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Clinical Alimentary System > 3.15. Liver + Biliary Tree Disease - Cholestasis (Gallstones) > Flashcards

3.15. Liver + Biliary Tree Disease - Cholestasis (Gallstones) Flashcards

1
Q

What are the 2 Types of Cholestasis (Gallstones) which occur?

A
  1. Cholesterol Gallstones

2. Bile Pigmented Stones

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2
Q

Which if the 2 types of Gallstones are more common?

A

Cholesterol Gallstones - 80%

Bile Pigmented Stones - 20%

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3
Q

What are the Risk Factors for developing Cholesterol Gallstones?

A
  1. Increasing Age
  2. Being Female
  3. Rapid Weight Loss
  4. High Fat, Low Fibre Diet
  5. Alcoholism
  6. Predisposing Conditions
  7. Certain Medications
  8. Ileal Disease / Resection
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4
Q

At what age do Gallstones appear more frequently?

A

After the age of 30

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5
Q

How much more common are Gallstones in Females?

A

2-3 times, especially in those who have had many Children

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6
Q

Why can Rapid Weight Loss cause Cholesterol Gallstones?

A

Due to elevated Leptin levels, which are associated with the formation of Cholesterol Gallstones

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7
Q

What Predisposing Conditions are there?

A
  1. Diabetes Mellitus
  2. Obesity (+/- Metabolic Syndrome)
  3. Liver Cirrhosis
  4. Viral Hepatitis
  5. Acromegaly
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8
Q

What is an example of medication which can put you at risk of getting Cholesterol Gallstones?

A

The Oral Contraceptive Pill

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9
Q

Why can Ileal Disease or an Ileal Resection cause Cholesterol Gallstones?

A

Due to the resulting Bile Loss (Lack of Bile Reabsorption)

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10
Q

What are the Risk Factors for developing Bile Pigmented Stones?

A
  1. Haemolytic Conditions (e.g. Sickle Cell Anaemia, Hereditary Spherocytosis)
  2. Infection in the Biliary Tree
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11
Q

What forms the Cholesterol Gallstones?

A

The formation of Cholesterol Gallstones is due to Cholesterol Crystallization from Gallbladder Bile

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12
Q

What is the Cholesterol Crystallization from Gallbladder Bile (forming Cholesterol Gallstones) dependent on?

A
  1. Cholesterol Supersaturation in the Bile
  2. Crystallizing Promoting Factors within the Bile
  3. The Motility of the Gallbladder
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13
Q

How is Cholesterol Crystallization dependent on Cholesterol Supersaturation in the Bile?

A
  1. Cholesterol is formed and co-secreted with Phospholipids in the Biliary Canaliculus
  2. Supersaturation can occur due to:
    a) Excess Cholesterol Secretion into the Bile
    b) A decrease of Bile Salt Content, which can occur due to Bile Salt Loss (e.g. Ileal Resection, Crohn’s Disease)
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14
Q

Is everyone who has Cholesterol Supersaturation guaranteed to have Cholesterol Gallstones?

A

No, Many people who have this will never develop Gallstones

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15
Q

What are the Crystallizing Promoting Factors, within the Bile?

A
  1. There are a number of Lipoproteins which have been reported as Putative Crystallizing Factors
  2. There is Evidence to suggest a Genetic Factor is prevalent (After being ected on by an Environmental Factor)
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16
Q

How is Cholesterol Crystallization dependent on Gallbladder Motility?

A

A decrease in Gallbladder Motility, leads to Bile Stasis, which lead to Cholesterol Crystallization

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17
Q

What are the 2 Types of Bile Pigmented Stones?

A
  1. Black Pigmented Stones

2. Brown Pigmented Stones

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18
Q

What are Black Pigmented Stones comprised of?

A
  1. Calcium Bilirubinate
  2. A Network of Mucin Glycoproteins, which interlace with salts, such as:
    a) Calcium Carbonate
    b) Calcium Phosphate
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19
Q

What are Brown Pigmented Stones comprised of?

A
  1. Calcium Salts
  2. Fatty Acids
  3. Calcium Bilirubinate
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20
Q

What is the Pathology of Black Pigmented Gallstones?

A
  1. Bile Salt loss in the Colon (Due to Ileal Resection / Crohn’s) promotes Colic Reabsorption of Bilirubin
  2. This enhances the Enterohepatic Circulation of Bilirubin which leads to the formation of Gallstones
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21
Q

When are Brown Pigmented Gallstones found?

A
  1. In the presence of Bile Stasis / Biliary Infection

2. In the Intrahepatic Ducts in circumstances of Duct Disease (e.g. Primary Sclerosing Cholangitis)

22
Q

What are Brown Pigmented Gallstones a common cause of?

A

Recurrent Bile Duct Stones following a Cholecystectomy

23
Q

What are Black Pigmented Gallstones related to?

A

Bacterial Colonization of the Biliary Tree

24
Q

What do All Types of Gallstones produce?

