Gastrointestinal > Biliary tree damage > Flashcards

Biliary tree damage Flashcards

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1
Q

Risk factors for gallstones

A

5 Fs
- fat
- female
- forty
- fertile (pregnancy)
- family history

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2
Q

What two structure form the common bile duct?

A

Common hepatic duct
Cystic duct

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3
Q

define cholelithiasis

A

presence of gallstones

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4
Q

define choledocholithiasis

A

gallstones in the bile duct

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5
Q

Complications of gallstones

A

Biliary colic
Acute cholecystitis
Acute ascending cholangitis
Acute pancreatitis

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6
Q

What is biliary colic?

A
  • sudden constant onset right upper quadrant pain (radiates to back)
  • caused by temporary obstruction of cystic duct by gallstones at neck of gallbladder
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7
Q

Treatment of biliary colic

A

Pain relief
Cholecystectomy (gallbladder removal)

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8
Q

What is acute cholecystitis?

A
  • inflammation of gallbladder
  • due to impaction of gallstones in cystic duct
  • right upper quadrant pain + fever
  • Murphy’s sign
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9
Q

Presentation of acute cholecystitis

A
  • RUQ pain
  • radiation of pain to shoulder
  • fever
  • Murphy’s sign
  • N+V
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10
Q

What is Murphys sign?

A
  • place hand on patients right side of abdomen
  • ask to take a deep breath in
  • gall bladder hits hand > patient sudden breath in and pain
  • no pain on left side
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11
Q

imaging of acute cholecystitis + findings

A

USS
- thickened gallbladder wall
- stones or sludge in gallbladder
- fluid around gallbladder

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12
Q

Treatment of acute cholecystitis

A
  • hospital admission
  • nil by mouth
  • Analgesia
  • IV fluids
  • IV abc e.g. co-amoxiclav
  • ERCP
  • laparoscopic cholecystectomy within 1 week
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13
Q

What is gallbladder empyema?

A

infected tissue + pus collecting in gallbladder

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14
Q

Diagnosis of gallbladder empyema

A

Abdominal USS or CT scan + contrast

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15
Q

Treatment of gallbladder empyema

A
  • IV antibiotics
  • laparascopic cholecystectomy
  • or percutaneous cholecystostomy (if unsuitable for surgery)
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16
Q

What is acute ascending cholangitis?

A
  • inflammation of the bile ducts
  • infection of the biliary tree caused by gallstone blocking the common bile duct
  • Charcot’s triad presentation: RUQ pain, fever/inflammation + jaundice
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17
Q

Two main causes of acute ascending cholangitis

A
  • obstruction in bile duct (gallstone)
  • infection introduced during ERCP | most commonly E.coli
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18
Q

Presentation of acute ascending cholangitis

A

Charot’s triad: RUQ pain, fever, jaundice (raised bilirubin)
- Reynold’s Pentad: RUQ pain, fever, jaundice, hypotension, confusion

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19
Q

What is Reynold’s pentad?
what is it suggestive of?

A
  • RUQ pain
  • fever
  • jaundice
  • hypotension
  • confusion
    .
  • acute ascending cholangitis
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20
Q

Imaging for acute ascending cholangitis

A
  • abdominal USS
  • CT abdo-pelvis with contrast
  • MRCP
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21
Q

Management of acute ascending cholangitis

A
  • hospital admission
  • nil by mouth
  • IV fluids
  • blood cultures
  • IV ABx
  • ERCP to remove the stone
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22
Q

What is gallstone pancreatitis?

A
  • gallstone obstructs distal common bile duct where the pancreatic duct joins
  • this causes premature activation of pancreas enzymes
  • protease enzymes auto digest the pancreas
  • epigastric pain (can radiate to back)
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23
Q

Causes of acute pancreatitis

A

I GET SMASHED

  • Idiopathic
  • Gall stones
  • Ethanol
  • Trauma
  • Scorpion stings
  • Mumps
  • Autoimmune
  • Steroids
  • Hypercalcaemia
  • ERCP
  • Drugs
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24
Q

