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Gallbladder & Biliary Tract Disorders Flashcards

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1
Q

Which hormone stimulates the gallbladder to release bile into the duodenum?

A

Cholecystokinin (CCK)

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2
Q

What is bile used for?

A

Emulsify fats

Assist with the excretion of cholesterol

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3
Q

Types of Biliary Tract Disorders

A 
Cholelithiasis
Choledocholithiasis
Acute cholecystitis
Cholangitis
Primary sclerosing cholangitis
Primary biliary cirrhosis
CA of the biliary tract
Hyperbilirubinemia
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4
Q

Define Cholelithiasis

A

Formation of gallstones which are solid concentrations of varying quantities of cholesterol, Ca, and bilirubin

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5
Q

What leads to the formation of cholesterol stones?

A

Supersaturation of bile with cholesterol and GB hypomotility

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6
Q

Types of Gallstones

A

Cholesterol (90%)

Pigmented (10%)

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7
Q

Types of Pigmented Gallstones

A

Black stones: contain Ca bilirubinate, associated with cirrhosis and hemolysis
Brown stones: associated with biliary tract stasis & infection

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8
Q

Major Risk Factors for the Development of Gallstones

A 
Age
Female
Genetic
Pregnancy
Obesity
Rapid weight loss
Cirrhosis
Hemolytic anemias
Hypertriglyceridemia
Medications: BC, clofibrate, ceftriaxone, octreotide
Terminal ileal resection
Gallbladder stasis
Reduced physical activity
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9
Q

The 4 F’s of Cholelithiasis

A

Fat
Fertile
Female
Forty

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10
Q

Signs/Symptoms of Cholelithiasis

A

Biliary colic
Steady RUQ pain radiates to back/R shoulder
Nausea
Pain after eating

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11
Q

Treatment of Cholelithiasis

A

Observation

Cholecystectomy

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12
Q

Consider Prophylactic Cholecystectomy in these Patients

A 
Diabetics
Porcelain gallbladder
Sickle cell disease
Hereditary spherocytosis
Gastric bypass
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13
Q

Define Porcelain Gallbladder

A

Blue discoloration & brittle consistency

Due to calcification from excessive gallstones

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14
Q

Gallstone Complications

A 
Gallstone ileus
Gallstone pancreatitis
Acute cholecystitis
Choledocholithiasis
Cholangitis
Bile duct injuries
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15
Q

Define Gallstone Ileus

A

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

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16
Q

Protective Factors of Cholelithiasis

A

Statins
Ascorbic acid
Coffee- caffeinated
Vegetable protein

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17
Q

Define Choledocholithiasis

A

Presence of gallstones within the common bile duct

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18
Q

Signs/Symptoms of Choledocholithiasis

A

RUQ/epigastric pain
N/V
LFT’s elevated
Bilirubin & alkaline phosphatase may be elevated

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19
Q

Choledocholithiasis Imaging

A

Transabdominal ultrasound
Abdominal CT
ERCP
Intraoperative cholangiography or ultrasonography
Magnetic resonance cholangiopancreatography (MRCP)

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20
Q

What is the gold standard for diagnosis of choledocholithiasis?

A

ERCP

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21
Q

Advantages of an ERCP

A

Therapeutic option
Stone retrieval
Sphincterotomy

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22
Q

Complications of an ERCP

A

Pancreatitis
Cholangitis
Perforation of duodenum or bile duct
Bleeding

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23
Q

Advantage of an MRCP

A

Detects choledocholithiasis, neoplasms, strictures, biliary dilations
High sensitivity & specificity
Minimally invasive

