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105 Cards in this Set
- Front
- Back
|
Absorptive and Secretive functions of the gall bladder
|
absorptive: concentrate bile by pulling out salt/water; secrete: protective mucus layer and H+ to increase Ca2+ solubility (prevent stones)
|
|
|
Types of Gallstones: cholesterol (formation, composition, color, prevalence, location, risk factors)
|
formation = chol. overprod or failure to retain bile salts, composition = chol + mucoprotein (strengthen); color = yellow-green; prevalence = 80%; location = GB > ducts; risk = female, obese, pregnancy (progesterone), IV nutrition, dec. bile reuptake
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|
Types of Gallstones: black pigment (formation, composition, color, prevalence, location, risk factors)
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formation = anything that causes unconj. Bilirubin; composition = polymerized Ca2+ bilirubinate; color = black; prevalence = 10-20%; location = GB > ducts; risk factors = ineffective erythropoiesis, sickle cell (hemolysis), ileal disease, cirrhosis
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Types of Gallstones: cholesterol (formation, composition, color, prevalence, location, risk factors)
|
formation = bacterial infections of the bile duct; composition = Ca2+ bilirubinate; color = brown to orange; Location = ducts > GB; risk factors = BD dyskinesia, IgA deficiency, Asian populations
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Three basic components of bile
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cholesterol, lecithin, bile salts
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|
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1' vs 2' bile duct stones…which type of stone is 1'?
|
1' = formed due to biliary stasis or infection; soft, mud-like quality; usually brown pigment stones are 1'; 2' stones form in the GB and migrate elsewhere
|
|
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two kinds of patients in which the mere presence of gallstones merits GB removal
|
sickle cell patients (complications during urgent removal) and Native-Americans (cancer-risk)
|
|
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biliary pain
|
paroxysmal, 1-3 hours, steady pain RUQ, radiate R shoulder, nausea/vomiting, not an indication for GB removal unless its recurrent
|
|
|
acalculous cholecystitis
|
rare presentation of acute cholecystitis that is not caused by stone obstruction (seen in acutely ill patients)
|
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acute cholecystitis
|
either resolves w/ in 72 hours or goes on to necrosis; high recurrence rate; progression signs = temp. inc., peritonitis, persistent sx, WBC ele; GB removal is the proper tx
|
|
|
choledocholithiasis
|
stone in BD; 20% of patients w/ stones; jaundice; ALKphosph elevation seen; AST ele acutely
|
|
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jaundice
|
backpressure from duct obstruction causes conj. Bilirubin passage into blood; yellowing of skin appearance
|
|
|
ascending cholangitis
|
infection of biliary tree; seen w/ prolonged obstruction; Charcot's triad (RUQ pain, jaundice, fever) usually seen; NOT CAUSED BY TUMOR OBSTRUCTION; Tx = surgical decompression
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|
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papillary stenosis
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tight sphincter of Oddi w/ poor bile flow; caused by chronic passage of stones through ampulla; Sx = jaundice and LFT abnormalities; Tx w/ ERCP, sphincterotomy
|
|
|
choledochoduodenal fistula
|
stone impaction leads to erosion into duodenum; CT scan may show air/fluid levels in enlarged stomach (gastric outlet obstruction)
