1
Q
What is the primary site of bile formation?
A
Hepatocytes
Hepatocytes are liver cells responsible for producing bile.
2
Q
What is the pathway of bile secretion from hepatocytes?
A
Bile formed in hepatocytes is secreted into:
* Canaliculi
* Small bile ductules
* Larger bile ducts
* Interlobular bile ducts
* Septal bile ducts
* Common hepatic duct
* Common bile duct
* Duodenum
The bile pathway includes various ducts and culminates in the duodenum.
3
Q
What joins the common hepatic duct to form the common bile duct?
A
Cystic duct of the gallbladder
The cystic duct connects the gallbladder to the common hepatic duct.
4
Q
Where does the common bile duct enter the duodenum?
A
Through the ampulla of Vater
The ampulla of Vater is a structure where the bile duct and pancreatic duct converge.
5
Q
What is the electrolyte composition of hepatic bile compared to gallbladder bile?
A
Hepatic bile resembles blood plasma, while gallbladder bile has removed chloride and bicarbonate
This composition difference is due to reabsorption processes in the gallbladder.
6
Q
What causes the increase in total solute concentration of bile from hepatic bile to gallbladder bile?
A
Water reabsorption
This process increases the solute concentration from 3-4 g/dL in hepatic bile to 10-15 g/dL in gallbladder bile.
7
Q
Fill in the blank: The common bile duct often joins the main pancreatic duct before entering the _______.
A
Duodenum
8
Q
True or False: The electrolyte composition of gallbladder bile is the same as that of hepatic bile.
A
False
Gallbladder bile has a different composition due to the reabsorption of certain ions.
9
Q
What are the components of bile secretion and composition?
A
Bile is formed in:
* Hepatocytes
* Secreted into a network of ducts
* Composed of electrolytes resembling blood plasma
Bile plays a crucial role in digestion and absorption.
10
Q
What are the major solute components of bile by moles percent?
A
Bile acids (80%), phospholipids (16%), unesterified cholesterol (4.0%)
Other constituents include conjugated bilirubin, proteins, electrolytes, mucus, heavy metals, and drugs.
11
Q
What is the critical concentration of bile acids required to form micelles?
A
~2 mM
At this concentration, bile acids aggregate to form molecular structures called micelles.
12
Q
What is the total daily basal secretion of hepatic bile?
A
~500-600 mL
This is the amount of bile secreted by the liver into the bile canaliculi.
13
Q
What are the three important mechanisms regulating bile flow?
A
- Active transport of bile acids from hepatocytes into bile canaliculi
- Active transport of other organic anions
- Cholangiocellular secretion
The last mechanism is secretin-mediated and cyclic AMP-dependent.
14
Q
What is the normal bile acid pool size?
A
~2-4 g
This pool circulates approximately 5-10 times daily during digestion.
15
Q
How much bile acids are typically lost in feces daily?
A
0.2-0.4 g
This loss is compensated by daily synthesis of bile acids by the liver.
16
Q
What role do bile acids play in intestinal absorption?
A
Facilitate normal intestinal absorption of dietary fats, cholesterol, and fat-soluble vitamins
This occurs via a micellar transport mechanism.
17
Q
What hormone regulates gallbladder evacuation?
A
Cholecystokinin (CCK)
CCK is released from the duodenal mucosa in response to fats and amino acids.
18
Q
Fill in the blank: The primary bile acids, _______ and ________, are synthesized in hepatocytes from cholesterol.
A
cholic acid, chenodeoxycholic acid
These bile acids are conjugated with glycine or taurine before secretion.
19
Q
What is the capacity of the gallbladder?
A
~30 mL
This capacity allows for storage of bile before it is released into the duodenum.
20
Q
True or False: Secondary bile acids are formed in the colon as bacterial metabolites of primary bile acids.
A
True
Examples include deoxycholate and lithocholate.
21
Q
What is the main factor that promotes the filling of the gallbladder?
A
Tonic contraction of the sphincter of Oddi (SOD)
This contraction prevents reflux of duodenal contents into the pancreatic and bile ducts.
