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Gallbladder Flashcards

1
Q

Gallstone are caused by _

A

Gallstone are caused by precipitation of bilirubin and/or cholesterol in the bile

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2
Q

Gallstones can be diagnosed via (2) modalities _ or _

A

Gallstones can be diagnosed via (2) modalities ultrasound or hepatobiliary iminodiacetic acid (HIDA) scan

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3
Q

The (4) risk factors for cholelithiasis

A

Cholelithiasis risk factors: 4 F’s
1. Fat
2. Female
3. Fertile (pregnant)
4. Forty

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4
Q

The most common type of gallstone is _

A

The most common type of gallstone is cholesterol gallstone

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5
Q

_ is an enzyme that converts cholesterol –> bile

A

Cholesterol 7a-hydroxylase is an enzyme that converts cholesterol –> bile
* This is a rate limiting step of bile production

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6
Q

Cholesterol gallstone formation is associated with (high/low) cholesterol and (high/low) bile

A

Cholesterol gallstone formation is associated with high cholesterol and low bile
* Recall that cholesterol –> bile via 7a-hydroxylase

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7
Q

Explain the pathogenesis of cholesterol gallstones

A

Supersaturation of cholesterol + insufficient bile acids/salt + biliary stasis –> stone

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8
Q

Cholesterol gallstones are associated with the following risk factors:

A

Cholesterol gallstones are associated with the following risk factors:
* Native Americans
* Rapid weight loss
* Fibrates
* Age
* Obesity
* Crohn’s disease

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9
Q

Cholesterol gallstones are (radiolucent/radiopaque)

A

Cholesterol gallstones are radiolucent

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10
Q

Black pigmented gallstones result from _

A

Black pigmented gallstones result from hemolysis

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11
Q

Explain the pathogenesis of black pigmented gallstones

A

Hemolysis –> increase in unconjugated bilirubin –> increase in calcium bilirubinate

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12
Q

Brown pigmented gallstones result from _

A

Brown pigmented gallstones result from infection

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13
Q

Explain the pathogenesis of brown pigmented gallstones

A

Infection –> increase in beta-glucuronidase –> increase in calcium bilirubinate, increase in fatty acids

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14
Q

Brown pigmented gallstones most commonly result from infection with _ or _

A

Brown pigmented gallstones most commonly result from infection with E.coli or Clonorchis sinensis

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15
Q

Associated risk factors of pigmented gallstones include:

A

Associated risk factors of pigmented gallstones include:
* TPN
* Alcoholic cirrhosis
* Crohn’s disease
* Hemolysis
* Biliary infection

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16
Q

Cholecystitis is _

A

Cholecystitis is acute or chronic inflammation of the gallbladder due to cystic duct obstruction

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17
Q

Cholecystitis is caused by an obstruction in _

A

Cholecystitis is caused by an obstruction in cystic duct

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18
Q

Cholecystitis may be suspected with a positive _ (physical exam finding)

A

Cholecystitis may be suspected with a positive Murphy’s sign

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19
Q

_ sign is arrest of inspiration during palpation of the RUQ

A

Murphy’s sign is arrest of inspiration during palpation of the RUQ

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20
Q

A positive Murphy’s sign is arrest of inspiration during palpation of _ quadrant

A

A positive Murphy’s sign is arrest of inspiration during palpation of RUQ

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21
Q

_ is a form of cholecystitis caused by stasis, hypoperfusion, or infection (hypokinesis of gallbladder emptying) that mainly occurs in critically ill patients

A

Acalculous cholecystitis is a form of cholecystitis caused by stasis, hypoperfusion, or infection (hypokinesis of gallbladder emptying) that mainly occurs in critically ill patients

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22
Q

_ is a gallstone in the common bile duct

A

Choledocholethiasis is a gallstone in the common bile duct

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23
Q

Expected lab findings in a choledocholethiasis

A

Expected lab findings in a choledocholethiasis:
* Elevated ALP
* Elevated GGT
* Elevated conjugated bilirubin
* Elevated AST/ALT