|
|
|
Gallstone ileus
|
one of two outcomes of fistula; stone travels through bowel and gets stuck @ ileocecal valve; Sx = small bowel obstruction (vomiting, abdominal distension, pain)
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|
|
Bouveret's syndrome
|
one of two outcomes of fistula; stone blocks gastric outflow; Sx = vomiting +/- bile regurgitation depending on obstruction location relative to ampulla
|
|
|
Acute (biliary) pancreatitis
|
stone obstruction causes pancreatitis (most common acute cause); obstruction is usually gone at time of presentation; no surgical tx needed UNLESS concurrent infection of biliary tree (cholangitis)
|
|
|
Mirizzi’s syndrome
|
stone in cystic duct / GB neck extrinsically compresses hepatic duct, leading to dilation and jaundice; Tx = GB removal w/ pre-op BD stenting
|
|
|
GB cancer risk increased in…(3)
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1. patients with symptomatic gall stones, 2. Calcified GB, 3. Native-American descent
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|
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Role of US in assessing gallstone complications
|
US great for detection of gallstones and detection of acute cholecystitis; can help confirm CBD stone obstruction if dilation is seen
|
|
|
HIDA scan
|
more sens/specific than US for GB obstruction; positive test means there will be delays in contrast filling the GB/duodenum; not accurate when jaundice is present
|
|
|
MRCP
|
MRI based; better than ERCP for visualizing biliary tree and GB; used after a negative US if obstruction is suspected, and used in pregnancy for safety reasons
|
|
|
EUS
|
endoscopic US: detect stones in CBD; used when all other tests are negative, but stones are still suspected
|
|
|
CT scans and gallstones
|
CT won't catch cholesterol stones; has the advantage of being able to detect stones in the intestine; not very useful at onset of episode (more useful 2-3 days into event)
|
|
|
modern use of ERCP (2)
|
1. remove stones just before/after GB removal, 2. poor surgical candidiates for GB removal + absence of cholecystitis
|
|
|
ERCP procedure
|
endoscopy, insert into ampulla, inject contrast up CBD/PD; visualization + ability to perform sphincterotomy and stone removal along with stenting
|
|
|
Percutaneous therapy
|
used to fragment/dissolve stones as well as drain infected bile; good for poor surgical candidates (this is interventional)
|
|
|
Dissolution therapy
|
reserved for non-surgical candidates; oral (URSA) or direct (MTBE) agents to dissolve stones; poor option overall due to risk of recurrence and potential complications
|
|
|
ESWL
|
shockwaves, bad idea unless there are huge stones that cannot be removed
|
|
|
Biliary disease involving cancer (generalities)
|
Either caused by direct obstruction or extrinsinc compression; stenting helps keep ducts patent; general sx are painless jaundice
|
|
|
(rare) tumor within bile ducts (intra/extra hepatic)
|
cholangiocarcinoma
|
|
|
Bismuth classification
|
categorization of cholangiocarcinoma by location and degree of involvment in biliary tree; location determines ability to resect tumor (if you can't resect, then give chemo/radiation)
|
|
|
Klatskin tumor
|
cholangiocarcinoma involving bifurication of hepatic duct (confluence of L/R hepatic ducts); cannot resect due to location
|
|
|
tx of ampullary cancer
|
ampullectomy if not invasive, whipple (remove pancreas/duodenum) procedure if invasive
|
|
|
PSC associations/risks (2)
|
70% PSC cases associated w/ IBS; greater chance (15%) of developing cholangiocarcinoma
|
|
|
PSC tx (3)
|
Ursodiol (stone dissolution), antibiotics (superimposed infections), ERCP stenting (jaundice) + sampling to rule out cancer, liver transplant
|
|
|