Presentation of acute pancreatitis

A
  • Epigastric pain > radiates to back
  • Vomiting
  • abdominal tenderness
  • systemically unwell
  • Cullen’s sign
  • Grey Turner’s sign
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25
Investigations of pancreatitis
- **amylase + lipase**: diagnostic if x 3 of upper limit of nromal - ABG + routine bloods - USS - CT abdomen if complications suspected
26
what is used to assess the severity of pancreatitis?
**RANSON score**
27
What is Cullen’s sign?
Superficial oedema + bruising in subcutaneous fatty tissue around umbilicus **C**ullen - **C**entral
28
What is Grey Turner’s sign?
Bruising of the flanks
29
Management of acute pancreatitis
- IV fluids - analgesia - nutritional support - ERCP or cholecystectomy - percutaneous drainage of pancreatic collections - abx if infection evidence - treat complications - most revolve within 3-7 days
30
Complications of acute pancreatitis
- necrosis of pancreas - infection - abscess formation - chronic pancreatitis - pseudocyst (collection of pancreatic juice) - acute respiratory distress syndrome
31
What is the most common cause of chronic pancreatitis?
excessive alcohol
32
What investigation can aid diagnosis of chronic pancreatitis?
low **faecal elastase levels**
33
Complications of chronic pancreatitis
- chronic epigastric pain - loss of exocrine function - loss of endocrine function > diabetes - pseudocysts or abscesses - damage + strictures to duct system > obstruction
34
Management of chronic pancreatitis
- alcohol + smoking cessation - analgesia - *Creon* to replace pancreatic enzymes - diabetes treatment - ERCP with stenting - surgery to treat complications
35
Differentiate between the presentations of biliary colic, acute cholecystitis + acute ascending choangitis
- **BC**: RUQ pain - **AC**: RUQ + fever/inflammation (+ Murphys sign) - **AAC**: RUQ + fever/inflammation + jaundice
36
What is the pain associated with gallstone called?
Biliary colic
37
Why does biliary colic come on about an hour after food?
CCK is released during digestion
38
Potential complications of stone lodging in proximal common bile duct
Cholangitis > post hepatic jaundice
39
Potential complications of a stone lodging in the distal common bile duct
Acute pancreatitis
40
What can gallstones form from?
Cholesterol Bile pigment Both
41
A gallstone stuck in the neck of gall bladder causes what?
Biliary colic
42
A gallstone stuck in cystic duct causes what?
Cholecystitis
43
A gallstone stuck in common bile duct causes what?
Ascending cholangitis
44
What is Charot’s triad?
Fever Jaundice RUQ pain
45
What causes biliary colic?
- cholecystokinin **CCK release by small intestine** during digestion - causes **contraction of gallbladder** > bile release - gallstones irritate entrance to galbadder - **intermittent pain associated with eating**
46
What causes cholecystitis?
- gallstone stuck in **cystic duct** - fluid statins inside gallbladder > **inflammation + infection** - causes **RUQ pain + fever**
47
WHat is magnetic resonance cholangio-pancreatography MRCP ? what is it used for
MRI scan used to get a detailed picture of the biliary system
48
Management of gallstone
- analgesia - ERCP - cholecystectomy
49
what does an endocsopic retrograde cholangio-pancreatography ERCP involve? what is it used for?
- inserting an endoscope down the oesophagus + GI tract to the sphincter of Oddi - main indication to clear gallstones
50
What does an ECRP allow the operator to do?
- clear gallstones - insert stents - biopsy tumours - cholagnio-pancreatography: inject contrast + take x-rays to visualise the biliary system - perform a sphincterotomy on the sphincter of oddi
51
Complications of ERCP
- pancreatitis - excessive bleeding - cholangitis
52
what is percutaneous transhepatic cholangiogram?
- radiologically guided insertion of a drain through the skin + liver into the bile ducts - relieves the immediate obstruction - option if ERCP has failed
53
outline a cholecystecomy
- kosher incision - most commonly laparoscopic - surgical removal of the gall bladder
54
Cholecystectomy vs cholecystostomy
- **cholecystectomy**: removal of gallbladder - **cholecystostomy**: inserting a drain into the gallbladder
55
Complications of cholecystectomy
- bleeding, infection, pain, scars - stones left in bile duct - VTE - damage to bowel, bladder or bile duct - post cholecystectomy syndrome
56
what is post cholecystectomy syndrome?
non specific symptoms that can occur after a cholecystectomy: - diarrhoea - indigestion - epigastric or RUQ pain - nausea - intolerance to fatty foods - flatulence
57
Complications of gallstones
- gallstone ileus - bouveret's syndrome - mirizzi syndrome - gallstone empyema - chronic cholecystitis
58
What is gallstone ileus?
Small bowel obstruction where gallstone passes through a fistula between gallbladder + small intestine > becomes impacted + obstructs bowel (often terminal ileum)
59
Presentation of gallstone ileus
