Biliary Diseases

Question 1

What are some of the consequences of disruption of the flow of bile

Answer 1

Pain
Inflammation
colonisation by micro-organisms 
infection 
loss of essential digestive functions of bile

Question 2

Why does disruption of bile flow most commonly occur

Answer 2

Because of a mechanical blockage caused by biliary stones

Question 3

What is bile composed of

Answer 3

Water
electrolytes
bile salts 
bilirubin
phospholipds and cholesterol
proteins that regulate GI function
Drugs and drug metabolites

Question 4

How does the gallbladder concentrate the bile

Answer 4

By absorbing 90% of the water content

Question 5

Where do bile salts circulate

Answer 5

Through the entero-hepatic circulation

Question 6

What is the difference between cholecystitis and cholangitis

Answer 6

Infection of gallbladder = cholecystitis

infection of the bile ducts = cholangitis

Question 7

What are the most common organisms involved in biilary microbiology

Answer 7

Gram negatives (Escheria coli, Klebsiella, Enterobacter

Question 8

What should patients with symptomatic gallstones ave

Answer 8

A cholecystectomy

Question 9

What are gallstones made up of

Answer 9

Poorly soluble components of bile precipitated on a three dimensional matrix of mucins and proteins

Question 10

What are the three main types of gallstones

Answer 10

Cholesterol
Black pigment
Brown pigment

Question 11

What are the vast majority of gallstones in Western countries

Answer 11

Cholesterol or mixed type

Question 12

What are some of the risk factors for cholesterol gallstones

Answer 12

FHx
Age
Female
Pregnancy 
Obesity
Rapid weight loss
Prolonged fasting
Diabetes mellitus 
Crohn's disease 
TPN

Question 13

What are some of the possible preventative factors

Answer 13

High fibre diet
Low consumption of saturated fatty acids
high relative amount of trans-fatty acids
nut consumption
moderate physical activity

Question 14

What are the clincal features of gallstones

Answer 14

Pain (right hypochondrial or epigastric)
Radiates to the upper back or right shoulder
Steady and intense - occurs more than an hour after meals
Often associated with an urge to walk
Each episode lasts 1-24 hours
Murphy’s sign positive
Fever

Question 15

What are some routine investigations

Answer 15

Liver tests
MRCP
US

Question 16

What are some routine investigations

Answer 16

Liver tests
MRCP
US

Question 17

What is the treatment of choice for gall stones

Answer 17

Laparoscopic cholecystectomy

Question 18

What might be a sufficient treatment for patients with gallstones who are not suitable for surgery

Answer 18

ERCP and sphincterotomy

Question 19

How does acute cholangitis develop

Answer 19

When bacterial infection complicates obstruction within the biliary tract

Question 20

What are some causes of acute bacterial cholangitis

Answer 20

Choledocholithiasis or sludge 
Biliary strictures
Choledochal cysts 
Stenosis of the papilla of Vater 
Parasitic infection 
Iatrogenic (post ERCP)

Question 21

What is the classical presentation of acute cholangitis

Answer 21

Fever
RUP pain
Jaundice

Question 22

What are the investigations for acute cholangitis

Answer 22

Bloods: Serum biochemistry, FBC, clotting screen
Transabdominal US: first step in detecting bile duct stones
MRCP
ERCP - gold standard
Endoscopic US

Question 23

What causes cholecystitis

Answer 23

An obstruction of the cystic duct usually by a gallstone

Question 24

What are the clincal features of cholecystitis

Answer 24

Unremitting RUQ pain 
anorexia 
nausea 
vomiting 
fever

Question 25

What is gangrenous cholecystitis

Answer 25

Severe acute cholecystitis can lead to necrosis of the gall bladder wall

Question 26

What are some of the complications of cholecystitis

Answer 26

Perforation of the gallbladder Pericholecystic abscess fistula

Question 27

What is the treatment of choice for cholecystitis

Answer 27

Open or laparoscopic cholecystemoctomy EARLY

Question 28

What is meant by Acualculous biliary pain

Answer 28

Recurrent biliary type abdominal pain in patients with no evidence of cholelithiasis

Question 29

What are some of the causes of acalculous biliary pain

Answer 29

Altered gallbladder motility Impairment of gallbladder filling Gallbladder hyperalgesia

Question 30

What is the management for patients with Acalculous biliary pain

Answer 30

Usually conservative - treatments target chronic visceral pain

Question 31

What are the three major adult manigestations of cholestasis

Answer 31

Primary biliary cirrhosis (PBC) primary sclerosing cholangitis (PSC) cholangiocarcinoma

Question 32

What are the three major adult manigestations of cholestasis

Answer 32

Primary biliary cirrhosis (PBC) primary sclerosing cholangitis (PSC) cholangiocarcinoma

Question 33

Primary sclerosing cholangitis has which sex prodominance

Answer 33

Male

Question 34

What does primary sclerosing cholagitis have a strong associateion with

Answer 34

IBD - especially UC

Question 35

What occurs in PSC

Answer 35

Progressive liver disease that causes inflammation, fibrosis and strictures in the intra-hepatic and extrahepatic bile ducts

Question 36

WHat are the clinical features of PSC

Answer 36

``` Jaundice steatorrhoea pruritus weight loss failure or proper absoroption of calcium and fat soluble vitamins ```

Question 37

What might be found on examination of suspected PSC

Answer 37

Xanthomas of the eyes, neck, chest and back

Question 38

What do the lab tests show in PSC

Answer 38

Elevated conjugated bilirubin An extremely high ALP (more than 3 times the upper limit of normal) Elevated GGT

Question 39

What is the management for PSC

Answer 39

Symptom management

Question 40

What is the only life-extending therapy for PSC

Answer 40

Liver transplantation

Question 41

Why do patients with PSC complicating IBD require more frequent colonic surveillance than those with iBD alone

Answer 41

Because of the increased risk of colon cancer

Question 42

What is Primary Biliary cirrhosis

Answer 42

An autoimmune cholestatic liver disease in which the epithelial cells linign the intrahepatic bile ducts are damaged by the immune system

Question 43

Who does Primary biliary cirrhosis predominantly affect

Answer 43

Women ages 30-65

Question 44

What is the male to female ratio of PBC

Answer 44

1:10

Question 45

What are the clincal features of PBC

Answer 45

``` Fatigue intense pruritus cutaneous hyperpigmentation xanthelasmas hepatosplenomegaly ```

Question 46

What is PBC often associated with

Answer 46

Autoimmune diseases such as scleroderma | thyroiditis and Sjogren's syndrome

Question 47

What is the management for PBC

Answer 47

UDCA ist eh first line treatment in early disease

Question 48

What prolong life in PBC

Answer 48

Liver transplant

Question 49

What is cholangiocarcinoma

Answer 49

A slow growing malignancy of the bile duct

Question 50

How are at risk of cholangiocarcinoma

Answer 50

``` Parasitic diseases of the biliary tract Congenital choledochal cysts IBD PSC Hisotry of other malignancy Previous surgery for choledochal cyst or biliary atresia Alpha 1 antitripsin deficiency Autosomall dominant polycycsti ckidneyy disease Gallstones Papillomatosis of the bile ducts thorotrast exposure chronic typohoid carrier status ```

Question 51

What are the clincal features of cholangiocarcinoma

Answer 51

``` Abdominal pain palpable masses weight loss progressive obstructive jaundice Hepatomegaly ```

Question 52

What investigations should be carried out for cholangiocarcinoma

Answer 52

US Abdominal CT MRCP ERCP

Question 53

What is the management of cholangiocarcinoma

Answer 53

Complete surgical resection Palliation Orthotopic liver transplantation