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24
Q

Ascending cholangitis is _

A

Ascending cholangitis is infection of the biliary tree due to stasis/obstruction

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25
Ascending cholangitis may present with _ phenomenon
Ascending cholangitis may present with **Charcot's triad** * *Jaundice, fever, RUQ pain*
26
Charcot's triad presents with _ pathology
Charcot's triad presents with **ascending cholangitis**
27
Charcot's triad encompasses:
Charcot's triad encompasses: 1. **Jaundice** 2. **Fever** 3. **RUQ pain**
28
Reynold's pentad includes Charcot's triad + _ and _
*Reynold's pentad* includes Charcot's triad + **altered mental state** and **shock**
29
A gallstone at the ampulla of vater can lead to _
A gallstone at the ampulla of vater can lead to **acute pancreatitis**
30
A fistula between the gallbladder and bowel can lead to _
A fistula between the gallbladder and bowel can lead to **gallstone ileus** * The gallstone enters the intestinal lumen --> ileocecal valve
31
Signs of a gallstone ileus:
Signs of a gallstone ileus: **Rigler triad** 1. **Pneumobilia** (air in biliary tree) 2. **Small bowel obstruction** 3. **Gallstone visualized**
32
Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts is called _
Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts is called **primary sclerosing cholangitis**
33
PSC will show periductal fibrosis with _ appearance
PSC will show periductal fibrosis with **onion-skin** appearance
34
PSC will appear with _ sign on contrast imaging
PSC will appear with **beading** on contrast imaging * Uninvolved regions are dilated * Alternating strictures and dilations
35
PSC most commonly presents with _
PSC most commonly presents with **obstructive jaundice** * Pruritis, pale stool, dark urine
36
A late complication of PSC is _
A late complication of PSC is **cirrhosis**
37
Etiology of PSC is largely unknown but it is commonly associated with _ and may have a positive _
Etiology of PSC is largely unknown but it is commonly associated with **ulcerative colitis** and may have a positive **p-ANCA**
38
PSC is associated with HLA markers _ and _
PSC is associated with HLA markers **HLA-B8** and **HLA-DR3**
39
PSC is associated with an increased risk of _ malignancy
PSC is associated with an increased risk of **cholangiocarcinoma**
40
Both PSC and PBC are associated with an increase in _ antibody
Both PSC and PBC are associated with an increase in **IgM**
41
Primary biliary cholangitis is _
Primary biliary cholangitis is **autoimmune granulomatous destruction of intrahepatic bile ducts**
42
PBC presents with _ ; _ is a late complication
PBC presents with **obstructive jaundice** ; **cirrhosis** is a late complication * Pruritis, pale stools, dark urine (same as PSC)
43
PBC is commonly associated with _ and _ autoantibodies may be present
PBC is commonly associated with **autoimmune disorders** and **anti-mitochondrial autoantibodies** may be present
44
PSC tends to present in _ population
PSC tends to present in **middle aged men**
45
PBC tends to present in _ population
PBC tends to present in **middle aged women**
46
(PBC/PSC) is associated with auto-mitochondrial antibodies
**PBC** is associated with **auto-mitochondrial antibodies**
47
(PBC/PSC) is associated with p-ANCA
**PSC** is associated with **p-ANCA**
48
Histology of primary biliary cholangitis will show _
Histology of primary biliary cholangitis will show **lymphocytic infiltrate** and **granulomas**
49
(PBC/PSC) involves the intra AND extrahepatic bile ducts
**PSC** involves the intra AND extrahepatic bile ducts * PBC only affects the intrahepatic bile ducts
50
PBC causes an increased risk of _
PBC causes an increased risk of **hepatocellular carcinoma** * Progression from chronic cirrhosis
51
Secondary biliary cholangitis/cirrhosis is _
Secondary biliary cholangitis/cirrhosis is **extrahepatic obstruction of the bile ducts** --> causing duct fibrosis and bile stasis * Associated with bile duct obstruction
52
Chronic cholecystitis --> gallbladder calcification --> increase risk of _
Chronic cholecystitis --> gallbladder calcification --> increase risk of **adenocarcinoma** * We call this a "porcelain gallbladder"
53
_ is an adenocarcinoma of the bile duct epithelium
**Cholangiocarcinoma** is an adenocarcinoma of the bile duct epithelium
54
Risk factors of cholangiocarcinoma include things that cause _
Risk factors of cholangiocarcinoma include things that cause **chronic inflammation of bile duct epithelium** * Chronic cholecystitis * Choledochal cysts * PSC * *Clonorchis sinensis* (Liver fluke)
