Biliary Conditions

Question 1

what are the risk factors for developing gallstones?

Answer 1

• female
• pregnancy
• obesity
• age >40
  family history
• diabetes
• Crohn’s disease

Question 2

what are the symptoms of gallstones, when they are symptomatic?

Answer 2

• RUQ pain -> biliary colic that radiates to back

- jaundice (+/-)

Question 3

what makes gallstones symptomatic?

Answer 3

if they migrate to the cystic duct or common bile duct and beyond

Question 4

describe biliary colic

Answer 4

pain in the RUQ that tends to increase in intensity and lasts several hours before resolving

Question 5

what is the management of symptomatic gallstones?

Answer 5

• Analgesia (morphine)
• fluid rehydration
• nil baby mouth
• elective laparoscopic cholecystectomy

Question 6

what is acute cholecystitis?

Answer 6

• inflammation of the gallbladder

Question 7

what is the most common cause of acute cholecystitis?

Answer 7

impaction in the neck of the gallbladder by sludge or a gallstone

Question 8

what are the symptoms of acute cholecystitis?

Answer 8

• Constant epigastric or RUQ pain, referred to the shoulder tip
• vomiting
• fever
• rigors
• jaundice
• pale stools

Question 9

what are the signs of acute cholecystitis?

Answer 9

• local peritoneum
• gallbladder mass
• Murphy’s sign +

Question 10

how would you elicit Murphy’s sign?

Answer 10

lay 2 fingers on patient’s RUQ
ask patient to breathe in
causes pain and arrest of inspiration if positive - cholecystitis
Repeat in LUQ - Murphy’s sign only positive if negative in LUQ

Question 11

how would you investigate acute cholecystitis?

Answer 11

• FBC (raised WCC)
• CRP (Raised)
• Serum amylase (slightly raised - very high suggests pancreatitis)
• Ultrasound (thick walled, shrunken gallbladder, may see gallstones)

Question 12

how would you manage acute cholecystitis?

Answer 12

• Nil by mouth
• Pain relief (morphine)
• IV antibiotics (co-amoxiclav)
• laparoscopic cholecystectomy if no perforation
• laparaotomy if there is perforation of GB

Question 13

what is chronic cholecystitis?

Answer 13

chronic inflammation of the gallbladder +/- biliary colic

Question 14

what are the symptoms of chronic cholecystitis ?

Answer 14

vague abdominal discomfort 
distension 
nausea
flatulence 
fat intolerance 
chronic diarrhoea

Question 15

what are the investigations for chronic cholecystitis?

Answer 15

ultrasound - to look for gallstones

Question 16

what is the management for chronic cholecystitis?

Answer 16

cholecystectomy

Question 17

what is acute cholangitis?

Answer 17

infection in the bile duct

Question 18

what is acute cholangitis usually caused by?

Answer 18

bacteria ascending from the junction between bile duct and the duodenum
it tends to occur if the bile duct is already partially obstructed by a gallstone

Question 19

what are the symptoms of acute cholangitis?

Answer 19

Charcot's triad:
- RUQ pain 
- Fever +/- rigors 
- jaundice 
Reynold's pentad:
- above +
- mental state changes
- low blood pressure

Question 20

where can the infection in acute cholangitis ascend and what does this cause?

Answer 20

infection can ascend to the liver, causing liver abscess and cirrhosis

Question 21

what are the investigations carried out when suspecting acute cholangitis?

Answer 21

• FBC (increased WCC)
• Inflammatory markers (raised ESR and CRP)
• U&Es
• LFTs (raised ALP, gamma GT, AST and ALT)
• ABG (sepsis)
• Blood cultures
• Imaging - ultrasound, CT (biliary dilatation, stones, strictures)

Question 22

what is the management for acute cholangitis?

Answer 22

• fluid resuscitation (if patient is septic)
• monitor fluid and electrolyte balance
• IV antibiotics (piperacillin with tazobactam)
• Endoscopic retrograde cholangiopancreatography (clears bile ducts)

Question 23

what is primary biliary cholangitis?

Answer 23

chronic autoimmune granulomatous inflammation of the small interlobular bile ducts (part of portal triad) in the liver

Question 24

what is the pathophysiology of primary biliary cholangitis?

Answer 24

autoimmune granulomatous inflammation of interlobular bile ducts causes cholestasis which damages bile duct cells and hepatocytes and leads to fibrosis, cirrhosis and portal hypertension

Question 25

what are the symptoms of primary biliary cholangitis?

Answer 25

- asymptomatic in early disease - lethargy -> most common - pruritus (cholestasis)

Question 26

what are the signs of primary biliary cholangitis?

Answer 26

- hepatomegaly - hyperpigmentation (increased amounts of melanin) - splenomegaly - jaundice - cirrhosis (ascites, spider naevi)

Question 27

what are the investigations for primary biliary cholangitis?

Answer 27

- FBC (often normal) - ESR (elevated) - LFTs (alkaline phosphatase and gamma GT elevated, AST and ALT can sometimes be mildly elevated) - bilirubin rises as disease progresses - prothrombin time (increased) - albumin (decreased- impaired liver function) - abdominal US (to exclude obstructive lesion within bile ducts) - serum immunoglobulin - IgM is raised - antimitochondrial antibodies present

Question 28

what are the risk factors for primary biliary cholangitis?