A

A Blockage / Obstruction of the Biliary Pathway, leading to a Backlog of Bile within the Hepatocytes

25
Q

What is the Clinical Presentation of Gallstones?

A
  1. Asymptomatic (commonly)
  2. Jaundice with Pruritus
  3. Dark Urine / Pale Stools
  4. Nausea + Vomiting
  5. Fever + Rigors
  6. Biliary (Gallstone) Colic (Pain)
  7. Acute Cholecystitis
  8. Empyema
26
Q

Do Gallstones causes Vague Upper Abdominal Symptoms, such as Dyspepsia, Flatulence, GORD upon Fat ingestion?

A

No

27
Q

What type of Jaundice is present?

A

Post-Hepatic Jaundice

28
Q

What is Pruritus? And why is it associated with the Jaundice present?

A

The itching sensation is associated with the increased levels of Serum Bilirubin

29
Q

Why do Dark Urine / Pale Stools occur?

A

Dark Urine - Due to the increased presence of Bilirubin in the Urine
Pale Stools - Due to the lack of Bilirubin in the Stool

30
Q

Why does Nausea and Vomiting occur?

A

This is related to the Biliary (Gallstone) Colic (Pain)

31
Q

What are Fevers and Rigors suggestive of?

A

Complications of a Gallstone, such as:

  1. Cholecystitis
  2. Cholangitis
  3. Gallstone related Pancreatitis
32
Q

What are the Characteristics of the Biliary (Gallstone) Colic (Pain?

A
  1. Severe and Constant
  2. Its onset is related to the over-indulgence of Food (usually with a High Fat content)
  3. The Pain starts in Epigastric Region, then radiates to the Right Upper Quadrant, and then (potentially) to the Right Subscapular (Shoulder) Area
33
Q

What is Acute Cholecystitis?

A

Progressive Distension of the Gallbladder which can occlude its vascular supply?

34
Q

What causes the Gallbladder Distension?

A
  1. Obstruction of Gallbladder Emptying - this increases the Gallbladder Glandular secretion, worsening the Distension
  2. The Inflammatory response to the Retained Bile within the Gallbladder
35
Q

What can occur as a Secondary Phenomenon following the Vascular Inflammatory Events of the Gallbladder?

A

Infection

36
Q

What can infection lead to?

A

Empyema

37
Q

What is Empyema of the Gallbladder?

A

The Gallbladder can become Distended with Puss

38
Q

What are the Worries of Empyema of the Gallbladder?

A
  1. Perforation - causing Peritonitis
  2. Gangrene occurring due to the lack of vascular supply
  3. Further Distension of the Gallbladder
39
Q

What is the presentation of the Pain of Acute Cholecystitis?

A
  1. Severe Right Upper Quadrant

2. Associated with Tenderness and Muscular Rigidity

40
Q

What investigations are requires in Cholestasis?

A
  1. Liver Function Test (and Biochemistry)
  2. Abdominal Ultrasound
  3. MRCP / ERCP
41
Q

What does a Liver Function Test (and Biochemistry) test for?

A

Liver Function Test:

  1. Serum Albumin
  2. Prothrombin Time (PT)

Liver Biochemistry:

  1. Serum Bilirubin
  2. Alkaline Phosphatase (ALP)
  3. Gamma-Glutamyl Transpeptidase (G-GT)
  4. Aminotransferases:
    a) Aspartate Aminotransferase (AST)
    b) Alanine Aminotransferase (ALT)
42
Q

What would a Liver Function Test (and Biochemistry) find in a patient with Gallstones?

A

There is unlikely to be any major abnormality:

  1. Elevated Serum Bilirubin
  2. Elevated Alkaline Phosphatase
  3. Elevated Aminotransferases
43
Q

What is the purpose of the Abdominal Ultrasound?

A

This is used to diagnose and locate the Gallstone

44
Q

What does MRCP and ERCP stand for?

A

MRCP - Magentic Resonance Cholangio-Pancreatography

ERCP - Endoscopic Retrograde Cholangio-Pancreatography

45
Q

Why would an MRCP / ERCP be useful as an investigation?

A

To view the inside of the Biliary Tree, to diagnose and locate the Gallstone

46
Q

What are the Treatment Options for Gallstones?

A
  1. Treat the Underlying Cause
  2. Analgesics
  3. I.V. fluid and Nutrients whilst being Nil by Mouth
  4. ERCP
  5. Cholecystectomy
47
Q

How can the underlying cause be treated?

A
  1. Change in Diet
  2. Alcohol Cessation
  3. Antivirals (if due to infection)
48
Q

What is the purpose of giving Analgesics?

A

For the pain control

49
Q

What is the function of an ERCP as a treatment option?

A

This can break up and remove the Gallstone

50
Q

What is a Cholecystectomy? And what is it’s purpose?

A

The Surgical Removal of the Gallbladder - this is the last resort due to Acute Cholecystitis

Clinical Alimentary System (64 decks)

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