22
Q
What is the role of fibroblast growth factor 19 (FGF19) in bile acid metabolism?
A
Suppresses hepatic synthesis of bile acids from cholesterol
FGF19 is stimulated by bile acids in the intestine.
23
Q
What is the mechanism for the active transport of conjugated bile acids in the distal ileum?
A
Na+/taurocholate cotransporter (NTCP)
This mechanism is crucial for bile salt recirculation.
24
Q
What condition is associated with a defect in the bile salt export pump (BSEP)?
A
Progressive familial intrahepatic cholestasis type 2 (PFIC2)
BSEP is an ATP-binding cassette transporter responsible for bile salt export.
25
What is the function of the cystic fibrosis transmembrane regulator (CFTR) in the biliary system?
Regulates cholangiocellular pH during ductular bile formation
## Footnote
Defects in CFTR can lead to chronic cholestatic liver disease.
26
What are congenital anomalies of the biliary tract?
Abnormalities in number, size, and shape, including agenesis, duplications, rudimentary or oversized gallbladders, and diverticula
## Footnote
Examples include a Phrygian cap, left-sided gallbladder, and intrahepatic gallbladder.
27
What is a Phrygian cap?
A clinically innocuous entity where a partial or complete septum separates the fundus from the body of the gallbladder.
28
What are some anomalies of position or suspension of the gallbladder?
Left-sided gallbladder, intrahepatic gallbladder, retrodisplacement, and floating gallbladder.
29
What conditions can a floating gallbladder predispose to?
Acute torsion, volvulus, or herniation of the gallbladder.
30
What is the primary composition of cholesterol stones?
>90% cholesterol monohydrate, calcium salts, bile pigments, proteins, and fatty acids.
31
What are pigment stones primarily composed of?
Calcium bilirubinate, containing <20% cholesterol.
32
What are the two types of gallstones?
Cholesterol stones and pigment stones.
33
What role do bile acids play in cholesterol solubilization?
They convert unilamellar bilayered vesicles into mixed micelles consisting of bile acids, phospholipids, and cholesterol.
34
What happens when there is an excess of cholesterol in bile?
Unstable, cholesterol-rich vesicles remain which aggregate into large multilamellar vesicles, leading to cholesterol crystal precipitation.
35
What is the most important mechanism in the formation of lithogenic bile?
Increased biliary secretion of cholesterol.
36
What factors may increase biliary cholesterol secretion?
* Obesity
* Metabolic syndrome
* High-caloric and cholesterol-rich diets
* Certain drugs (e.g., clofibrate).
37
What genetic factors are associated with gallstone disease?
Mutations in the CYP7A1 and MDR3 genes are implicated.
38
What is the role of the MDR3 gene?
It encodes the phospholipid export pump in the canalicular membrane of the hepatocyte.
39
What is the significance of a single nucleotide polymorphism in the ABCG5/G8 gene?
It is found in 21% of patients with gallstones and thought to contribute to cholesterol hypersecretion.
40
What is the relationship between environmental and genetic factors in gallstone pathogenesis?
Genetic factors accounted for 25%, shared environmental factors for 13%, and individual environmental factors for 62% of phenotypic variation.
41
What population has a high prevalence of gallstones?
First-degree relatives of gallstone carriers and certain ethnic populations such as American Indians and Chilean Hispanics.
42
What is the effect of dietary cholesterol on biliary cholesterol secretion?
Increases biliary cholesterol secretion in patients with gallstones, but not in non-gallstone patients.
43
What is a common genetic trait identified in certain populations with gallstones?
Identified through mitochondrial DNA analysis.
44
What is a potential disturbance in bile acid metabolism related to cholesterol gallstones?
Enhanced conversion of cholic acid to deoxycholic acid.
45
True or False: Supersaturation of bile with cholesterol is sufficient for gallstone formation.
False.
46
What is the initial step in cholesterol catabolism?
Bile acid synthesis.
47
Fill in the blank: Mutations in the CYP7A1 gene result in a deficiency of the enzyme _______.
cholesterol 7-hydroxylase.
