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Biliary Tree Disease Flashcards

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1
Q

Primary biliary cholangitis (AKA PB cirrhosis) is an autoimmune condition where T cells attack small bile ducts where? What does this cause?

A

In the liver

Bile leaks into intersitium ->
Chronic inflam in bile ducts ->
Destruction of bile ducts ->
Cirrhosis

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2
Q

Who is most likely to present with PBC? Who is most likely to present with PSC?

A

PBC - Middle aged woman
B = boobs

PSC - middle aged men

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3
Q

What symptoms would you get with PBC?

A

Linked to leakage of bile ducts:

Increased bilirubin

  • Jaundice
  • Pruritus (itchiness)

Increased cholesterol (from leaking bile)

  • Xanthoma
  • Xanthelasma (e = eye)
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4
Q

What condition is associated with Anti-Mt (mitochondria) antibodies (AMA)?

A

PBC

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5
Q

For what condition what you prescribe ursodeoxycholic acid and why?

A

PBC
Helps delay liver damage, improves bilirubin + aminotranferase levels

(Can also be prescribed obeticholic acid - improves bile flow and reduces inflammation)

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6
Q

What drug is given as an anti-pruritic? What must the patient be told when getting prescribed?

A

Colestryamine

  • takes a few weeks to work,
  • shouldn’t be taken at same time as ursodeoxycholic acid,
  • constipation
  • must be dissolved in solvent
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7
Q

What is PSC?

Where does it occur?

A

Primary scleorosing cholangitis

Autoimmune condition that causes progressive inflammation and fibrosis of bile duct

Can happen in bile ducts in OR out of liver

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8
Q

What condition will patients with PSC commonly have?

A

UC - ulcerative colitis

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9
Q

How do you diagnose PSC?

A

MRCP - with a BEADED APPEARANCE (can appear similar to carcinoma so must be ruled out)

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10
Q

How will PSC appear histologically?

A

Onion skin

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11
Q

What is the definitive treatment for PSC?

A 
Liver transplantation (use UKELD)
- Stents and balloon dilation can help to prevent obstruction
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12
Q

Cholelithiasis

A

Gallstones

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13
Q

Cholecystolithiasis

A

Gallstone in gallbladder

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14
Q

Coledocholithiasis

A

Gallstone in bile duct

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15
Q

Mnemonic for most likely to develop gallstones

A 
Fair - (caucasian)
Fat - (rapid weight loss as well)
Fertile - Pregnancy/HRT
Female
Forty
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16
Q

What is biliary colic?

A

Temporary obstruction of cystic duct/common bile duct by a gallstone

(“Gallbladder attack”)

INTENSE severe colicky pain 2-6hrs

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17
Q

Where can pain refer to in gallbladder inflammation/irritation?

A

Right shoulder/scapula

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18
Q

Severe colicky pain that lasts 2-6hrs after eating high fat foods e.g. big burger

A

Biliary colic

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19
Q

How do you manage biliary colic?

A

Better diet
Mod. pain = NSAIDS and paracetamol
Severe pain = diclofenac IM

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20
Q

What is cholecystis?

What kind of jaundice does it cause?

A

Obstruction of the cystic duct causes inflammation of gallbladder

Post-hepatic = obstructive jaundice =conjugated (light stools and dark urine)

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21
Q

What is Murphy’s sign and what is it assoc with?

A

Pain on deep inspiration when examiners fingers are over RUQ at costal margin (due to inflamed gallbladder coming into contact with examiners fingers)

Cholecystitis

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22
Q

What is acalculous cholecystitis?

A

Inflammation of gallbladder in absence of gallstone

Far worse prognosis than calculous cholecystitis

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23
Q

Who typically presents with acalculous cholecystitis?

A

Very ill patients who are no longer oral feeding (hence CCK not being released and bile not released)

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24
Q

What is ascending cholangitis and why is it so serious?