Diseases that present with contrast-filling like PSC cholangiogram (3)
|
1. AIDS cholangiopathy, 2. autoimmune pancreatitis, 3. paucity of intrahepatic ducts (hypoplasia, congential condition)
|
|
|
condition involving the immune system and IgG4 antibodies
|
autoimmune pancreatitis: recurrent episodes, looks like PSC on cholangiogram (strictures), responds to steroids in majority of cases (unlike PSC)
|
|
|
AIDs cholangipathy
|
infection 2' to immunosuppression; common agents = cryptosporidium parvum, CMV, microspra; Sx = RUQ pain, diarrhea (ONLY THING IN BILIARY LECTURE THAT PRESENTS WITH DIARRHEA), occurs late in the course of AIDS (CD4 counts < 100); doesn't respond to antimicrobial Tx; ERCP stenting is your best bet; if severe abdominal pain is seen, papillary stenosis indicated (get sphincterotomy)
|
|
|
Sphincter of Oddi dysf(x): commonly seen after _______; describe the three types of dysf(x)
|
commonly seen after GB removal; 1 = pain/dilation(12mm)/LFTs, 2 = pain + something else, 3 = just pain
|
|
|
#1 cause of fatal liver dz and transplant in children
|
extrahepatic atresia; also accounts for 30% of neonatal jaundice cases
|
|
|
Choledochal cysts
|
more common in Japan; dilation of ducts; different presentation in kid (dramatic) and adults (jaundice/pain); higher risk of colangiocarcinoma; Type 1 (extrahepatic fusiform) most common @ 50%, while Type 4 (mixed intra/extra hepatic) is 2nd most common @ 25%
|
|
|
triad of sx in choledochal cysts (only seen in 20% of patients)
|
abdominal pain/mass + jaundice
|
|
|
hypoplasia (paucity of intrahepatic ducts)
|
CMV or idiopathic; Alagille's syndrome ; cholangiogram looks like PSC;
|
|
|
Alagille's syndrome
|
associated with hypoplastic intrahepatic duct paucity; also have facial abnormalities, butterfly vertebra, and pulmonic stenosis
|
|
|
Cystic Fibrosis and biliary disease
|
thick secretions (meconium ileus and obstruction); pancreatic cysts; biliary cirrohsis
|
|
|
name diseases associated with the following procedures: pediatric liver transplant, biliary reconstruction, partial hepatectomy
|
transplant = biliary atresia; reconstruction = choledochal cyst resection; hepatectomy = cholangiocarcinoma of intrahepatic duct
|
|
|
three conditions in which stenotic papilla may be seen
|
AIDS cholangiopathy, ampullary cancer, sphincter of oddi dysfunction
|
|
|
increased risk of cholangiocarcinoma (2)
|
choledochol cysts, PSC
|
|
|
Absorptive and Secretive functions of the gall bladder
|
absorptive: concentrate bile by pulling out salt/water; secrete: protective mucus layer and H+ to increase Ca2+ solubility (prevent stones)
|
|
|
Types of Gallstones: cholesterol (formation, composition, color, prevalence, location, risk factors)
|
formation = chol. overprod or failure to retain bile salts, composition = chol + mucoprotein (strengthen); color = yellow-green; prevalence = 80%; location = GB > ducts; risk = female, obese, pregnancy (progesterone), IV nutrition, dec. bile reuptake
|
|
|
Types of Gallstones: black pigment (formation, composition, color, prevalence, location, risk factors)
|
formation = anything that causes unconj. Bilirubin; composition = polymerized Ca2+ bilirubinate; color = black; prevalence = 10-20%; location = GB > ducts; risk factors = ineffective erythropoiesis, sickle cell (hemolysis), ileal disease, cirrhosis
|
|
|
Types of Gallstones: cholesterol (formation, composition, color, prevalence, location, risk factors)
|
formation = bacterial infections of the bile duct; composition = Ca2+ bilirubinate; color = brown to orange; Location = ducts > GB; risk factors = BD dyskinesia, IgA deficiency, Asian populations
|
|
|
Three basic components of bile
|
cholesterol, lecithin, bile salts
|
|
|
1' vs 2' bile duct stones…which type of stone is 1'?