- presentation of small bowel obstruction - early N+V - abdominal pain - constipation (later) - previous cholecystitis or gallstones - pneumophilia on CXR
60
Management of gallstone ileus
laparotomy + removal of gallstone from small bowel
61
what is bouveret's syndrome
gallstone passes from gallbladder into small bowel via fistula + impacts in proximal duodenum > gastric outlet obstruction
62
How does gallstone ileus + bouveret's syndrome occur?
recurrent inflammation of gallbladder can cause a fistula to form between the gallbladder + small bowel > cholecystoduodenal fistula > gallstones can pass directly from gallbladder into small bowel + cause obstructions
63
What is Mirizzi syndrome?
Gallstone located in Hartman’s pouch or cystic duct > compression to adjacent common hepatic duct > obstructive jaundice
64
Diagnosis and investigations of mirizzi syndrome
MRCP
65
Management of mirizzi syndrome
Laparoscopic cholecystectomy
66
Triad of chronic pancreatitis
Calcifications Diabetes Steatorrhoea
67
what is primary sclerosing cholangitis
- condition where the intrahepatic + extrahepatic bile ducts becomes inflamed+ develop strictures - obstruction of bile flow - stiffening + hardening of bile ducts
68
What condition has a strong association with primary sclerosing cholangitis?
ulcerative colitis
69
risk factors of primary sclerosing cholangitis
- male - UC - 30-40 - family history
70
presentation of primary sclerosing cholangitis
- often asymptomatic + picked up on abnormal LFTs - RUQ pain - pruritus - faitgue - jaundice - hepatomegaly - splenomegaly
71
Investigations of primary sclerosing cholangitis
- **LFTs** : raised ALP - **MRCP** to view strictures - **colonoscopy** to assess for UC
72
management of primary sclerosing cholangitis
- ERCP to dilate strictures - abx alongside to reduce risk of bacterial cholangitis - colestyramine for pruritis - replacement of fat soluble vitamins - monitoring of complications
73
complications of primary sclerosing cholangitis
- biliary strictures - bacterial cholangnitis - cholangiocarcinoma - cirrohsis > varices + portal hypertension - fat soluble vitamin deficiney - osteoporosis
74
What are the fat soluble vitamins?
A D E K
75
What is primary biliary cholangitis?
autoimmune condition attacking the intrahepatic bile ducts > obstructive jaundice + liver disease
76
Pathophysiology of primary biliary cholangitis
- affects intrahepatic ducts - inflammation + damage to cholangiocytes > bile flow obstruction - back pressure > liver cirrhosis + failure - build-up of bile acids, bilirubin + cholesterol in blood
77
Presentation of primary biliary cholangitis
- white women 40-60 - fatigue - pruritus - abdominal pain - jaundice - pale, greasy stools - dark urine
78
Examination findings of primary biliary cholangitis
- xanthoma + xanthelasma - excoriation of skin due to itching - hepatomegaly
79
What causes pururitis?
raised bile acids
80
why can primary biliary cholangitis cause abdominal symptoms + greasy stools?
- bile acids help with digestion of fats - reduced bile acids in GI tract > malabsorption of fat - steatorrhoea
81
investigations of primary biliary cholangitis
- **LFTs**: raised ALP - **antibodies**: ANA, AMA - **raised IgM** - **USS** to exclude other pathology
82
Treatment of primary biliary cholangitis
- ***ursodeoxycholic acid*** - colestyramine for pruritiis - replacement of fat soluble vitamins - steroids - liver transplant
83
What drug can be used for pruritis?
colestyramine
84
What causes Cullen’s + grey turner’s sign?
- **cullen’s**: intraabdominal haemorrhage - **Grey turner**: retroperitoneal haemorrhage
85
Pathophysiology of gallstone pancreatitis
- gallstones blocks the flow of bile + pancreatic juice into duodenum - reflux of bile into pancreatic duct > inflammation of pancreas - early activation of pancreatic enzymes > auto digestions
86
Imaging of biliary colic + acute cholecystitis
Abdominal USS
87
Pathophysiology of alcohol induced pancreatitis
Alcohol is directly toxic to pancreatic cells > inflammation
88
What score is used to assess pancreatitis severity?
GLASGOW score
89
Outline Glasgow score for pancreatitis severity
**PANCREAS** - **P**aO2 <8kPa - **A**ge >55 - **N**eutrophil >15 - **C**alcium <2 - u**R**ea high -**E**nzymes - deranged LFTs - **A**lbumin <32 - **S**ugar >10 . - 0/1 mild pancreatitis - 2 moderate - 3+ severe
90
What is Boas sign? What is it seen in?
Increased sensitivity/pain in right hypochondriac region/12th rib Acute cholecystitis
91
Pathophysiology of gallstone formation in biliary colic
Occurs due to increased cholesterol, reduced bile salts + biliary stasis
92
Complications of cholecystectomy
- **early**: bleeding, bile leak, infection, bile duct injury - **late**: postcholecystectomy syndrome
93
Why is Crohn’s disease a risk factor for gallstones?
Due to ileal involvement or resection Location of bile salt absorption
Gastrointestinal
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