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24
Q

Disadvantages of an MRCP

A

Cannot sample bile, test cytology, remove stone

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25
Contraindications for an MRCP
Pacemaker Implants Prosthetic valves
26
Indications for an MRCP
Cholangitis not severe | Risk of ERCP high
27
Treatment for Choledocholithiasis
Remove the stone via ERCP, lithotripsy, lap CBD exploration
28
Define Acute Cholecystitis
Syndrome of RUQ pain, fever, and leukocytosis associated with gallbladder inflammation usually caused by cystic duct obstruction
29
Important Findings on H&P
``` RUQ/epigastric pain which radiates to right shoulder Anorexia N/V Fever + Murphy's sign Jaundice ```
30
Diagnostics of Acute Cholecystitis
``` LFT's & bilirubin elevated CBC: left shift CRP elevated US: stones/sludge, pericholecystic fluid, distended GB, thickened GB wall HIDA scan: failure of GB filling ```
31
What is the imagining modality of choice for the gallbladder?
US
32
Advantages of an Abdominal US
Fast Real-time Non-invasive No radiation
33
Indications for a HIDA Scan
Functional assessment of the hepatobiliary system Evaluation of acute cholecystitis, chronic biliary tract disorders, CBD obstruction, congenital abnormalities Detection of bile extravasation
34
Requirements for HIDA Scan
Patient prep: fast 2-4 hours
35
Other Important Information for a HIDA Scan
``` Hx previous surgeries Time of most recent meal Current meds: opioids (4 hours after last dose) Bilirubin & liver enzyme levels Results of US ```
36
Treatment of Acute Cholecystitis
Admit: supportive care, NPO, IV fluids, analgesia, vitals, urinary output Antibiotics: cipro, levo, flagyl, cefuroxime Lap chole: PREFERED Percutaneous cholecystotomy tube
37
Complications of Acute Cholecystitis
``` Emphysematous cholecystitis Gangrenous cholecystitis Pericholecystic abscess formation Sepsis Peritonitis Ascending cholangitis Cholecystoenteric fistula Perforation ```
38
What to look for with complications in acute cholecystitis?
``` Fever Shaking chills High WBC Increased abdominal pain Persistent symptoms ```
39
Chronic Cholecystitis
Repeated episodes of mild attacks Due to presence of stones Mild inflammation can lead to shrinking, scarring, thickened walls, mucosal atrophy, & fibrosis of GB wall
40
Signs/Symptoms of Chronic Cholecystitis
Transient RUQ pain: precipitated by fatty meal | N/V
41
Treatment of Chronic Cholecystitis
Cholecystectomy Look for choledocholithiasis Prevent future complications
42
Define Porcelain Gallbladder
Extensive calcium encrustation of the gallbladder wall
43
What is a porcelain gallbladder a risk for?
GB adenocarcinoma
44
Treatment of Porcelain Gallbladder
Surgery
45
Define Acute Cholangitis
Inflammation or infection of the bile duct system
46
What is the most important predisposing factor for acute cholangitis?
Biliary obstruction & stasis secondary to biliary calculi or benign stricture
47
Define Charcot's Triad
RUQ Pain Jaundice Fever/Chills
48
Define Renold's Pentad
``` RUQ pain Jaundice Fever/Chills Hypotension Altered mental status ```
49
What is the mortality rate for patients with septic cholangitis?
50%
50
Diagnstics of Cholangitis
``` Leukocytosis Elevated LFTs, CRP Blood cultures: gram negative ABGs: metabolic acidosis Elevated BUN & creatinine US: dilated bile duct, CBD stones ERCP: bile duct stone/obstruction or stricture ```
51
Treatment of Cholangitis
Admit Treat infection Remove stones (ERCP) Biliary drainage
52
Define Primary Sclerosing Cholangitis
Chronic inflammatory cholestatic disease characterized by diffuse inflammation of the biliary tract
53
Having primary sclerosing cholangitis increases your risk of what?