55
Cholangiocarcinoma is characterized by _ on histology
Cholangiocarcinoma is characterized by **glands and mucin** on histology (very disorganized)
56
Cholangiocarcinoma presents with _
Cholangiocarcinoma presents with **obstructive jaundice** * Pruritis, pale stool, dark urine
57
Pruritus associated with jaundice occurs due to the build up of _
Pruritus associated with jaundice occurs due to the build up of **bile salts**
58
Pale stools occur in obstructive jaundice due to the decrease in _
Pale stools occur in obstructive jaundice due to the **decrease in stercobilin** * Decreased intestinal bilirubin
59
Dark urine occurs in obstructive jaundice due to _
Dark urine occurs in obstructive jaundice due to **increased conjugated bilirubin in blood** * Increase bilirubin going to the kidneys for excretion --> dark urine
60
Jaundice is yellowing of the skin and sclera due to _ deposition
Jaundice is yellowing of the skin and sclera due to **bilirubin deposition**
61
Conjugated jaundice most commonly occurs due to _
Conjugated jaundice most commonly occurs due to **obstruction** * ie gallstones, cancers, *Clonorchis sinensis*, PBC, PSC
62
Unconjugated jaundice most commonly occurs due to _
Unconjugated jaundice most commonly occurs due to **hemolysis** or **enzyme deficiency**
63
Hepatitis and cirrhosis tend to cause a _ type jaundice
Hepatitis and cirrhosis tend to cause a **mixed jaundice** * They impair enzymes and export
64
Neonatal jaundice is caused by _
Neonatal jaundice is caused by **immature UDP-glucuronosyltransferase** (UDP-GT) * Typically resolves within weeks of birth
65
Babies at risk of kernicterus will need _ therapy
Babies at risk of kernicterus will need **non-UV phototherapy**
66
Non-UV phototherapy treats newborn jaundice by _
Non-UV phototherapy treats newborn jaundice by **increasing water solubility of bilirubin** to increase excretion
67
Bilirubin is a byproduct of _
Bilirubin is a byproduct of **RBC breakdown** * Senescent RBCs (120 day lifespan) get broken down by macrophages into iron, globin, bilirubin
68
Unconjugated bilirubin is water (soluble/insoluble)
Unconjugated bilirubin is **water insolube**; cannot be excreted in the urine
69
Unconjugated bilirubin is (free/bound) in the blood
Unconjugated bilirubin is **bound to albumin** in the blood
70
The enzyme that converts unconjugated bilirubin to conjugated bilirubin is _
The enzyme that converts unconjugated bilirubin to conjugated bilirubin is **UDP-glucuronosyl-transferase** * Found in the liver
71
Conjugated bilirubin is excreted from the liver as _ and goes into the intestine where gut bacteria turn it into _
Conjugated bilirubin is excreted from the liver as **bile** and goes into the intestine where gut bacteria turn it into **urobilinogen**
72
Urobilinogen becomes _ (excreted in stool) and _ (excreted in urine)
Urobilinogen becomes **stercobilin** (excreted in stool) and **urobilin** (excreted in urine)
73
Some pediatric jaundice is caused by improper formation of the bile ducts/ fibrosis and destruction of the extrahepatic bile ducts called _
Some pediatric jaundice is caused by improper formation of the bile ducts/ fibrosis and destruction of the extrahepatic bile ducts called **biliary atresia** * Cholestasis can cause worsening jaundice, dark urine, pale stool, hepatomegaly * Liver damage from high direct bilirubin
74
G6PD deficiency can result in an increase in (conjugated/unconjugated) bilirubin
G6PD deficiency can result in an increase in **unconjugated bilirubin** * Recall that G6PD converts NADP --> NADPH which protects RBCs from ROS damage * Deficiency leads to RBC hemolysis
75
All hereditary hyperbilirubinemias have _ inheritance
All hereditary hyperbilirubinemias have **autosomal recessive** inheritance
76
_ is a condition of reduced UDP-GT that causes an increase in unconjugated bilirubin and jaundice during stress, fasting, illness
**Gilbert syndrome** is a condition of reduced UDP-GT that causes an increase in unconjugated bilirubin and jaundice during stress, fasting, illness
77
Crigler-Najjar syndrome is caused by _
Crigler-Najjar syndrome is caused by **absent UDP-GT** * Leads to severe jaundice, kernicterus
78
Kernicterus is caused by _
Kernicterus is caused by **basal ganglia bilirubin deposition**
79
We treat Crigler-Najjar syndrome with _ and _
We treat Crigler-Najjar syndrome with **plasmapheresis** and **phototherapy** * Increase polarity and water solubility to increase excretion
80
The curative treatment for Crigler-Najjar is _