48
What accelerates nucleation of cholesterol monohydrate crystals?
Human lithogenic bile.
49
What are pronucleating factors?
Mucin and certain nonmucin glycoproteins, principally immunoglobulins
50
What are antinucleating factors?
Apolipoproteins A-I and A-II, and other glycoproteins
51
What role do pigment particles play in gallstone formation?
They may act as nucleating factors
52
Which gene variant is associated with gallstone disease?
Uridine diphosphate-glucuronyltransferase 1A1 (UGT1A1) Gilbert's syndrome gene variant
53
What type of stones are most commonly associated with the UGT1A1 variant?
Cholesterol stones
54
Where does cholesterol monohydrate crystal nucleation and growth likely occur?
Within the mucin gel layer
55
What leads to the formation of solid cholesterol monohydrate crystals?
Vesicle fusion leading to liquid crystals
56
What is a significant mechanism in cholesterol gallstone formation?
Gallbladder hypomotility
57
What abnormalities are observed in gallstone patients regarding gallbladder emptying?
Increased gallbladder volume during fasting and decreased fractional emptying
58
What conditions are associated with increased incidence of gallstones?
Fasting, parenteral nutrition, pregnancy, drugs that inhibit gallbladder motility
59
What is biliary sludge?
A thick, mucous material containing lecithin-cholesterol liquid crystals, cholesterol monohydrate crystals, calcium bilirubinate, and mucin gels
60
What does the presence of biliary sludge imply?
Derangement in the balance of gallbladder mucin secretion and nucleation of biliary solutes
61
What percentage of patients with biliary sludge may develop gallstones?
14%
62
What are two key changes during pregnancy that contribute to a cholelithogenic state?
* Marked increase in cholesterol saturation of bile during the third trimester
* Sluggish gallbladder contraction
63
What percentage of women develop gallbladder sludge during pregnancy?
20-30%
64
What is the effectiveness of UDCA in preventing gallstone formation during rapid weight reduction?
UDCA reduced gallstone formation from 28% to 3% in a study
65
What are the three main defects that lead to cholesterol gallstone disease?
* Bile supersaturation with cholesterol
* Nucleation of cholesterol monohydrate and stone growth
* Abnormal gallbladder motor function
66
What are black pigment stones composed of?
Pure calcium bilirubinate or polymer-like complexes with calcium and mucin glycoproteins
67
In which conditions are black pigment stones more common?
* Chronic hemolytic states
* Cirrhosis (especially alcoholic)
* Gilbert's syndrome
* Cystic fibrosis
68
What are the demographic factors associated with cholesterol stone formation?
* Highest prevalence in North American Indians
* Greater in Northern Europe and North America than in Asia
* Familial disposition
69
What hormonal factors contribute to cholesterol stone formation?
* Estrogens increase biliary cholesterol secretion
* Decreased bile salt secretion due to natural and synthetic estrogens
70
What dietary factors may predispose individuals to cholesterol stones?
* High-calorie, high-fat diet
* Rapid weight loss
71
What is a common finding in patients with gallbladder hypomotility?
Formation of biliary sludge
72
What is the relationship between age and cholesterol stone formation?
Increasing age is associated with increased biliary secretion of cholesterol and decreased bile acid pool
73
What is one genetic defect associated with decreased bile acid secretion?
CYP7A1 gene defect
74
What is a common condition associated with pigment stones?
Chronic hemolysis, such as sickle cell disease
75
What contributes to the pathogenesis of gallstones in ileal disease states?
Enterohepatic recycling of bilirubin
76
What are brown pigment stones composed of?
Calcium salts of unconjugated bilirubin with varying amounts of cholesterol and protein
77
What causes brown pigment stones?
Increased amounts of unconjugated, insoluble bilirubin in bile
78
What is one method that was historically useful for gallstone diagnosis but is now obsolete?
Oral cholecystography (OCG)
79
What is a characteristic of biliary sludge?
Forms a layer in the most dependent position of the gallbladder
80
What symptom is most specific and characteristic of gallstone disease?