``` Cholangiocarcinoma Gallbladder CA Colon CA Ulcerative colitis Hepatocellular CA ```
54
Presentation of Primary Sclerosing Cholangitis
``` Progressive, obstructive jaundice Malaise Fatigue Pruritus Anorexia Dyspepsia Symptoms of cirrhosis Symptoms of portal HTN Elevated alkaline phosphatase, ALT, AST ```
55
Diagnosis of Primary Sclerosing Cholangitis
ERCP ANCA (Anti-neutrophil cytoplasmic antibodies) MRCP alternative to ERCP
56
Treatment of Primary Sclerosing Cholangitis
Balloon dilation or stenting | Liver transplantation
57
Define Primary Biliary Cirrhosis (PBC)
Slowly progressive autoimmune liver disease
58
Epidemiology of Primary Biliary Cirrhosis (PBC)
``` Females >> Males Peak in 40s Portal inflammation & autoimmune destruction of bile ducts Leads to cirrhosis & liver failure Antimitochondrial antibody (AMA) ```
59
Clinical Features of Primary Biliary Cirrhosis (PBC)
``` Fatigue Pruritus Skin hyperpigmentation Rheumatic symptoms Musculoskeletal complaints Hyperlipidemia Hypothyroidism Osteopenia Autoimmune disease Portal HTN Liver failure ```
60
PE in Primary Biliary Cirrhosis (PBC)
``` Hyper pigmented skin Excoriations Xanthelasmas Hepatomegaly Spider nevi Jaundice Muscle wasting Ascites Edema ```
61
Diagnosis Criteria of Primary Biliary Cirrhosis
2 of 3 criteria Positive AMA Abnormal LFT: alkaline phosphatase & GGTP Compatible biopsy shows destruction of interlobular bile ducts
62
Treatment of Primary Biliary Cirrhosis
``` UDCA (ursodiol) Colchicine (severe inflammation) Methotrexate (severe inflammation) Budesonide (severe inflammation) Liver tranplant ```
63
What does UDCA (ursodiol) do for primary biliary cirrhosis?
Reduces bilirubin, LFTs, cholesterol, IgM Delays fibrosis & varices Reduce risk of need for liver transplant & death over 4 years
64
Known Risk Factors for Cholangiocarcinoma
Primary Sclerosing cholangitis Congenital liver malformations Infection with parasitic liver flukes Exposure to Thorotrast (thorium dioxide)
65
Diagnostic Testing for Cholangiocarcinoma
US: tumor & spread, dilation of GB & ducts CT: tumor & spread, dilation of GB & ducts, enlarged lymph nodes MRI: bile ducts & blood vessels Cholangiography via ERCP: access to biliary tree
66
Treatment of Cholangiocarcinoma
Palliative chemo +/- radiation | Resect if possible
67
What is the prognosis of cholangiocarcnoma?
Resectable: 5% in 5 years | Non-resectable: 0% in 5 years
68
Epidemiology of Gallbladder CA
Women > Men | Found incidentally
69
Risk Factors for Gallbladder CA
``` Gallstones Gallbladder Polyps Chornic salmonella infection Abnormal pancreaticobiliary duct junction Porcelain gallbladder DM Obesity ```
70
Presentations for Gallbladder CA
During/after lap chole for benign disease Diagnostic eval: found on imaging Advanced stage at presentation
71
Surgical Management of Gallbladder Disease if Resectable
Simple chole Radical chole Radical whole with anatomic liver resection Radical whole with Whipple
72
Clinical Features of Ampulla of Vater CA
``` Obstructive jaundice Weight loss Anorexia Fatigue Abdominal Occult GI bleeding Positive FOBT ```
73
Imaging for Ampulla of Vater CA
``` US CT ERCP EUS MRCP ```
74
Treatment of Ampulla of Vater CA
Whipple procedure
75
Define Bilirubin
Yellow pigment formed by breakdown of heme present in hemoglobin
76
Causes of Hyperbilirubinemia
Increased production of bilirubin | Decreased clearance of bilirubin
77
What is Gilbert's Syndrome caused by?
Reduction in the glucuronidation activity of the UGT1A1 enzyme
78
Lab Results of Gilbert's Syndrome
Elevated unconjugated bilirubin | Normal conjugated bilirubin

GI (20 decks)

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