1
Q
What is the pathway of bile (Biliary Tract)?
A
- Bile Canaliculi
- Bile Ductules (in portal tracts)
- Intrahepatic Bile Ducts
- L and R Hepatic Ducts
- Merge to form the Common Hepatic Duct
- Exits liver and joins cystic duct to form the Common Bile Duct
- Joins with the Pancreatic duct to form the Ampulla of Vater
- Enters the Duodenum through the Sphincter of Oddi
2
Q
This condition occurs in 7-15% of adults in the US and is typically asymptomatic in most patients, though they are susceptible to pain due to the occlusion of the cystic duct, passage into the common bile duct and/or erosion into the gall bladder wall that this condition can cause.
A
Cholelithiasis
3
Q
Where are primary bile acids synthesized? Examples of primary bile acids?
A
Liver; cholic acid, chenodeoxycholic
4
Q
Where are secondary bile acids created? Examples?
A
Gut bacteria; deoxycholic, lithocholic
5
Q
If a patient is fasting, will the concentration of bile increase or decrease?
A
Gall Bladder will increase concentration about 10 fold when fasting.
6
Q
When there is fat and protein in the duodenum, this will cause the release of _________ which will cause the Gall Bladder to _________.
A
CCK; contract (therefore releasing bile)
7
Q
Where is the majority of bile acids absorbed?
A
Terminal Ileum
8
Q
What are the three main causes of cholelithiasis?
A
- Hepatic secretion of bile supersaturated with cholesterol (lithogenic bile)
- Nucleation of cholesterol molecules (mucin, alpha-1 acid glycoproteins, IgG/IgM)
- Stasis of bile within the Gall Bladder
9
Q
What are the primary risk factors for cholesterol stones?
A
- 40+ years old
- Females»_space; Men (2:1)
- Genetic predisposition
- Obesity
- Rapid Weight Loss/Bariatric Sx
- Those Native Americans…you know how they love cholesterol.
10
Q
What are the secondary risk factors for cholesterol stones?
A
- TPN
- High estrogen levels (i.e. preggo, parity)
- Ileal Dz
- Ceftriaxone
- Parasites like Clonorchis sinesis
- DM
11
Q
Circulation of the bile per day?
A
4-12 cycles
12
Q
What are the three types of Stones? Technically 2 but one has 2 subcategories.
A
- Cholesterol — 75%
2. Pigmented Stones (Black or Brown) — 25%
13
Q
When do we see black stones (aka bilirubinate)?
A
- Chronic Hemolysis
- Cirrhosis
14
Q
When do we see brown stones (aka cholesterol)?
A
- Biliary Infection
- Stricture
- Post-spincterotomy
15
Q
In patients with cholelithiasis (gallstones), how many are asymptomatic? And which risk factors/co-morbidities would we be looking for asymptomatic stones?
A
- DM pts
- Porcelain GB
- Sickle Cell Pts
- Native American Children
16
Q
What percent of people with stones will develop chronic cholecystitis?
A
33%
17
Q
What percent of people with stones will develop acute cholecystitis?
A
7-17%
18
Q
WTH is a Porcelain Gall Bladder?
A
A condition where calcification may be caused by excess gall stones. It occurs predominantly in overweight female patients of middle age. It can be a variant of chronic cholecystitis.
Essentially, the inflammatory scarring of the wall and calcification can cause it to look porcelain.
Can be assc with GB cancer.
19
Q
This type of pain is most common in patients with Chronic Cholecystitis.
A
Biliary or Colic Pain
20
Q
What causes Biliary/Colic pain?
A
Neurohumerol input causes GB contraction which leads to the stone transiently occluding the opening of the cystic duct. Womp womp womp.
21
Q
How does biliary/colic pain typically present?
A
Episodic pain!
Steady ache in the RUQ/epigastric pain that can radiates to the R scapula/shoulder
Begins abruptly and resolves slowly (30 min - 3 hr)
May be precipitated by large meals
Assc. symptoms? NV Bloating
PE: afebrile with or without
22
Q
This condition refers to distention, edema, ischemia, inflammation and potential secondary infection that could most likely be caused by a stone or sludge obstructing the cystic duct.
A
Acute Cholecystitis
23
Q
How would you diagnose cholelithiasis?
