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Disorders of the Biliary Tract - Exam 4 Flashcards

1
Q

What are the 2 components of the common bile duct?

A

common hepatic duct and cystic duct

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2
Q

**What are the components of the Calot’s triangle? Why is it important clinically?

A

Medial-common hepatic duct

Inferior-cystic duct

Superior-inferior surface of the liver

important to verify in a lap chole to take into account any anatomical variation and allow cystic duct/artery to be delineated

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3
Q

What is the main function of a gallbaldder?

A

concentrate and store bile that is produced in the liver

to release bile after a meal that contain fats

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4
Q

What is the physiology of bile? The presence of lipids in the duodenum stimulates the release of _____ which in turn stimulates ______ and relaxation of ______

A

cholecystokinin (CCK)

gallbladder wall contraction

Sphincter of Oddi

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5
Q

Where does bile get released? Then where does it go?

A

release of the bile into the cystic duct and common bile duct

Bile then flows into the second part of the duodenum and causes emulsification of large fat droplets into small ones (Micelles)

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6
Q

What are the 5 main functions of bile?

A
  1. Aids in the digestion of fat via fat emulsification
  2. Absorption of fat and fat-soluble vitamins
  3. Excretion of bilirubin and excess cholesterol
  4. Provides an alkaline fluid in the duodenum to neutralize the acidic pH of the chyme that comes from the stomach
  5. It provides bactericidal activity against microorganisms present in the ingested food
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7
Q

What 4 things are in bile? What is the highlighted one?

A

Water
**Cholesterol
Bile Salts
Bilirubin

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8
Q

_______ A hormone which is secreted by cells in the duodenum and stimulates the release of bile into the intestine and the secretion of enzymes by the pancreas. What is an additional role?

A

Cholecystokinin (CCK)

inhibits gastric emptying and also acts a hunger suppressant. stimulates bile production in liver

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9
Q

What is the effect of CCK on the GI tract?

A

Cholecystokinin is secreted by I-cells in the small intestine and induces contraction of the gallbladder
Relaxes the sphincter of Oddi, increases bile acid production in the liver
Delays gastric emptying
Induces digestive enzyme production in the pancreas.

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10
Q

Gallstones form as a result of what 3 processes?

A

Ratio of cholesterol too high

Ratio of bilirubin too high

Gallbladder not emptying bile enough

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11
Q

What are the 2 different types of gallstones? Which one is the MC?

A

Cholesterol gallstones - m/c

Calcium Bilirubinate (pigmented) gallstones

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12
Q

What is the technical name for gallstones? Are they MC in men or women?

A

Cholelithiasis

MC in women, think excess estrogen from pregnancy, hormone replacement and OCPs

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13
Q

A ____ diet and a ____ diet as well as physical activity and cardiorespiratory fitness may help prevent gallstones. _____ appears to protect gallstones in women

A

low-carb

Mediterranean

caffeinated coffee

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14
Q

What is another name for biliary colic? What is happening?

A

Symptomatic Cholelithiasis

Gallbladder contracts in response to stimulation, forces gallstones to move blocking the cystic duct

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15
Q

**What is the hallmark symptom for biliary colic? **What is important to note about the pt’s appearance? **Where does the pain often radiate?

A

**RUQ pain

**Pt do NOT appear ill, just intense, dull discomfort, often associated with diaphoresis, nausea and vomiting that is usually constant often followed by a fatty meal

**may radiate to the RIGHT shoulder blade

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16
Q

**What is the time frame associated with a biliary colic attack? **How long is the total attack?

A

The severe pain lasts about 30 minutes
Plateaus in an hour, total attack about 6 hours

usually episodic!

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17
Q

What will the lab results be like in cholelithiasis? Will the pt have any guarding?

A

Lab results generally wnl:

Cbc, LFTs, amylase/lipase, alkaline phosphatase

NO GUARDING!

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18
Q

**What is the imaging of choice for cholelithiasis?

A

Abdominal Ultrasound (RUQ)

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19
Q

What is the tx of choice for cholelithiasis? _____ are given for pain control

A

Laparoscopic Cholecystectomy

NSAIDs for pain control

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20
Q

Do you need to treat asymptomatic cholelithaisis?

A

NOPE!

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21
Q

When do you need to do prophylactic cholecystectomy in asymptomatic cholelithaisis?

A

gallbladder is calcified

stones 3cm or greater in diameter

or the patient is a Native American (d/t higher rate of cholesterol stones)

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22
Q

When can cholecystectomy be preformed in a pregnant person?