The curative treatment for Crigler-Najjar is **liver transplant**
81
Type II Crigler-Najjar is a more (severe/mild) form
Type II Crigler-Najjar is a **more mild form**
82
Type II Crigler-Najjar can be treated with _
Type II Crigler-Najjar can be treated with **phenobarbital**
83
Phenobarbital improves jaundice by _
Phenobarbital improves jaundice by **increasing liver enzyme synthesis**
84
Dubin-Johnson syndrome is a hyperbilirubinemia condition caused by _
Dubin-Johnson syndrome is a hyperbilirubinemia condition caused by **impaired liver excretion of conjugated bilirubin**
85
_ is a benign condition notable for black liver due to accumulated epinephrine metabolites
**Dubin-Johnson syndrome** is a benign condition notable for black liver due to accumulated epinephrine metabolites
86
Rotor syndrome is caused by _
Rotor syndrome is caused by **impaired hepatic uptake/excretion of conjugated bilirubin** * A milder version of Dubin-Johnson without a black liver
87
Common bile duct
88
ALT, AST, ALP, bilirubin will be (normal/elevated) in cholecystitis
ALT, AST, ALP, bilirubin will be **normal** in cholecystitis
89
_ is often asymptomatic; stones are just sitting in the gallbladder
**Cholelithiasis** is often asymptomatic; stones are just sitting in the gallbladder
90
Biliary colic is when _
Biliary colic is when **stones intermittently obstruct the gallbladder neck/cystic duct**, causing transient episodes of pain/discomfort
91
_ is when a stone gets wedged in the cystic duct causing inflammation of the gallbladder
**Acute cholecystitis** is when a stone gets wedged in the cystic duct causing inflammation of the gallbladder
92
Cholecystitis is associted with (colicky/ persistent) pain
Cholecystitis is associted with **persistent pain**
93
_ occurs when a stone gets impacted in the common bile duct causing bile to back up into the hepatic bile ducts and LFTs to go up
**Choledocholithiasis** occurs when a stone gets impacted in the common bile duct causing bile to back up into the hepatic bile ducts and LFTs to go up
94
_ is a progression of choledocholithiasis in which bile fluid gets infected from the obstruction
**Ascending cholangitis** is a progression of choledocholithiasis in which bile fluid gets infected from the obstruction
95
We manage biliary colic via _
We manage biliary colic via **observation, elective cholecystectomy**
96
Acute cholecystitis will have an elevation in (WBC/LFTs)
Acute cholecystitis will have an elevation in **WBCs** * Liver enzymes will be normal
97
Imaging of acute cholecystitis may show _
Imaging of acute cholecystitis may show **stones, gallbladder wall thickening and pericholecystic fluid**
98
We treat acute cholecystitis with _
We treat acute cholecystitis with **urgent cholecystectomy**
99
Of the gallstone pathologies, _ and _ are most certain to elevate liver enzymes
Of the gallstone pathologies, **choledocholithiasis** and **cholangitis** are most certain to elevate liver enzymes * Gallstone pancreatitis (stone at the ampulla of vater) may or may not have elevated LFTs
100
Choledocholithiasis and ascending cholangitis are treated with _
Choledocholithiasis and ascending cholangitis are treated with **urgent ERCP, then cholecystectomy**
101
Autoimmune hepatitis is often positive for...
* Positive anti-nuclear antibody (ANA) * Positive anti-smooth muscle antibody * Positive anti-liver-kidney microsomal Ab * Elevated IgG
102
Autoimmune hepatitis will reveal _ on histology
Autoimmune hepatitis will reveal **plasma cells and mononuclear infiltrates around the portal triad** on histology
103
(ALP/GGT) comes from liver *and bones*
**ALP** comes from liver *and bones* * GGT only comes from hepatocytes
104
Differential for elevated ALP and GGT
Differential for elevated ALP and GGT: * Biliary obstruction (stone, tumor) * Biliary disease (PSC, PBC) * Infiltrative disease invading bile duct (sarcoidosis, lymphoma) * Medications
105
(PBC/PSC) is associated with intense pruritus
**PBC** is associated with intense pruritus
106
(PBC/PSC) is associated with recurrent biliary obstructions/infections (cholangitis)
**PSC** is associated with recurrent biliary obstructions/infections (cholangitis)
107
(PBC/ PSC) will have positive ANA
**PBC** will have positive ANA
108
We can treat PBC with _ , a medication which changes the composition of bile
We can treat PBC with **ursodeoxycholic acid** , a medication which changes the composition of bile
109
PBC
110
(PBC/PSC) has granulomas
**PBC** has granulomas * Spillage of bile --> macrophages try to contain
111
PSC
112
PSC

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