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26 Cards in this Set

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Functions of bile.
Lipid digestion

Disposal of hphobic materials

Aids in absorption of fat soluble vits
Synthesis of bile acid. Begin with cholesterol, end with a bile salt.
Cholesterol-->CholylCoA-->Cholic Acid/Chenodeoxycholic acid (primary bile acids)


Cholic acid-->deoxycholic acid (secondary bile acid; via bacteria)

Chenodeoxycholic acid-->lithocholic acid (secondary bile acid; via bacteria)

-->within liver, conjugated to glycine or taurine before being re-secreted (in gut, glycine/taurine removed)-->glychocholic/taurocholic acid
Why must bile acids be conjugated before their secretion?
Conjugation to glycine/taurine improves hydrophilicity (lose less bile acid this way)
Describe location of bile during:
Fasting state
Beginning of meal
After a meal
Fasting: bile acid moves down biliary tract and concentrated in gallbladder (low levels of bile acids in small intestine, portal vein, liver)

Meal-->CCK released from intestinal mucosa-->relax sphincter of Oddi, stimulates gallbladder. Bile acids flow into intestines.

GB remains contracted, bile acids secreted by liver bypass gallbladder and go directly to duodenum.

After meal: SOD contracts, gallbladder relaxes and begins to fill.
Gall stones are highly prevalent in this population.
Pima Indians
How are stones formed?
Motility: gall bladder not contracting well-->gall bladder stasis-->stone formation

Nucleation Factors(...)

Supersaturation of Bile w/cholesterol: supersaturation of cholesterol-->more potential for crystal formation
Risk factors for gallstones.
Sex (women!)
Race, weight, age
PREGNANCY
OCPs (estrogen!)
Rapid weight loss (gastric bypass)
Cirrhosis
TPN (gallbladder stasis)
Why is pregnancy a risk for gallstones?
Supersaturation due to E2-induced increase in cholesterol secretion and Progest-induced reduction in BA secretion

Overproduction of hphobic bile acids-->reduced ability to solubilize cholesterol

Progesterone-induced slowing of gall bladder emptying.
Cholesterol gallstones:
Composition
Color
Location
50-100% cholesterol
Yellow-brown
Location: gallbladder +/- common duct
Cholodocolithiasis:
What is it?
Gall stone stuck in common bile duct
Black Pigment Stones:
Composition
Color
Location
Calcium bilirubinate polymer
Black
Gallbladder +/- common duct
Seen with anyone who has RBC destruction
Brown Pigment Stones:
Composition
Color
Location
Unconj'd bilirubin, calcium soaps
Brown
Bile ducts
Seen in pts with infection/inflammn
This stone is seen in patients with increased RBC destruction.
Black pigment
This stone is seen in patients with metabolic derangement.
Cholesterol gallstone

Metabolic derangement = obestiy, +famhx, aging (excessive chol secretion), women
This stone is seen in patients with infections.
Brown pigment
Biliary colic:
Presentation
Cause
Labs
Dx
Tx
Severe, localized RUQ pain
Due to intermittent obstruction of cystic duct

Note: 30% asyx
Labs: nl

Dx:
Ultrasound along w/clinical hx

Tx:
Cholecystectomy
Ursodeoxycholic acid:
Effects
Indication
Mech unknown but:
-inhibits biliary secretion of cholesterol
-increases hepatic bile secreiton
-inhibits deposition of cholesterol into stones
-improves gallbladder emptying
-improves gallbladder muscle contractility
-reduces gallbladder inflammn

Indication: Pts w/small gallstones sans calcification
Acute Cholecystitis:
Presentation
Cause
Labs
Dx
Tx
Severe, localized pain in RUQ with n/v/f

Causes: impacted stone in cystic duct, acute inflammn of gallbladder mucosa, secondary bacterial infection

Labs:
Elevated WBCs, bilirubin, ALT/AST

Dx: U/S, hepatobiliary scintigraphy (HIDA)--gallbladder doesn't light up!

Tx: Abx, sx
Murphy's Sign:
What is it?
Indicative of?
Upon palpation, right subcostal tenderness and inspiratory arrest (can't inspire when palpate!)

Indicates acute cholecystitis
Choledocholithiasis:
Presentation
Cause
Labs
Dx
Tx
Often asyx, but can present ~biliary colic; can see painless jaundice or RUQ tenderness

Due to obstruction of common bile duct

Labs: elevated bilirubin, ALP

Dx: U/S, MRCP (specialized MRI)

Tx: ERCP (snip common bile duct and remove stones)
Cholangitis:
Presentation
Cause
Tx
Pain, jaundice, fever;
mental confusion, lethargy, delirium

Cause: impacted stone in common bile duct-->bile stasis-->bacterial superinfection of stagnant bile

Tx: Bile duct decompression (ERCP)
Risk factors for developing gallbladder cancer.
Porcelain gallbladder (intramural calcification of gallbladder wall)
Gallbladder polyps
Salmonella infection
Biliary cysts
Medical term for gallstone.
Cholelithiasis
Cholangiocarcinoma:
What is it?
Risks of developing it
Cancer of bile ducts

Risks:
Primary sclerosing cholangitis
Parasitic infection
Primary Sclerosing Cholangitis:
What is it?
Associated with?
Progressive inflammation, stricturing, and fibrosis of bile ducts.

Associated with IBD, esp UC.

Appears as beading.