A

can be performed in 2nd trimester preferably in pregnant women after conservative approach fails for repeated attacks

threat of harm during 1st semester, DO NOT DUE IN FIRST TRIMESTER

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23
Q

What is the surgeon actively trying to avoid damaging when preforming an lap chole?

A

common bile duct

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24
Q

What is the pharm tx for cholelithiasis if pt is NOT a surgical candidate? What is it?

A

Ursodeoxycholic acid (Ursodiol, Actigall)

bile salt given PO for up to 2 years and helps to dissolve cholesterol stones

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25
What are the 3 different types of cholecystitis?
1. Acute Calculous Cholecystitis 2. Acute Acalculous Cholecystitis 3. Chronic Cholecystitis
26
______ is due to gallstones and with a sudden, severe onset. What is the MC cause?
Acute Calculous Cholecystitis stones becomes lodged in cystic duct
27
______ results from gallbladder stasis and ischemia, which then causes a local inflammatory response in the gallbladder wall. When is it commonly seen? What secondary infection is common?
Acute Acalculous Cholecystitis Generally seen in critically ill patients/post op after major surgery E. coli
28
________ result of mechanical irritation or recurrent attacks of acute cholecystitis. Episodes of biliary colic. Stone becomes lodged, inflammation of gallbladder develops, stone moves, symptoms resolve
chronic cholecystitis
29
What is the MC cause of acute cholecystitis? What happens next?
> 90% d/t gallstones Stone becomes impacted at cystic duct, causes inflammation, inflammatory mediators are released in response have the potential to get infected if the pt is immunocompromised
30
What is the common presentation for acute cholecystitis? **Where is the pain located? **How long will the pain be present?
**ILL APPEARING RUQ pain: that will be steady, sharp and severe pain that is precipitated by fatty meal **May present as epigastric or shoulder blade pain ** >4-6hrs, up to 18, lasts LONGER than 6 hours
31
Will the pt want to move in acute cholecystitis? Will there be guarding present?
the pt will NOT want to move GUARDING WILL BE PRESENT
32
What is murphy sign?
Inhibition of inspiration by pain on palpation of RUQ Ask pt to inspire deeply, which makes gallbladder descend toward and press against examining fingers leading to discomfort Associated with muscle guarding and rebound tenderness aka pain on inspiration
33
What will the lab findings be in acute cholecystitis?
Leukocytosis with left shift elevated serum bilirubin, Aminotransferases, Alkaline Phosphatase are NOT COMMON
34
____ is the first line imaging in acute cholecystitis. What will it show?
Ultrasound Stone lodged at cystic duct Gallbladder wall thickening Greater than 4-5mm
35
What is sonographic murphy's sign?
similar to abdominal palpation except use an US probe so you can indeed verify that the source of the pain is the gallbladder
36
_____ is used in acute cholecystitis if US is inconclusive. more _____. What is a very good at showing?
HIDA scan sensitive Useful in showing an **obstructed cystic duct**
37
What is a HIDA scan? What is generically going on during the procedure? What are you looking for?
Hepatobiliary Iminodiacetic Acid Scan (Cholescintigraphy) IV injection of Technetium-labeled iminodiacetic acid liver takes up the dye, then watch move to gallbladder (15-30 minutes), biliary ducts, & duodenum (60 minutes) watch for filling defects
38
What does a nonvisualized gallbladder indicate on a HIDA scan?
acute cholecystitis
39
HIDA scan can also measure _______. How does it work? What is considered normal? What is considered gallbladder disease?
gallbladder ejection fraction Cholecystokinin (CCK) is injected which stimulates contraction of the gallbladder Normal is considered 35-75% < 35% is indicative of gallbladder disease
40
What do you do if the gallbladder ejection fraction on HIDA scan is found to be less than 35%?
Indication for cholecystectomy
41
What are indications for a HIDA scan?
and inconclusive US
42
Is a HIDA scan safe in pregnancy? What is the pt education?
HIDA scan NOT safe in pregnancy fast for 4 hrs before - can have clear liquids need current list of medications
43
What are the 5 complications of acute cholecystitis?
Gangrenous Gallbladder Gallbladder perforation Hydrops of the gallbladder Mirizzi syndrome Porcelain gallbladder
44
______ results when acute cholecystitis subsides but cystic duct obstruction persists producing distention of the gallbladder with a clear mucoid fluid
Hydrops of the gallbladder
45
______ stone in neck of gallbladder may compress common hepatic duct and cause jaundice. Seen as one of the five complications of acute cholecystitis
Mirizzi syndrome
