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Flashcards in Biliary Pathophys Deck (43):
1

ascending cholangitis

the most serious and lethal complication of galstones

85% of cases caused by stone in the bile duct causing bile stasis, bacterial superinfection of stagnant bile, bacteremia 

obstruction is necessary but not sufficient

need a duct that contains bacteria

blood cultures are usually positive 

2

treatment for choledocholithiasis

ERCP with stone extraction followed by laproscopic cholecystectomy

3

natural history of gallstones in asymptomatic

biliary pain in 2% per year, decreases over time

pain is the initial symptom in 90%

low complications

don't need to remove gallbladder

4

What is the best test for acute cholecystitis 

cholescintigrapy

assesses patency of the cystic duct 

if it's a normal scan, excludes acute cholecystitis

5

porcelain gallbladder

intramural calcification of the gallbladder wall - usually associated w stones 

no symptoms but 20% carcinoma of the gallbladder 

prophylactic cholecystectomy

6

emphysematous cholecystitis 

infection of the gallbladder wall with a gas forming organism 

mostly in old diabetic men 

high morbidity and mortality!! treat with IV abx and cholecystectomy

7

choldedochal cysts

Choledochal cysts (aka bile duct cyst) are congenital conditions involving cystic dilatation of bile ducts.[1] They are uncommon in western countries[2] but not as rare in East Asian nations like Japan and China.

high incidence of biliary cancer - surgical excision - remove all cyst tissue

if involves liver, may require liver transplantation

8

acute cholecystitis 

swelling and irritation of gallbladder

Acute cholecystitis occurs when bile becomes trapped in the gallbladder. This often happens because a gallstone blocks the cystic duct, the tube through which bile travels into and out of the gallbladder. When a stone blocks this duct, bile builds up, causing irritation and pressure in the gallbladder. This can lead to swelling and infection.

9

charcot's triad

clinical manifestation of ascending cholangitis 

fever

RUQ pain

jaundice 

(can also have hypotension and metnal confusion) 

suggests gram neg sepsis

10

What is the best test for choledocholithiasis

endoscopic ultrasound 

highly accurate for excluding/confirming stones in the CBD 

can be used instead of MRCP to exclude CBD stones - use for low to moderate clinical probablity of choledocholithiasis 

11

What is the best test for choledocholithiasis? 

Choledocholithiasis is the presence of gallstones in the common bile duct (thus choledocho- + lithiasis). This condition causes jaundice and liver cell damage

MRCP - rapid and non invasive - prvides bile duct and pancreatic duct images equal to ECRP 

low to mod clinical porbabolity of choledocholithiasis 

medical imaging technique that uses magnetic resonance imaging to visualize the biliary and pancreatic ducts in a non-invasive manner.

12

brown pigment stones

calcium salts of unconjugated bilirubin w varying amts of cholesterol and protein 

usually associated w biliary infection 

can form in galllbladder or within biliary tree

almost always associated w colonization of bile by enteric organisms and with ascending cholangitis 

more likely than other stones to form de novo in bile ducts

13

treatment for biliary colic? 

elective laparascopic cholecystectomy 

ERCP

14

what is the most common type of cholangiocarcinoma

adenocarcinoma (90%) - nodular - intense desmoplastic with extensive fibrosis 

15

do gallstones have a genetic predisposition? 

yes, first degree relatives are 4.5x more likely to develop gallstone disease

16

What is the best test for complications of gallstones

CT scan

abscesses, perforation of gallbladder/CBD, pancreatitis 

17

choledocholithiasis

Choledocholithiasis is the presence of gallstones in the common bile duct (thus choledocho- + lithiasis). This condition causes jaundice and liver cell damage

18

primary sclerosing cholangitis

all parts of biliary tree can be involved in chronic fibrosing inflammatory process resulting in obliteration of biliary tree and ultimately biliary cirrhosis 

generalized beading and stenosis of the biliary tree on cholangiography

"onion skinning"

progressive - life expencance is 10-12 years

19

treatment when calculi within bile duct and symptomatic? 