|
1' = formed due to biliary stasis or infection; soft, mud-like quality; usually brown pigment stones are 1'; 2' stones form in the GB and migrate elsewhere
|
|
|
two kinds of patients in which the mere presence of gallstones merits GB removal
|
sickle cell patients (complications during urgent removal) and Native-Americans (cancer-risk)
|
|
|
biliary pain
|
paroxysmal, 1-3 hours, steady pain RUQ, radiate R shoulder, nausea/vomiting, not an indication for GB removal unless its recurrent
|
|
|
acalculous cholecystitis
|
rare presentation of acute cholecystitis that is not caused by stone obstruction (seen in acutely ill patients)
|
|
|
acute cholecystitis
|
either resolves w/ in 72 hours or goes on to necrosis; high recurrence rate; progression signs = temp. inc., peritonitis, persistent sx, WBC ele; GB removal is the proper tx
|
|
|
choledocholithiasis
|
stone in BD; 20% of patients w/ stones; jaundice; ALKphosph elevation seen; AST ele acutely
|
|
|
jaundice
|
backpressure from duct obstruction causes conj. Bilirubin passage into blood; yellowing of skin appearance
|
|
|
ascending cholangitis
|
infection of biliary tree; seen w/ prolonged obstruction; Charcot's triad (RUQ pain, jaundice, fever) usually seen; NOT CAUSED BY TUMOR OBSTRUCTION; Tx = surgical decompression
|
|
|
papillary stenosis
|
tight sphincter of Oddi w/ poor bile flow; caused by chronic passage of stones through ampulla; Sx = jaundice and LFT abnormalities; Tx w/ ERCP, sphincterotomy
|
|
|
choledochoduodenal fistula
|
stone impaction leads to erosion into duodenum; CT scan may show air/fluid levels in enlarged stomach (gastric outlet obstruction)
|
|
|
Gallstone ileus
|
one of two outcomes of fistula; stone travels through bowel and gets stuck @ ileocecal valve; Sx = small bowel obstruction (vomiting, abdominal distension, pain)
|
|
|
Bouveret's syndrome
|
one of two outcomes of fistula; stone blocks gastric outflow; Sx = vomiting +/- bile regurgitation depending on obstruction location relative to ampulla
|
|
|
Acute (biliary) pancreatitis
|
stone obstruction causes pancreatitis (most common acute cause); obstruction is usually gone at time of presentation; no surgical tx needed UNLESS concurrent infection of biliary tree (cholangitis)
|
|
|
Mirizzi’s syndrome
|
stone in cystic duct / GB neck extrinsically compresses hepatic duct, leading to dilation and jaundice; Tx = GB removal w/ pre-op BD stenting
|
|
|
GB cancer risk increased in…(3)
|
1. patients with symptomatic gall stones, 2. Calcified GB, 3. Native-American descent
|
|
|
Role of US in assessing gallstone complications
|
US great for detection of gallstones and detection of acute cholecystitis; can help confirm CBD stone obstruction if dilation is seen
|
|
|
HIDA scan
|
more sens/specific than US for GB obstruction; positive test means there will be delays in contrast filling the GB/duodenum; not accurate when jaundice is present
|
|
|
MRCP
|
MRI based; better than ERCP for visualizing biliary tree and GB; used after a negative US if obstruction is suspected, and used in pregnancy for safety reasons
|
|
|
EUS
|
endoscopic US: detect stones in CBD; used when all other tests are negative, but stones are still suspected
|
|
|
CT scans and gallstones
|
CT won't catch cholesterol stones; has the advantage of being able to detect stones in the intestine; not very useful at onset of episode (more useful 2-3 days into event)
|
|
|
modern use of ERCP (2)
|
1. remove stones just before/after GB removal, 2. poor surgical candidiates for GB removal + absence of cholecystitis
|
|
|
ERCP procedure
|
endoscopy, insert into ampulla, inject contrast up CBD/PD; visualization + ability to perform sphincterotomy and stone removal along with stenting
|
|
|
Percutaneous therapy
|
used to fragment/dissolve stones as well as drain infected bile; good for poor surgical candidates (this is interventional)
|
|
|
Dissolution therapy
|
reserved for non-surgical candidates; oral (URSA) or direct (MTBE) agents to dissolve stones; poor option overall due to risk of recurrence and potential complications