Biliary colic
81
What can cause obstruction of the cystic duct or CBD?
Migration of gallstones
82
What is the typical pain experience during biliary colic?
Severe, steady ache or fullness in the epigastrium or right upper quadrant
83
What are some advantages of ultrasound in gallbladder diagnostics?
* Rapid
* Accurate identification of gallstones (>95%)
* Not limited by jaundice or pregnancy
84
What is a limitation of plain abdominal X-ray for gallstone diagnosis?
Relatively low yield
85
What does cholescintigraphy (HIDA, DISIDA) accurately identify?
Cystic duct obstruction
86
What is the yearly incidence of complications for patients with asymptomatic gallstones?
About 0.1-0.3%
87
What percentage of patients with asymptomatic gallstones remain asymptomatic over 25 years?
60 to 80%
88
What is the cumulative risk of death due to gallstone disease while on expectant management?
Small
89
True or False: Prophylactic cholecystectomy is warranted for all patients with gallstones.
False
90
What is the incidence of developing symptoms within 5 years after diagnosis of asymptomatic gallstones?
2-4% per year
91
What may precipitate biliary colic?
* Eating a fatty meal
* Consumption of a large meal after fasting
* Eating a normal meal
92
What are common complications associated with gallstones?
* Cholecystitis
* Pancreatitis
* Cholangitis
93
What does an elevated level of serum bilirubin suggest?
A common duct stone
94
Fill in the blank: The enzyme that may mediate deconjugation of bilirubin is _______.
p-glucuronidase
95
What is the role of ultrasound in gallbladder emptying function assessment?
To assess the emptying function of the gallbladder
96
What is the risk of developing symptoms for patients who remain asymptomatic for 15 years?
Unlikely to develop symptoms during further follow-up
97
What can be indicated by failure to image the gallbladder in the presence of biliary ductal visualization?
Cystic duct obstruction or acute/chronic cholecystitis
98
What is the abbreviation for gallbladder?
GB
99
What does CHD stand for in relation to biliary anatomy?
Common hepatic duct
100
What does CBD refer to?
Common bile duct
101
What is the abbreviation for pancreatic duct?
PD
102
What does an ultrasound study showing a distended gallbladder indicate?
Presence of a single large stone casting an acoustic shadow
103
What is the common indication for endoscopic retrograde cholangiopancreatogram (ERCP)?
Normal biliary tract anatomy
104
What is choledocholithiasis?
Presence of stones in the common bile duct
105
What is the recommended dose of UDCA for gallstone treatment?
10-15 mg/kg per day
106
True or False: Stones larger than 10 mm in size can dissolve with UDCA therapy.
False
107
What percentage of patients with symptomatic cholelithiasis are candidates for UDCA treatment?
Probably ≤10%
108
What are the three factors to consider for recommending cholecystectomy in gallstone patients?
* Frequency/severity of symptoms
* History of prior complications
* Presence of underlying conditions
109
What is the procedure of choice for most patients requiring elective cholecystectomy?
Laparoscopic cholecystectomy
110
What are the advantages of laparoscopic cholecystectomy?
* Shortened hospital stay
* Minimal disability
* Decreased cost
111
What is the complication rate for laparoscopic cholecystectomy?
~4%
112
What is the conversion rate to laparotomy during laparoscopic cholecystectomy?
5%
113
What is the death rate associated with laparoscopic cholecystectomy?
<0.1%
114
What is the rate of bile duct injuries in laparoscopic cholecystectomy?
0.2-0.6%
115
What is acute cholecystitis?
Acute inflammation of the gallbladder wall due to cystic duct obstruction
116
What are the three factors that can evoke an inflammatory response in acute cholecystitis?
* Mechanical inflammation
* Chemical inflammation
* Bacterial inflammation
117
What is the most frequently isolated organism in acute cholecystitis?
Escherichia coli
118
What percentage of patients with acute cholecystitis report prior attacks?
60-70%
119
What are common symptoms of acute cholecystitis?