ERCP!

endoscopy

20

what is the most important determinant of crystal formation? 

the extent of cholesterol saturation in gallbladder bile 

cholesterol, phospholipds, biles acids 

if CSI greater than 1 - bile is saturdated and cholesterol can precipitate out and form crystals 

21

natural history of gallstones in symptomatic 

more aggressive 

if episode of biliary pain, much more likely to have it 

risk of complications

cholecystectomy offered only after biliary symptoms dvelop

22

lab findings of acute cholecystitis

leukocytosis w bands 

bili, aminotransferase, alk phos all high (suspect stone of bili >4) 

 

23

cholesterol stones

most common type of gallstones

pure/mostly cholesterol

large and yellowish

24

indications for ercp in adults

obstructive jaundice

cholangitis 

recurrent pancreatitis 

pancreatic duct obstructions

25

ECRP

best for choledocholithiasis and cholelithaisis (ultrasound is still better)

high sensitivity and specificity

used to extract stones (or drain infected bile) 

life saving - reduces the need for CBD exploration at the time of cholecystectomy 

with high clinical probability of choledocholithiasis 

26

mirizzi's syndrone

impacted stone in the gallbladder neck or cystic duct 

extrinsic compression of the common hepatic duct 

janudince and RUQ pain

 

27

cholecystonenteric fistula

erosion of a large stone through the gallbladder nto adjacent bowel (duodenum) 

galstone ileus (terminal ileum) 

cholecystectomy and bowel closure

28

natural history of acute cholecystitis 

50% resolve spontaneously 

10% perforate if left untreated 

29

what is the best test for choledocholithiasis w high clinical probability

ERCP

high sensitivity and specificity

used to extract stones (or drain infected bile) 

life saving - reduces the need for CBD exploration at the time of cholecystectomy 

with high clinical probability of choledocholithiasis 

30

cholangitis lab findings

leukocytsosis 

high bili, alk phos, 

blood cultures usually positive

31

black pigment stones

10-25% - higher in asians 

increase with age, more in women then men

either pure calcium bilirubinate orpolymerlike complexes with calclum  and copper and mucin glycoproteins 

occur w greater frequency in patients w cirrhosis and chronic hemlytic states (sickle cell) and pancreatitis

32

treatment for acute cholecystitis? 

cholecystectomy

If there are stones - CBD exploration/ERCP for stone removal

33

What is the best test for cholelithiasis

(stones in the gallbladder) 

ultrasound!! 

34

Mirizzi's syndrome

stone in the cystic duct compressing or fistulizing into the common bile duct

35

risk factors for gallstones

age

obesity (cholesterol hyper secretion and synthesis) 

weight loss (gallbladder hypomotility with high Ch) 

total pareneral nutrition (gallbladder hypomotility) 

pregnancy

some drugs (OCP) 

36

treatment when calculi within gallbladder and symptomatic> 

surgery! 

cholecystectomy

37

labs with choledocholithaisis

eleveated serum bili and alk phos (CBD obstruction) 

can have a transient spike in aminotransferase when stone is passed 

38

pathogenesis of cholesterol stones

cholesterol crystals fom in and are trapped by mucin gel which accumulates as a result of gallbladder hypomotility and gallbladder hypersecretion

mucin glycoproteins act as an annealing agent in the agglomeration of crystals to form gallstones 

vol of bile that resides in the gallbladder decreases by 80-90% because of active sodium transport and water absorption - promote more gallstone formation

39

treatment for cholangitis

emergency ERCP with stone removal or biliary decompression 

antibiotics to cover gram neg organisms 

interval cholecystectomy

40

natural history of cholangitis

high mortaiity rate

emergency decompression of the CBD (usually by ERCP) improves survival 

41

intermittent bilary colic

stone intermitently obstructing cistic duct 

RUQ pain 1-2 hours after eating, no pain when not eating

 

42

cholangiocarcinoma

from epithelialc ells of intra and extra hepatic bile ducts 

risk: PSC, choledochal cysts, stone disease, parasites 

jaundice, weight loss, rapid deterioration 

 

43

pathogenesis of brown pigment stones

enteric bacteria make beta-glucaronidase, phospholipase A, conjugated bile acid hydrolases

beta-glucoronidase activity results in the production of uncongjuaged bilirubin

phospholipase A liberates free fatty acids from phospholipids

unconjugated bile acid hydrolases make unconj bile acids 

all complexes can complex w calcium to produce insoluble calcium salts and result in stone fprmation

dead bacteria/bacterial glycoproteins are annealing agents