extrahepatic billiary diseases

Question 1

bile composition

Answer 1

pigment- bilirubin

bile acids- cholesterol

Question 2

Gallstone formation factors

Answer 2

Cholesterol oversaturation
Mucin hypersecretion by the GB mucosa
Bile stasis (motility disorders)

Question 3

Gallstone Risk Factors (5)

Answer 3

Fair
Fat
Fertile
Female
Forty

Question 4

Gallstones Types

Answer 4

Cholesterol stones (85%)

Pigment stones (15%) :

Black- excess bilirubin enters the bile and polymerizes into calcium bilirubinate (chronic hemolysis)

Brown - bacteria secretion of beta glucuronidase and phospholipase

Question 5

locations of gall stones

Answer 5

right hepatic duct
gall bladder
cytic duct
common bile duct
spincher of oddi

Question 6

Cholelithiasis

Answer 6

Presence of stones
Asymptomatic vs. Symptomatic
Asymptomatic gallstones generally do not need to be treated

Question 7

Biliary Colic

Answer 7

Intermittent obstruction of the cystic duct, no inflammation of GB

Severe epigastric/ RUQ pain - over 15 min and remaining constant up to 3h

Normal examination (unless in an attack)

Lab tests usually normal

US, EUS

Question 8

Acute Calculous Cholecystitis

Answer 8

Impacted stone in the cystic duct

Fever, Murphy’s sign, palpable GB

Leucocytosis, normal or mild elevation of bilirubin

50% resolve spontaneously in 7-10 days

US – gallbladder wall thickening, EUS, CT

Question 9

Choledocholithiasis

Answer 9

Intermittent obstruction of CBD

jaundice with pain

Elevated bilirubin
transient spike in Transaminases / Amylase

US, EUS, CT

treatment- ERCP - Endoscopic Retrograde CholangioPancreatography

Question 10

ascending cholangitis

Answer 10

Impacted stone in CBD causing bile stasis

Bacterial superinfection

Charcot’s triad 70%

confusion, hypotension, RUQ tenderness, jaundice (80%)

Elevated WBC, BIL

treatment: ERCP

Question 11

Acute biliary pancreatitis

Answer 11

Pancreatic duct obstruction or chemical inflammation

Signs - Variable – None to Sepsis

Bloods – U&E, WBC, LFT, Amylase, CRP
US
MRCP
CT Pancreas

treatment- ERCP

Question 12

Gallstone ileus

Answer 12

small bowel Obstruction by a large gallstone

at the terminal ileum/acending colon

Question 13

Acute Acalculous Cholecystitis

Answer 13

inflamed gallbladder in the absence of an obstructed cystic or common bile duct

occurs in the setting of a critically ill patient

ischemic basis

Question 14

Biliary Tract Cysts

Answer 14

Choledochal cysts (risk of malignancy)

90% diagnosed before age 30

Surgery

Question 15

Biliary Tract Tumors

Answer 15

Cholangiocarcinoma
slow
to infiltrate locally and metastasize late
90% adenocarcinoma

Cancer of the Gall Bladder

Question 16

Cholangiocarcinoma locations

Answer 16

60-70% at the bifurcation of hepatic ducts (klatskin)
20-30% - in the distal CBD
5-10% - arise within the liver (peripheral)

Question 17

Cholangiocarcinoma treatment

Answer 17

Surgical Removal – many patients have tumors that are not resectable

palliative
Stent
Chemotherapy +/- Radiation Therapy

Question 18

Gall Bladder Cancer treatment

Answer 18

If negative for metastasis:
Radical cholecystectomy with nodal dissection, central hepatectomy, +- bile duct excision

Followed by Chemo/Radiation

5 year survival = 60%