A

Bacterial infection in the bile duct due to obstruction (normally gallstones) causing bile stasis

Bacteria in the duodenum which is normally flushed away from travelling through the sphincter of Oddi up into the Ampulla of Vater by bile is no longer

Increase in pressure caused by obstruction -> spaces between cholangiocytes increase and bacteria can enter the bloodstream -> sepsis

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25
Gallstone ileus
A fistula forms between gallbladder and duodenum which allows large gallstone to pass through intestine A form of bowel obstruction caused by a gallstone within the lumen of the small bowel Most likely to be lodged in terminal ileum (>2.5cm stones) - due to this being the narrowest point in small intestine
26
What triad is used for the diagnosis of gallstone ileus? Relate this to how a patient will present
``` Rigler's Triad - Pneumobilia (air in biliary tree) - Small bowel obstruction - Gallstone outside gallbladder ^^ all seen radiologically ^^ ``` ``` Small bowel obstruction = Nausea and vomiting Abdo distension Abdo pain Dehydration ``` Cholecystitis = RUQ pain
27
What is a stricture?
A narrowing of a structure
28
How do you treat a benign biliary stricture?
REMOVABLE Stent via ERCP
29
Congential biliary atresia
ADD EVERYTHING - potentially move to congenital section
30
Carcinoma of Ampulla of Vater
Rare cancer to form - very bad prognosis due to close proximity to other structures and very difficult to operate on
31
What is acute pancreatitis
Inflammation of pancreas leading to auto digestion (exocrine enzymes eat away at pancreas)
32
Nmemoic for causes of acute pancreatitis What are the most common causes?
I GET SMASHED IDIOPATHIC GALLSTONES ETHANOL Trauma Steroids Mumps Autoimmune Scorpion bite Hypercalcaemia, hyperparathyroidism, hyperlipidemia ERCP Drugs (azathriorpine, antibiotics, oestrogen) (no.1 = gallstones, plus alcohol and idiopathic)
33
What signs would be present in haemorrhaging pancreatitis?
Cullen's sign - (bruised kinda look around bellybutton) Grey Turner's sign (brusing around flanks)
34
What criteria is used for pancreatis?
Glasgow Prognostic Criteria (>/= 3 = severe pancreatitis) IMPORTANT TO KNOW: >/=3 and PANCREAS is used ``` PaO2 (<8kPa) Age (>55) Neutrophils Calcium (<2mmol/l) Renal function (>16mmol/l) Enzymes (AST/ALT) Albumin <32g/l (low levels = low osmotic pressure = ascites) Sugar -> glucose >10mmol/l ```
35
How to treat acute pancreatitis?
IV fluid resuscitation (plus antibiotics, O2, Analgesics) Enteral feeding (still using GI tract) in moderate and severe cases
36
What happens during chronic pancreatitis
Chronic inflammation of pancreas - progressive and irreversible Eventually loses exocrine function
37
Causes of chronic pancreatitis - take note of most common and what is the most common cause in children
1. Chronic excessive alcohol consumption Autoimmune type 1 - middle aged men 2 - IBD CF - most common in children Alpha1 anti-typrsin
38
Pain associated with pancreatitis?
Epigastric pain with vomiting and nausea - radiates to back Worse on movement Better in foetal position In chronic it may worsen when eating fatty foods or alcohol
39
What is a helpful investigation in acute pancreatitis but not chronic?
Amylase - peaks acutely (>3x upper limit of normal) - (due to leakage of amylase enzymes into blood) (Lipase is more expensive test but more accurate)
40
Most helpful investigation of chronic pancreatitis?
CT pancreas - sometimes see calcifications/stones in pancreas and pancreatic ducts due to proteins accumulating and forming plugs in ducts
41
What kind of tumours form in pancreas and where?
Adenocarcionmas - form in exocrine component of pancreas Head and neck of pancreas
42
Symptoms of pancreatic cancer?
"Painless jaundice" (conjugated = dark urine and pale stools) Midepigastric pain which may radiate to back pain
43
Courvoisier's sign What disease is it associated with?
Palpable non-tender gallbladder and painless/obstructive jaundice Pancreatic malignancies
44
Prognosis of pancreatic cancer? What sex is more likely to get it?
Very poor Female
45
How will a patient present with PSC?
Generally asymptomatic - raised LFTs Can present like acute hepatitis - fever, jaundice, RUQ pain, pruritus
46
Why may a patient with acute pancreatitis have hypocalcemia?
Lipases leaked into blood break down fatty deposits -> fatty necrosis Fatty necrosis requires calcium -> hypocaleamia