* Anorexia
* Nausea
* Vomiting
* Low-grade fever
120
True or False: Jaundice is common in the early stages of acute cholecystitis.
False
121
What might cause jaundice during acute cholecystitis?
Edematous inflammatory changes involving bile ducts
122
What is acalculous cholecystopathy?
Disordered motility of the gallbladder without the presence of gallstones
## Footnote
It is characterized by recurrent biliary pain in patients without gallstones.
123
What is the significance of Murphy's sign during RUQ palpation?
Increased pain and inspiratory arrest, indicative of gallbladder issues
## Footnote
It is commonly used to diagnose acute cholecystitis.
124
What triad is highly suggestive of acute cholecystitis?
Sudden onset of RUQ tenderness, fever, and leukocytosis
## Footnote
This triad helps in diagnosing acute cholecystitis.
125
What leukocytosis range is typically found in acute cholecystitis?
10,000-15,000 cells per microliter with a left shift
## Footnote
This indicates an inflammatory response.
126
What imaging finding is important for diagnosing emphysematous cholecystitis?
Gas within the gallbladder lumen or wall
## Footnote
This is seen on plain abdominal films.
127
What bacteria are commonly associated with emphysematous cholecystitis?
Clostridium welchii, C. perfringens, and E. coli
## Footnote
These organisms are typically gas-producing.
128
What is Mirizzi syndrome?
A complication where a gallstone becomes impacted in the cystic duct, causing CBD obstruction
## Footnote
It leads to jaundice and requires careful surgical management.
129
What is the most common cause of chronic cholecystitis?
Repeated bouts of subacute or acute cholecystitis
## Footnote
It is often associated with the presence of gallstones.
130
What is the typical presentation of empyema of the gallbladder?
High fever, severe RUQ pain, marked leukocytosis, and prostration
## Footnote
It results from superinfection of stagnant bile.
131
What can lead to acalculous cholecystitis?
Prolonged fasting, serious trauma, burns, or major nonbiliary surgeries
## Footnote
These conditions increase the risk of gallbladder inflammation.
132
What is hydrops of the gallbladder?
Distention of the gallbladder lumen due to prolonged obstruction
## Footnote
It can be caused by a large solitary calculus or other factors.
133
What are the typical symptoms of gangrene of the gallbladder?
Ischemia of the wall and patchy or complete tissue necrosis
## Footnote
It often leads to perforation.
134
What is the management strategy for acute acalculous cholecystitis?
Early diagnosis and surgical intervention
## Footnote
Attention to postoperative care is also crucial.
135
What is the typical finding on ultrasound for a patient with hydrops?
A large, tense, static gallbladder without stones
## Footnote
This may indicate poor emptying.
136
True or False: Chronic cholecystitis can be asymptomatic for years.
True
## Footnote
It may progress to symptomatic gallbladder disease or acute cholecystitis.
137
What is the complication rate for acalculous cholecystitis compared to calculous cholecystitis?
The complication rate for acalculous cholecystitis exceeds that for calculous cholecystitis
## Footnote
This highlights the need for prompt treatment.
138
What is the primary treatment for patients with abscess formation due to gallbladder issues?
Cholecystectomy
## Footnote
Some seriously ill patients may be managed with cholecystostomy and drainage of the abscess.
139
What is the mortality rate associated with free perforation of the gallbladder?
Approximately 30%
## Footnote
Free perforation is less common but carries significant risk.
140
What is a common complication of gallbladder inflammation that can lead to fistula formation?
Adhesion formation
## Footnote
Fistulas commonly form into the duodenum.
141
Gallstone ileus refers to what type of medical condition?
Mechanical intestinal obstruction
## Footnote
It occurs due to the passage of a large gallstone into the bowel lumen.
142
Where does the impacted gallstone usually obstruct in gallstone ileus?
Ileocecal valve
## Footnote
This is provided that the more proximal small bowel is of normal caliber.
143
What size of gallstone is thought to predispose to fistula formation?
>2.5 cm in diameter
## Footnote
Large stones can erode through the gallbladder fundus.