Answer 28

- female gender - positive family history - age between 45-60

Question 29

describe the management for primary biliary cholangitis

Answer 29

- ursodexycholic acid - prednisolone (immunomodulatory) - colestyramine (sequesters bile acids in the intestine, preventing their absorption) - liver transplantation is the only cure but disease can recur in transplanted liver

Question 30

what is primary sclerosis cholangitis?

Answer 30

progressive cholestasis with bile duct inflammation and strictures - both intrahepatic and extrahepatic bile ducts can be affected

Question 31

what is the difference between primary biliary cholangitis and primary sclerosis cholangitis?

Answer 31

primary biliary - inflammation of interlobular bile ducts (more common in women) primary sclerosing cholangitis - inflammation of both intrahepatic and extra hepatic bile ducts and stricture formation (more common in men)

Question 32

what are the symptoms of primary sclerosing cholangitis?

Answer 32

- may be asymptomatic - jaundice nd pruritos - RUQ pain - Fatigue - Weight loss - Fever - Sweats

Question 33

what are the signs of primary sclerosis cholangitis?

Answer 33

- hepatomegaly - jaundice - signs of cirrhosis and portal hypertension (caput medusa, oesophageal varices, ascites)

Question 34

what are the investigations for primary sclerosing cholangitis?

Answer 34

- LFTs (ALP, Gamma GT usually raised, AST slightly raised, bilirubin raised, albumin decreased and PT time increased) - FBC (normal or shows liver dysfunction such as thrombocytopenia) - antimitochondrial antibody (negative in sclerosis, positive in biliary) - Ultrasound (abnormal bile ducts, liver cirrhosis) - MRCP (strictures and dilatations)

Question 35

what is the management of primary sclerosis cholangitis?

Answer 35

- observation and lifestyle changes for asymptomatic patients - bone mineral density scan at diagnosis and at 2-3 year intervals - colestyramine for pruritus - ergocalciferol and calcium carbonate (vitamin D and calcium supplements) if hepatic osteopenia - ERCP with balloon +/- stent to treat strictures - liver transplantation

Question 36

what is cholangiocarcinoma?

Answer 36

cancers arising from bile duct epithelium | can bee intrahepatic or extrahepatic

Question 37

what is the presentation of cholangiocarcinomas?

Answer 37

- painless jaundice - most common | - weight loss and abdominal pain are fairly uncommon

Question 38

what are the risk factors for chlonagiocarcinoma?

Answer 38

- age>50 - cholangitis - gallstones - ulcerative colitis - primary sclerosing cholangitis - liver cirrhosis - alcoholic liver disease - HIV - Hepatitis B and C

Question 39

what investigations are done when suspecting cholangiocarcinoma?

Answer 39

- LFTs (serum bilirubin raised, alk phos raised, gamma GT raised, AST slightly raised, PT time increased) - Cancer markers (CA-19-9 and CEA elevated) - abdominal ultrasound (shows mass and dilated ducts) - abdominal CT or MRI

Question 40

what is the management for cholangiocarcinoma?

Answer 40

``` Resectable tumours: • Intrahepatic tumour: ◦ Partial liver resection ◦ Chemotherapy / radiotherapy • Extrahepatic tumour: ◦ Surgical excision ◦ Chemotherapy / radiotherapy ``` Unresectable tumours: • Liver transplant if they are a candidate • Chemotherapy / radiotherapy

Question 41

what problems does liver failure lead to?

Answer 41

- increased susceptibility to infections - increased susceptibility to toxins and drugs - increased blood ammonia -> hepatic encephalopathy

Question 42

what is acute liver failure?

Answer 42

rapid failure of the liver's synthetic and metabolic function in the absence of a known pre-existing liver disease

Question 43

how is acute liver failure classified?

Answer 43

based on the time interval between the initial onset of jaundice and the development of encephalopathy: - hyper acute (0-7 days) - acute (8-28 days) - subacute (29 days - 12 weeks)

Question 44

what is the most common cause for acute liver failure?

Answer 44

- paracetamol overdose (UK) | - acute viral hepatitis (worldwide)

Question 45

what is the presentation of acute liver failure?

Answer 45

- jaundice - evidence of risk factors such as overdose, hepatitis and hepatotoxic drugs - signs of hepatic encephalopathy (lethargy, confusion, asterixis) - abdominal pain - nausea and vomiting - hepatomegaly

Question 46

how would you investigate acute liver failure?

Answer 46

- LFTs (high bilirubin, very high AST and ALT in paracetamol overdose) - prothrombin time increased - U&Es (metabolic derangements and elevated urea) - FBC (leukocytosis, anaemia, thrombocytopenia) - blood type and screen (in case transfusion needed) - ABG (acidosis and raised lactate are prognostic factors) - paracetamol level - viral hepatitis serology - autoimmune hepatitis markers (autoantibodies) to help diagnosis - pregnancy test (can have liver disorders in pregnancy) - abdominal ultrasound with doppler (for hepatic vessel thrombosis and hepatomegaly)

Question 47

what is the management for acute liver failure?

Answer 47

- intensive care - liver transplantation assessment + contact transplant centre - neurological status monitoring for advanced encephalopathy - monitor blood glucose, electrolytes and blood cultures - acetylcysteine for paracetamol overdose - acyclovir for herpes simplex virus - methylprednisolone for autoimmune hepatitis - fluid resuscitation