A
RUQ Ultrasound (95% sensitive and specific)
Exception: Common Bile Duct
24
Q
How would you diagnose cholelithiasis if it is in the Common Bile Duct?
A
EUS and MRCP – 90-95% sensitivity and specificity
25
How do you manage cholelithiasis?
1. Cholecystectomy (usually laparoscopic)
| 2. Oral Dissolution Therapy (Only 20-30% of stones are dissolved)
26
When would you want to completed a cholecystectomy?
Symptomatic, risk of a calcified or porcelain gallbladder, or potential malignancy
27
What is a common Oral Dissolution Therapy? And what does it do?
```
Ursodeocycholic Acid (Ursodiol)
- Decreases intestinal absorption and increased nucleation time
```
28
What are some complications of cholelithiasis?
1. Cholecystitis (develops in 30% of symptomatic biliary colic within 2 years)
2. Cholangitis
3. Pancreatitis (#1 cause of acute pancreatitis)
4. Gallbladder carcinoma (~1%)
5. Gallstone ileus
29
This is the condition defined by the inflammation of the gall bladder. It is commonly caused by cystic duct occlusion by a gall stone (95%) or rarely, acalculous (5%)
Cholecystitis
30
What will we see happen if there is a cystic duct occlusion by a gall stone in Cholecystitis?
Bile Stasis
Gall bladder wall edema
Gall bladder distention
31
What will we see happen if there is an acalculous cause of Cholecystitis?
Bile Stasis
| Lithogenicity of Bile with or without Gall Bladder Wall Ischemia
32
What are some of the clinical manifestations of cholecystitis?
Steady RUQ or epigastric pain lasting 4+ hours
Nausea, Vomiting, Fever
PE: RUQ tenderness, Positive Murphy's Sign
Labs: Increased WBC with or without increased bilirubin
33
What are some of the complications of Cholecystitis?
Perforation 2%
Gangrenous cholecystitis (~15%)
Emphysematous Gallbladder
Cholecystenteric Fistula
34
How do you diagnose Cholecystitis?
1. RUQ Ultrasound (can see pericholecystic fluid, GB wall thinkening of 3+ mm or edema, and a sonographic Murphy's sign)
2. HIDA Scan (most sensitive test, non-visualization of GB)
35
How do you treat cholecystitis?
- NPO, IV fluids, Antibiotics
- Semi-urgent cholecystectomy within 72 hours (controversial)
- Consider cholecystostomy with percutaneous drainage for poor surgical candidates
- Intra-operative cholangiogram and bile duct exploration vs. ERCP for retained common duct stones
36
This condition is defined as an acute infection of the gall bladder wall caused by gas-forming organisms. It is generally considered a surgical emergency. Characterized by early gangrene, perforation of the gall bladder and high mortality.
Emphysematous Cholecystitis
37
If a patient is diagnosed with Emphysematous Cholecystitis, what are they more likely to get?
- Gangrene
- GB perforation
- Increased rate of mortality (15-25%)
38
This condition is characterized with people who are elderly, critically ill, long term TPN, fevers may be the only a clinical sign.
Acalculous Cholecystitis
39
How do you diagnose Acalculous Cholecystitis?
RUQ Ultrasound
40
How do you treat Acalculous Cholecystitis?
- IV abx
| - Percutaneous cholecystostomy for GB decompression
41
This condition can arise from a gall bladder perforation and decompression into a viscus. Most
Cholecystenteric Fistula
42
How would you know if a cholecystenteric fistula involves the colon?
Waterly, bilous diarrhea or cholangitis
43
How would you know if a cholecystenteric fistula involves the small bowel?
Gall stone ileus if there is cholelithiasis involved
44
This condition is the erosion of gallstone through the gall bladder wall into the small bowel. It most commonly obstructs at the terminal ileum.
Gallstone ileus
45
What would a gallstone ileus look like on a KUB?
Pneumobilia
| Dilated Loops of Bowel with air-fluid levels
46
What is the treatment for a gallstone ileus?
Surgical closure of cholecystenteric fistula and enterotomy with remove of stones.
47
The presence of at least one gallstone in the common bile duct
Choledocholithiasis
48
How does choledocholithiasis come to be?
