruction or liver transplant

85
Q

What is AIDS cholangiopathy?

A

Biliary obstruction resulting from infection related strictures of the biliary tract
Classically cryptosporidium parvum

86
Q

Who gets AIDS cholangiopathy?

A

Seen in AIDs patients with CD4 count <100/mm3

87
Q

What is the presentation of AIDS cholangiopathy?

A

RUQ pain
Epigastric pain
Diarrhea

88
Q

Diagnosis of AIDS cholangiopathy?

A

Elevation of cholestatic liver enzymes
Transabdominal ultrasounds
MRCP
ERCP

89
Q

Treatment of AIDS cholangiopathy

A

BIliary sphincterotomy during ERCP
Stending of dominant extrahepatic strictures
Sometimes ursodeoxycholic acid
**NOT antimicrobials

90
Q

What parasites are involved in biliary parasitosis?

A 
Ascaris lumbricoides (roundworm)*
Echinococcus granulosus (tapeworm)*
Clonorchis sinensis
Opithorchiasis
Fasciola hepatica (sheep liver fluke)*
91
Q

What is the roundworm that is found worldwide and inhabits human small intestine?

A

Ascaris lumbricoides

92
Q

What will be seen on ultrasound with ascarid lumbricoides?

A

Long, linear, parallel echogenic structures without acoustic shadowing

93
Q

Dx and tx of ascaris lumbricoides?

A

ERCP of dx and removal

Tx with anti-helminthic therapy

94
Q

What is the tapeworm that has a dog as a host and is found in S. america, middle east, e. mediterranian, china, etc

A

Echinococcus granulousus

95
Q

What happens with echinococcus granulosus?

A

Rupture of hepatic cyst into biliary system causing jaundice and hepatomegaly

96
Q

Tx of echinococcus granulosus related cyst?

A

Surgical resection or percutaneous injection of scolicidal agents as well as anti-helminth therapy

97
Q

What is a liver fluke found in the far east and russie, with dog and cat reservoir?

A

Clonorchis sinensis

98
Q

What does clonorchis sinensis cause?

A

Chronic infection associated with cholangiocarcinoma

99
Q

Dx and tx of clonorchis sinensis

A

ERCP for acute cholangitis

Tx with anti-helminth therapy

100
Q

What is a liver fluke of cates in SE asia and central and eastern europe with a similar presentation as clonorchis sinensis?

A

Opisthorchiasis

101
Q

What is a sheep liver fluke that causes human infection when eating raw veggies infected with metacercariae?

A

Fasciola hepatica

102
Q

What happens upon fasciola hepatica infection?

A

Penetrate duodenal wall
Migrate across peritoneum
Enter the biliary system

103
Q

Tx for Fasciola hepatica

A

ERCP for acute cholangitis

Tx with anti-helminthic therapy

104
Q

What is recurrent pyogenic cholangitis?

A

Pigment stone formation in the intrahepatic biliary system resulting in intrahepatic stricturing and biliary obstruction with recurrent bouts or acute cholangitis

105
Q

Who gets recurrent pyogenic cholangitis?

A

Patients from SE Asia

106
Q

What causes recurrent pyogenic cholangitis?

A

Biliary parasitosis
Bacterial infection
Stasis

107
Q

What is the key clinical manifestation of recurrent pyogenic cholangitis?

A

Acute cholangitis

108
Q

Dx of recurrent pyogenic cholangitis

A 
Abdomenal ultrasound
MRI
CT
PTC
ERCP
109
Q

Tx of recurrent pyogenic cholangitis

A

Treat acute cholangitis
Stone clearance–ERCP, PTC, surgical
Consider ursodeoxycholic acid
Hepatic resection and reanastomosis

110
Q

Possible SEs of recurrent pyogenic cholangitis?

A

Cirrhosis from seconday sclerosing cholangitis

INCREASED RISK FOR CHOLANGIOCARCINOMA

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