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Flashcards in Gallbladder/Biliary Tract Disorders Deck (89)
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1

The liver produces 1.______ml of bile each day which either drains directly into 2.where or is temporarily stored 3.where?

4. The gallbladder then releases bile into duodenum under stimulation of hormone what?



1. 500-1500
2. the duodenum via the common bile duct
3. in the gallbladder via the cystic duct.

4. cholecystokinin (CCK).

2

1. CCK released after food is ingested causes what?

2. Bile is used to do what?

1. Spincter of Oddi to contract and relax which sends a bolus of bile into duodenum

2. emulsify fats and assist with the excretion of cholesterol

3

Biliary Tract Disorders
8

1. Cholelithiasis
2. Choledocholithiasis
3. Acute cholecystitis
4. Cholangitis
5. Primary sclerosing cholangitis
6. Primary biliary cirrhosis
7. Carcinoma of the biliary tract
8. Hyperbilirubinemia

4

1. What is colelithiasis?



2. Supersaturation of bile with cholesterol and GB hypomotility leads to what?

1. the formation of gallstones (choleliths) which are solid concretions of varying quantities of cholesterol, ca+, and bilirubin… which usually form in the GB, but may form in the bile ducts (choledocholithiasis).

2. the formation of cholesterol stones.

5

What are the types of gallstones?
2

1. Cholesterol stones 90%
2. Pigmented (10%)

6

What are the pigmented types of gallstones? 2

1. Black stones (contain Ca bilirubinate, associated with cirrhosis and hemolysis)

2. Brown stones (a/w biliary tract stasis & infection)

7

Risk factor for gallstones?
4

1. Fat
2. Fertile
3. Female
4. Forty

8

CHOLELITHIASIS: Symptoms and Signs
1. Most common presentation?
2. The cardinal symptom?
3. Describe this?
4. Pain may be brought on by what?


If uncomplicated may have normal PE and normal labs

1. Most patients with stones are asymptomatic, however, approximately 20% will become symptomatic during up to 15 years of follow-up

2. The cardinal symptom of gallstones is biliary colic;

3. steady RUQ pain radiates to back and right shoulder, may be accompanied by nausea.

4. Pain may be brought on after ingestion of fatty foods.

9

How do you differentiate a gall stone from a polyp?

There is a shadow cast by the stone and no shadow with the polyp

10

CHOLELITHIASIS Treatment
1. 60-80% treated how?
2. Symptomatic?
3. Consider prophylactic cholecystectomy for who? 5

1. asymptomatic/observation
2. cholecystectomy
3.
-Diabetics (Not routinely recommended)
-Porcelain gallbladder ( blue discoloration and brittle consistency)
-Sickle cell disease
-Hereditary spherocytosis (Not routinely indicated in patients w/o gallstones)
-Gastric bypass surgery (usually recommended)


11

What is porcelain gallbladder due to?

due to calcification from excessive gallstones

12

Gallstone complications?
6

1. Gallstone ileus
2. Gallstone pancreatitis
3. Acute cholecystitis\
4. Choledocholithiasis
5. Cholangitis
6. Bile Duct injuries

13

What is gallstone ileus?

stone erodes through GB wall and develops a cholecystoenteric fistula leading to obstruction of narrowest segment of bowel causing ileus

14

Acute cholecystitis: 10-20% of pts w/ symptomatic gallstones

What can this cause? 4

1. GB gangrene
2. GB perforation
3. GB empyema (pus in the GB)
4. Emphysematous cholecystitis

15

What would be precipating factor to cause Emphysematous cholecystitis?
4

1. GB vascular compromise,
2. stones,
3. impaired immune system,
4. infection w/gas-forming organisms - clostridium, E. coli, Klebsiella

16

PROTECTIVE FACTORS
for gallstones?
(whats the big one?)

1. Statins***
2. Ascorbic acid
3. Coffee- caffeinated
4. Vegetable protein

17

Choledocholithiasis
1. What is this?
2. If symptomatic how does the pt usually present? 2
3. What labs will be elevated? 2
4. What also may be elevated? 2

1. The presence of gallstones within the common bile duct
-May be asymptomatic in up to 30% of pts.
2. If symptomatic typically present with
-RUQ or epigastric pain, &
-nausea and vomiting.

3.
-LFT’s (ALT-alanine aminotransferase,
-AST-aspartate aminotransferase) are elevated,

4.
-bilirubin
-alkaline phosphatase may be elevated.

18

Complicated choledocholithiasis
can lead to?
3

Complicated choledocholithiasis
1. acute cholangitis,
2. acute pancreatitis,
3. hepatic abscesses

19

Choledocholithiasis: imaging
5
(imaging of choice/first choice?)

1. Transabdominal ultrasound
2. Abdominal CT
3. Endoscopic retrograde cholangiography (ERCP)
4. Intraoperative cholangiography or ultrasonography
5. Magnetic resonance cholangiopancreatography (MRCP)



20

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the gold standard for what?
2

Gold standard for diagnosis of 1. CBD stones, and
2. sphincter of Oddi dysfunction

21

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Advanatages? 3

Disadvantages?4

1. Therapeutic option when CBD stone identified
2. Stone retrieval and
3. sphincterotomy

Disadvantage
Complications:
1. pancreatitis,
2. cholangitis,
3. perforation of duodenum or bile duct,
4. bleeding

22

Magnetic resonance cholangiopancreatography (MRCP)

Advantages? 3

Indications?

1. Detects choledocholithiasis, neoplasms, strictures, biliary dilations
2. Sensitivity of 81-100%, specificity of 92-100% of choledocholithiasis
3. Minimally invasive- avoid invasive procedure in 50% of patients

If cholangitis not severe, and risk of ERCP high, MRCP useful

23

Magnetic resonance cholangiopancreatography (MRCP)
1. Disadvantages? 3
2. Contraindications? 3

1. cannot
-sample bile,
-test cytology,
-remove stone

2. Contraindications:
-pacemaker,
-implants,
-prosthetic valves

24

Treatment for choledocholithiasis?

How do we accomplish this? 3

REMOVE THE STONE

1. ERCP
2. Lithotripsy
3. Laparoscopic CBD exploration

25

Acute cholecystitis
1. Symptoms? 3

2. What is this associated with?
3. Usually caused by?

1. A syndrome of
- RUQ pain,
- fever, and
- leukocytosis

2. associated with gallbladder inflammation
3. usually caused by cystic duct obstruction.

26

Acute cholecystitis
1. 90% caused by what?
2. 10% caused by what? 2

1. impacted gallstone
2.
-bile stasis or
-acalculus cholecystitis

27

Acute cholecystitis caused by bile stasis or acalculus cholecystitis happens in what pts?

Prognosis?

occurs in critically ill patients.


associated with high morbidity and mortality

28

Acute cholecystitis
History and Physical?
9

1. RUQ or epigastric pain
2. may have radiation to right shoulder,
3. often occurs after fatty meal.
4. anorexia,
5. nausea and vomiting,
6. fever
7. Murphy's sign
8. Palpable enlarged GB in 30% of pts
9. Jaundice in about 10%

29

What is the murphy sign?

(+) Murphy’s sign
1. Have patient breathe out
2. Examiner places hand below costal margin at RUQ
3. Have patient breathe in, if tender, then+ Murphy’s sign

30

Acute cholecystitis
Labs? 3

Imaging? 2

1. LFTs and bilirubin elevated
2. CBC- leukocytosis with left shift
3. C-reactive protein elevated >3 mg/dl

1. Ultrasound
2. Radionuclide scans (HIDA scan)