Originates in the gall bladder
Forms de novo
Retained stone after cholecystectomy.
49
True/False: 75% of patients with choledocholithiasis are asymptomatic.
50%
50
What are some symptoms of choledocholithiasis?
Biliary pain
| Jaundice
51
Typical labs of a patient with choledocholithiasis would show?
Transaminases 500+
| Bilirubin 4+
52
How do you diagnose choledocoholithiasis?
1. Right Upper Quadrant Ultrasound.
Highly sensitive for dilated ducts
33% sensitivity for stones in CBD
2. MRCP
3. EUS
4. ERCP
53
How do you treat choledocholithiasis?
ERCP with spincterotomy and stone extraction.
54
This procedure is when a dye is injected through a catheter into the pancreatic or bile ducts and allows for visualization.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
55
This condition is defined by an infection proximal to the common bile duct obstruction (CBD stone, stricture, Neoplasm) that can cause mortality in 5-10%.
Ascending Cholangitis
56
Where do these infections for cholangitis come from?
```
Biliary Tract Manipulation
Intrabiliary Pressure (migration from portal system)
```
57
How would cholangitis present?
1. Charcot's Triad (~70%) - RUQ pain, Jaundice, Fever
2. Reynauld's Pentad - RUQ pain, Jaundice, Fever, Shock, and AMS
3. High index of suspicion in elderly -CBD may be very dilated, not fully obstructed.
58
How do you diagnose cholangitis?
1. U/S to assess for stones, dilated ducts
2. ERCP is gold standard
3. Percutaneous transhepatic cholangiogram (PTC)
4. Stat blood cultures (Klebsiella, E. coli, Enterococcus, and anaerobes common)
59
How do you treat cholangitis?
1. Broad Spectrum Antibiotics (Amp/Gent, extended spectrum, 3rd gen. cephalosporin)
2. Mandatory Biliary Drainage - emergent if fevers 40+ degrees Celsius, Peritoneal Signs, Septic Shock or Bilirubin 10+
60
This condition is idiopathic, nonmalignant, non-pathogenic, chronic inflammatory state. It normally manifests as a fibrosis and obliteration of the intra- and extra-hepatic bile ducts. It commonly occurs in men younger than 45.
Primary Scelorsing Cholangitis
61
True/False: 70% of patients with Primary Sclerosing Cholangitis have Ulcerative Colitis.
True
62
How do you diagnose Primary Scelorsing Cholangitis?
ERCP or MRCP based on elevated LFTs with or without recurring episodes of fever, abdominal pain and jaundice
63
How do you treat Primary Sclerosing Cholagitis?
Dilation of Ducts by ERCP
MTX/Ursodeoxycholic acid
Antibiotics
64
This is a fibromuscular sheath encircling the terminal portion of the CBD, PD, and common channel as they transverse the duodenal wall
Sphincter of Oddi
65
This condition features post-cholecystectomy abdominal pain, recurrent pancreatitis in up to 50% of patients, and episodic biliary colic and negative diagnostic studies. Most commonly occurs in females 40-50
Sphincter of Oddi Dysfunction
66
What are three types of biliary tract neoplasms?
1. Gallbladder carcinoma
2. Cholangiocarcinoma
3. Adenocarcinoma of the Ampulla of Vater
67
This is the fifth most common GI cancer that is typically an adenocarcinoma. It is most commonly in the elderly, females > males (3:1), and 80-90% of people with gallstones.
Gallbladder carcinoma
68
If gall bladder cancer is aggressive, what is the 5-year survival rate?
5-10% because it spreads early.
69
In older patients with GB polyps 10+ mm, what is recommended for them?
Cholecystectomy
70
What are the risk factors for cholangiocarcinoma?
1. Primary Sclerosing Cholangitis
2. Ulcerative Colitis
3. Choledochal Cyst
4. Chronic Liver Fluke Infiltration
71
This type of cancer commonly presents with jaundice, weight loss, and pruritis. Sometimes has pain. It is usually locally invasive.
Cholangiocarcinoma
72
This law states: in the presence of a palpable gall bladder, painless jaundice is unlikely to be caused by gallstones.
Courvoisier's Law
73
These types of tumors in the class of cholangiocarcinoma are usually near the porta hepatis
Klatskin tumors
74
Cholangiocarcinoma is bad because...