46
______ calcification of gallbladder wall due to chronic inflammation due to gallstones which results in scarring and calcification
Porcelain gallbladder
47
What is this?
porcelain gallbladder
48
What is the tx for acute cholecystitis?
ADMIT!! IV Piperacillin/Tazobactam (Zosyn) OR 2nd or 3rd generation Cephalosporin or Cipro + metronidazole NPO, IV fluids IV meperidine or NSAIDs lap cholecystectomy within 24- 48 hours
49
What is the new tx for acute cholecystitis? Who is commonly used on?
Percutaneous cholecystostomy Drainage under radiologic guidance via a percutaneous cholecystostomy tube Decompressing the gallbladder allows both local inflammation and systemic illness to resolve. Tube left in place until resolved high risk pts: elderly and dm
50
What is choledocolithiasis?
occurs when gallstones are present in the common bile duct
51
What is considered "uncomplicated" Choledocholithiasis? What is the MC symptom?
passes on their own RUQ pain
52
What is cholangitis?
gallstones becomes lodged and causes obstruction in common bile duct and then become infected!
53
What is the MC pathogen to cause cholangitis? From what location?
E. Coli ascend from the duodenum
54
About ____ of patients with symptomatic gallstones will develop choledocolithiasis. Risk increases with _____
15% risk increases with age
55
Intermittent biliary colic symptoms (RUQ pain); severe and persists for hours Jaundice (sometimes without pain) Intermittent N/V Epigastric tenderness What am I?
Choledocholithiasis aka RUQ pain WITH jaundice
56
in choledocholithiasis, _____ typically elevated early in course. Followed by ______, ______ and ______
AST/ALT Alkaline Phosphatase, Gamma-glutamyl Transpeptidase
57
______ is another enzyme found in liver that raises in response to liver damage/bile duct damage
GGT
58
Patients are often suspected of having _______ when they present with RUQ pain with elevated liver enzymes with elevation of alkaline phosphatase, gamma-glutamyl transferase, and bilirubin. What is the imaging of choice?
choledocholithiasis transabdominal U/S first
59
What will an US show in Choledocholithiasis? Where is NOT good for visualization? Why?
Will show CBD dilation and impaired flow with stones Has poor sensitivity for stones in the distal CBD b/c distal CBD is often obscured by bowel gas in imaging field
60
What is the tx of choice for Choledocholilithiasis?
ERCP with sphincterotomy and stone extraction/stent replacement
61
Choledocholilithiasis with _______, _______ and or should go directly to ERCP with cholecystectomy
Acute Cholangitis Hyperbilirubinemia (>4mg/dL) and CBD dilation >50% chance of CBD stone
62
What are the 3 factors that qualifies as an intermediate risk for Choledocholilithiasis? What is the next step?
Abnormal LFTs Age >55 Dilated CBD on US Go to MRCP or EUS for confirmation stone present: ERCP no stone present: laparoscopic cholecystectomy
63
What is cholangitis? What is the MC pathogen?
inflammation in the bile duct caused by bacterial infection in pt with CBD obstruction e. coli think stasis which leads to infection
64
**What is Charcot triad? **What dz is it associated with? Is it considered a medical emergency?
RUQ Pain Fever (and chills) Jaundice acute cholangitis YES! medical emergency
65
**What is Reynolds Pentad? What does it indicate?
RUQ Pain Fever Jaundice Hypotension Mental Status Change acute suppurative severe cholangitis
66
What will the PE show on a pt with cholangitis?
RUQ tenderness Hepatomegaly possible
67
What are the diagnostic imaging in cholangitis? What will it reveal? **What is the diagnostic procedure of choice in acute cholangitis?
US/CT reveal stones and dilated ducts ERCP
68
______ is a complication associated with ERCP. Why?
Pancreatitis d/t mechanical injury of pancreatic duct and hydrostatic injury from contrast injection
69
What is the dx criteria for cholangitis?
need ONE of the following: ●Fever and/or shaking chills. ●Laboratory evidence of an inflammatory response (abnormal white blood cell count, increased serum C-reactive protein, or other changes suggestive of inflammation). AND BOTH of the following ●Evidence of cholestasis: Bilirubin ≥2 mg/dL or abnormal liver chemistries (elevated alkaline phosphatase, gamma-glutamyl transpeptidase, alanine aminotransferase, or aspartate aminotransferase, to >1.5 times the upper limit of normal). ●Imaging with biliary dilation or evidence of the underlying etiology (eg, a stricture, stone, or stent).
70
What are the complications of cholangitis?
liver damage: cirrhosis and liver failure if left untreated septic shock
71
What is the tx for cholangitis? **What is the procedure of choice? What is the pt still have gallbladder?