47
How may a patient present with acute pancreatitis?
Epigastric pain with vomitting and nausea Jaundice Tachycardia Fever
48
What management is important in chronic pancreatitis?
Stop smoking and drinking | Creon - replaces pancreatic enzymes (due to loss of exocrine function)
49
Enteral feeding should be considered for patients with moderate/severe acute pancreatitis. What is enteral feeding?
Still using the GI tract - tube either through mouth or via stomach etc.
50
What would make a case of acute pancreatitis change from moderately severe to severe? Give 3 examples of local complications
Moderately severe - suffer local complications but resolve in 48hrs Severe - persistent organ dysfunction with local complications Local complications = pseudocysts, necrosis, abscess etc.
51
Explain the 4 stages of pancreatitis
1. Fluid shift -> enzymes in peritoneal cavity -> eat fats (fatty necrosis) -> hypocalciemia 2. Autodigestion of blood vessels -> haemorrhage 3. Infarction due to blood supply inefficiency -> pancreatic necrosis 4. Necrotic tissue becomes infected -> abscess
52
What may be seen on AXR for acute pancreatitis
sentinel loop - small region of adynamic ileus (blockage in intestine due to intra-abdominal inflammation)
53
How do you investigate pancreatic cancer?
Endoscopic US - most accurate for diagnosis CT scan Most blood tests are pretty non-specific
54
Management of pancreatic cancer?
Chemo Majority is non-operable ERCP and stents can be used to improve bile flow and reduce symptoms Surgery = Whipple's procedure - (removal of head of pancreas, gallbladder, duodenum and bile duct)
55
What is a pseudocyst?
A complication of pancreatitis Collection of fluid in pancreas (not an epithelial lined pouch) Requires drainage/resection (removal) during surgery Not known to become malignant
56
What are the three types of gallstones which can be found?
Cholesterol - green/yellow - most common Pigmented (bilirubin) black - assoc. with haemolytic anaemia - due to too much bilirubin in bile Brown stones - parasites
57
How would cholecystitis present differently to biliary colic?
Both with severe epigastric/RUQ pain - colicky in nature which is worse when lying flat Cholecystitis - fever and RUQ tenderness
58
How do you diagnose cholecystitis?
Abdo USS - look for thickened gallbladder wall and stones Inflam pattern in bloods
59
How would you treat cholecystitis and what would be the URGENT first surgical option?
Supportive - IV antibiotics - Fluids - Analgesia Surgery = cholecystectomy
60
Cholangiocarcinoma Where is it most commonly found and how do patients present? What is the optimum way to diagnose? What is the only form of definitive treatment?
Cancer of the bile ducts - more commonly extra-hepatically Hilar cholangiocarcinoma is most common (at site where L and R hepatic ducts meet) Present with painless jaundice with weight loss etc. MRCP Surgery resection (removal)
61
What is the difference between Charcot's Triad and Reynolds Pentad? What condition would these combination of symptoms be present in?
Charcot's Triad = - obstructive jaundice - RUQ pain - fever Reynolds Pentad + Hypotension + Confusion (due to septic shock) Ascending cholangitis
62
What is the gold standard way to diagnose cholangitis? What must also be present? How do you treat?
ERCP + jaundice + inflammatory picture in bloods (high WCC, CRP) Symptom relief = IV fluids and antibiotics Cholecystectomy Removal of obstruction via ERCP
63
Patient with 3mnth history of weight loss and dull midepigastric pain which radiates to the back is most likely to have what carcinoma of head and neck of panceras or body/tail?
Body/tail more likely as patient does not report jaundice Jaundice is caused by obstruction of common bile duct which runs behind the head and neck of pancreas
64
Which oncogenic mutations is most commonly found in pancreatic adenocarcinomas?
KRAS (90% of cases)
65
CA19-9 is a tumour marker associated with what cancer?
Cholangiocarcinoma
66
What condition is associated with cholangiocarcinoma?
UC
67
What is the "chain of lakes" appearance on ERCP associated with?
Chronic pancreatitis Pancreatic duct has become dilated and tortuous
68
What is the best test of pancreatic function?
Faecal elastase
69
Loss of what enzyme is one of the biggest causes of the development of steatorrhea?
Lipase

GI (26 decks)

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