1. Median Survival for the perihilar tumorsis 12-24 months
2. Radiation offers some benefit and can prolong survival.
3. Chemotherapy is not beneficial
75
This type of cancer is very rare. It is increased risked with patients with a family history of familial adenomatous polyposis (FAP), Peutz-Jegher's Syndrome)
Adenocarcinoma of the Ampulla of Vater
76
What is the best treatment for an adenocarcinoma of the Ampulla of Vater?
Resection is feasible in 85+% with a 5 year survival of about 50%
77
What are the complications of the Cholecystectomy?
1. Bile leak at site of cystic duct clip
2. Injury to an anomalous duct
3. Transection of the bile duct
4. Using the laparoscopic technique, you are 2.5x likely to get a bile duct injury...although it is still only 0.4-0.6%
78
A 60 y/o female with hematuria and flank pain undergoes a non-contrast CT scan to evaluate for a renal stone. Her GB reveals intramural calcification of the GB wall, but no other abnormal findings seen. Her CBC and LFTs are normal. What is the most appropriate next step in management?
a) Cholecystectomy
b) ERCP to evaluate biliary tree
c) Ursodiol
d) EUS
e) Reassurance with patient education
a. Cholecystectomy
This patient is developing a “porcelain” GB suggestive of ischemic changes and damage to this organ which ‘sets the stage’ for cancer or infection.
79
A 65 y/o male veteran undergoes chest CT to surveil a pulmonary nodule. The nodule is unchanged in size, but four small stones are present in the gallbladder. Pt is asymptomatic and LFTs are normal. What is the most appropriate next step in management?
a) Cholecystectomy
b) ERCP
c) Ursodiol
d) EUS
e) Reassurance with patient education
E. Reassurance with patient Education.
- The consensus, except as indicated as identified below, is that asymptomatic gallstones should be left alone and the patient reassured that they will probably not develop symptoms.
- However, once gallstones become symptomatic (causing biliary colic, acute pancreatitis, acute cholangitis, jaundice, and other symptoms), the gallbladder should be removed because the symptoms tend to recur and the associated clinical syndromes have the potential to be severe.
- Patients with diabetes mellitus are advised to have a cholecystectomy for asymptomatic stones because these patients tend to have more complications related to acute surgery than patients without diabetes.
- Patients who are found to have a solitary large gallstone occupying the entire lumen of the gallbladder are at an increased risk for gallbladder cancer; therefore, they are advised to have prophylactic cholecystectomy.
- Patients with no other risk factors, but who are going to be living or traveling for a long period of time in a location that is far from basic medical care, are advised to have a prophylactic cholecystectomy because they may not have ready access to a surgeon or therapeutic endoscopist when their gallstones begin to "act up."
80
A 45 y/o male businessman presents with epigastric pain, jaundice and intermittent low grade fevers. He recently returned from China, where he dined on freshwater fish. His labs: AST 435, ALT 464, and TB 4. Viral hepatitis serologies are negative. Which of the following is the most likely causative organism?
a) Enterobius vermicularis
b) Taenia solium
c) Necator americanus
d) Clonorchis sinensis
e) Trypanosoma cruzi
d) Clonorchis sinensis
81
A 45 y/o male businessman presents with epigastric pain, jaundice and intermittent low grade fevers. He recently returned from China, where he dined on freshwater fish. His labs: AST 435, ALT 464, and TB 4. Viral hepatitis serologies are negative.
Which of the following diagnostic tests is least likely to be useful in this patient with clonorchis sinensis infection?
a) Upper endoscopy
b) Abdominal ultrasonography
c) Stool ova and parasites
d) Serum eosinophil count
e) MRCP
A. Upper Endoscopy
82
A 45 y/o male businessman presents with epigastric pain, jaundice and intermittent low grade fevers. He recently returned from China, where he dined on freshwater fish. His labs: AST 435, ALT 464, and TB 4. Viral hepatitis serologies are negative.
Abdominal sonography shows a dilated CBD of 15 mm. What is the most appropriate next step in management?
a) Upper endoscopy
b) ERCP
c) Prompt consultation for liver transplant
d) Flagyl
e) Reassurance; this is a self-limiting illness
B. ERCP
Gastroenterology
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