ADMIT!!! IV fluids, pain control, NPO **ERCP with stone extraction & sphincterotomy is the procedure of choice for Acute Cholangitis within 48 hours lap chole AFTER the ERCP
72
What abx is given in mild/moderate cholangitis? Severe? What differenitiates mild/mod from severe?
mild/mod: Cipro plus Metronidazole (Flagyl) severe: IV Zosyn plus Flagyl organ damage equals severe
73
________ is Chronic inflammatory disease of the biliary tract. What does it result from?
Primary Sclerosing Cholangitis Results from increased immune response to intestinal endotoxins
74
**What other dz is Primary Sclerosing Cholangitis associated with? Who is the MC pt type?
UC and Crohns but more so with ulcerative colitis men age 20-50, some hereditary component
75
What does Primary Sclerosing Cholangitis eventually lead to?
Inflammation can lead to obstructive symptoms and cholestasis, fibrosis, and strictures of biliary system
76
_____ and _____ are helpful in primary sclerosing cholangitis
coffee consumption and statin use
77
Asymptomatic phase Obstructive jaundice Progressive jaundice Pruritus Fatigue, anorexia, indigestion Hepatomegaly/splenomegaly What am I?
primary sclerosing cholangitis
78
What are some common lab findings seen with primary sclerosing cholangitis?
79
What is the diagnostic imaging you should order for primary sclerosing cholangitis?
MRCP can due ERCP if MRCP is inconclusive
80
**What is the MRCP finding consistent with primary sclerosing cholangitis?
MRCP: “beads on a string”
81
What will a detailed report show that is consistent with Primary Sclerosing Cholangitis?
The inflammation of the ducts show irregularity and tortuosity of ducts along with multifocal structuring Segmental fibrosis with saccular dilatations between areas of stricture
82
In primary sclerosing cholangitis, if the MRCP/ERCP is inconclusive, what do you do next? **What will it show?
liver biopsy Periductal fibrosis “onion skinning”
83
What are the essentials of diagnosis for primary sclerosis cholangitis?
84
What are the complications of primary sclerosing cholangitis?
Cirrhosis/Liver Failure: Ultimate cause of death Cholangiocarcinoma (10%) Cholelithiasis, Cholecystitis Acute Cholangitis
85
What is the tx for primary sclerosing cholangitis?
no cure!!! cipro for acute episodes, variety of immunosuppresives and anti-inflammatory agents have been studied ERCP with dilation and stenting liver transplant if advanced sz have the potential to advance to cancer
86
What is the prognosis in PSC? What is the health maintenance?
9 - 17 years from onset of diagnosis some have argued for annual screening with imaging studies (MRCP) and a serum CA 19-9
87
______ is the MC cancer of the biliary tract. _____ is the most deadly
Carcinoma of the gallbladder - most common Cholangiocarcinoma (bile ducts) - most deadly
88
What are the 3 co-exisitng factors for gallbladder carcinoma? Where does it often invade next?
-Chronic infection of gallbladder (Salmonella typhi) -Gallbladder polyp (growths that protrude from lining of gallbladder); can be cancerous, but rare -Calcification of the gallbladder (porcelain gallbladder) liver
89
Where does cholangiocarcinoma most commonly arise? What is a Klatskin tumor? What age range?
⅔ arise at confluence of right and left hepatic ducts, then 1/4 in common bile duct, then intrahepatic duct hilar cholangiocarcinoma 50-70 years old
90
Will find increased incidences of Cholangiocarcinoma with what 3 things?
Primary sclerosing cholangitis Biliary cirrhosis (chronic obstruction) immunocompromised states
91
Progressive jaundice RUQ pain/tenderness Anorexia, weight loss Acute cholangitis commonly develops Pruritus fever chills hepatomegaly distended, palpable gallbladder ascites What am I? **What is often the first sign? Especially in _____
Carcinoma of the Biliary Tract progressive jaundice Esp. in Cholangiocarcinoma
92
What is the Courvoisier sign?
painless jaundice with palpable gallbladder
93
What are common labratory findings with carcinomas of the biliary tract?**What is required for dx?
Elevated LFT’s Elevated CA 19-9 Hyperbilirubinemia ERCP with biopsy or US guided percutaneous biopsy required for diagnosis
94
What is the tx for biliary tract carcinomas? What if the tumor is unresectable?
sx: curative if well localized Biliary-enteric bypass surgery (roux-en-Y hepaticojejunostomy)
95
What is a brief description of the Roux-en-Y procedure?
Biliary stent placement helps reduce stricture at the anastomosis. Once stent has been positioned, the small bowel is divided and distal small bowel brought up and sutured to the bile duct. An end-to-side bowel-bowel anastomosis completes the reconstruction. Bypasses the bile duct to allow digestive juices to drain from liver directly to jejunum
96

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