|
|
|
ESWL
|
shockwaves, bad idea unless there are huge stones that cannot be removed
|
|
|
Biliary disease involving cancer (generalities)
|
Either caused by direct obstruction or extrinsinc compression; stenting helps keep ducts patent; general sx are painless jaundice
|
|
|
(rare) tumor within bile ducts (intra/extra hepatic)
|
cholangiocarcinoma
|
|
|
Bismuth classification
|
categorization of cholangiocarcinoma by location and degree of involvment in biliary tree; location determines ability to resect tumor (if you can't resect, then give chemo/radiation)
|
|
|
Klatskin tumor
|
cholangiocarcinoma involving bifurication of hepatic duct (confluence of L/R hepatic ducts); cannot resect due to location
|
|
|
tx of ampullary cancer
|
ampullectomy if not invasive, whipple (remove pancreas/duodenum) procedure if invasive
|
|
|
tortuous dilated biliary tree +/- stenosis (dominant strictures) is seen in…
|
Primary sclerosing cholangitis
|
|
|
PSC associations/risks (2)
|
70% PSC cases associated w/ IBS; greater chance (15%) of developing cholangiocarcinoma
|
|
|
PSC tx (3)
|
Ursodiol (stone dissolution), antibiotics (superimposed infections), ERCP stenting (jaundice) + sampling to rule out cancer, liver transplant
|
|
|
Diseases that present with contrast-filling like PSC cholangiogram (3)
|
1. AIDS cholangiopathy, 2. autoimmune pancreatitis, 3. paucity of intrahepatic ducts (hypoplasia, congential condition)
|
|
|
condition involving the immune system and IgG4 antibodies
|
autoimmune pancreatitis: recurrent episodes, looks like PSC on cholangiogram (strictures), responds to steroids in majority of cases (unlike PSC)
|
|
|
AIDs cholangipathy
|
infection 2' to immunosuppression; common agents = cryptosporidium parvum, CMV, microspra; Sx = RUQ pain, diarrhea (ONLY THING IN BILIARY LECTURE THAT PRESENTS WITH DIARRHEA), occurs late in the course of AIDS (CD4 counts < 100); doesn't respond to antimicrobial Tx; ERCP stenting is your best bet; if severe abdominal pain is seen, papillary stenosis indicated (get sphincterotomy)
|
|
|
Sphincter of Oddi dysf(x): commonly seen after _______; describe the three types of dysf(x)
|
commonly seen after GB removal; 1 = pain/dilation(12mm)/LFTs, 2 = pain + something else, 3 = just pain
|
|
|
#1 cause of fatal liver dz and transplant in children
|
extrahepatic atresia; also accounts for 30% of neonatal jaundice cases
|
|
|
Choledochal cysts
|
more common in Japan; dilation of ducts; different presentation in kid (dramatic) and adults (jaundice/pain); higher risk of colangiocarcinoma; Type 1 (extrahepatic fusiform) most common @ 50%, while Type 4 (mixed intra/extra hepatic) is 2nd most common @ 25%
|
|
|
triad of sx in choledochal cysts (only seen in 20% of patients)
|
abdominal pain/mass + jaundice
|
|
|
hypoplasia (paucity of intrahepatic ducts)
|
CMV or idiopathic; Alagille's syndrome ; cholangiogram looks like PSC;
|
|
|
Alagille's syndrome
|
associated with hypoplastic intrahepatic duct paucity; also have facial abnormalities, butterfly vertebra, and pulmonic stenosis
|
|
|
Cystic Fibrosis and biliary disease
|
thick secretions (meconium ileus and obstruction); pancreatic cysts; biliary cirrohsis
|
|
|
name diseases associated with the following procedures: pediatric liver transplant, biliary reconstruction, partial hepatectomy
|
transplant = biliary atresia; reconstruction = choledochal cyst resection; hepatectomy = cholangiocarcinoma of intrahepatic duct
|
|
|
three conditions in which stenotic papilla may be seen
|
AIDS cholangiopathy, ampullary cancer, sphincter of oddi dysfunction
|
|
|
increased risk of cholangiocarcinoma (2)
|
choledochol cysts, PSC
|
|
|
three conditions in which stenotic papilla may be seen
|
AIDS cholangiopathy, ampullary cancer, sphincter of oddi dysfunction
|
|
|
increased risk of cholangiocarcinoma (2)
|
choledochol cysts, PSC
|
|
|
tortuous dilated biliary tree +/- stenosis (dominant strictures) is seen in…
|
Primary sclerosing cholangitis
|
|
|
tortuous
|
dilated
|