144
What imaging technique may demonstrate a fistula associated with gallstones?
Barium contrast studies or endoscopy
## Footnote
These methods can show the fistula in the gastrointestinal tract.
145
What is the preferred surgical intervention for symptomatic gallstone ileus?
Laparotomy with stone extraction
## Footnote
Stone propulsion into the colon may also be performed.
146
What does 'limey bile' refer to in gallbladder pathology?
Calcium precipitation and opacification of bile
## Footnote
This condition may occur in the lumen of the gallbladder.
147
What is the association of porcelain gallbladder with cancer?
Historically thought to have high incidence of carcinoma
## Footnote
This association has been challenged by several studies.
148
What is the optimal timing for surgical intervention in acute cholecystitis?
Within 72 hours after diagnosis
## Footnote
Early surgery is preferred for better outcomes.
149
What is the complication rate for early elective cholecystectomy compared to delayed cholecystectomy?
Not increased in early cholecystectomy
## Footnote
Delayed surgery is best for patients with high surgical risk.
150
What are common postoperative complications following cholecystectomy?
* Atelectasis
* Abscess formation
* Hemorrhage
* Biliary-enteric fistula
* Bile leaks
## Footnote
Jaundice may indicate complications related to bile absorption.
151
What syndrome can occur due to a long cystic duct remnant post-cholecystectomy?
Cystic duct stump syndrome
## Footnote
Symptoms may resemble biliary pain or cholecystitis.
152
What is the mainstay of therapy for acute cholecystitis?
Surgical intervention
## Footnote
A period of in-hospital stabilization may be required before surgery.
153
What is the recommended antibiotic therapy for patients with severe acute cholecystitis?
* Piperacillin plus tazobactam
* Imipenem
* Meropenem
* Ceftriaxone plus metronidazole
* Levofloxacin plus metronidazole
## Footnote
Antibiotic therapy is guided by the organisms likely present.
154
What are the two patterns of gallbladder wall calcification recognized in porcelain gallbladder?
* Complete intramural calcification
* Selective mucosal calcification
## Footnote
The risk of cancer is higher with selective intramural calcification.
155
What is cholesterolosis characterized by?
Abnormal deposition of lipid, especially cholesteryl esters, within macrophages in the lamina propria of the gallbladder wall.
## Footnote
In its diffuse form, it is referred to as 'strawberry gallbladder'.
156
What are the two forms of cholesterolosis?
1. Diffuse form (strawberry gallbladder)
2. Localized form (cholesterol polyps)
## Footnote
The localized form shows solitary or multiple 'cholesterol polyps' studding the gallbladder wall.
157
What are the five criteria used to define SOD stenosis?
1. Upper abdominal pain, usually RUQ or epigastric
2. Abnormal liver tests
3. Dilatation of the CBD upon MRCP or ERCP examination
4. Delayed (>45 min) drainage of contrast material from the duct
5. Increased basal pressure of the SOD.
158
What is the prevalence of gallbladder polyps in the adult population?
1-4% with a marked male predominance.
## Footnote
Types of gallbladder polyps include cholesterol polyps, adenomyomas, inflammatory polyps, and adenomas (rare).
159
What is recommended for asymptomatic patients with gallbladder polyps >10 mm?
Cholecystectomy.
## Footnote
This recommendation applies especially if associated with gallstones or polyp growth on serial ultrasonography.
160
List the factors considered as indications for sphincterotomy.
1. Prolonged duration of symptoms
2. Lack of response to symptomatic treatment
3. Presence of severe disability
4. Patient's choice of sphincterotomy over surgery.
161
What are the three criteria characterizing biliary SOD disorders?
1. Biliary pain
2. Absence of bile duct stones or other abnormalities
3. Elevated liver enzymes or a dilated CBD, but not both.
162
What is biliary atresia characterized by?
Atretic and hypoplastic lesions of the extrahepatic and large intrahepatic bile ducts.
## Footnote
The clinical picture includes severe obstructive jaundice during the first month of life, with pale stools.
163
What is the typical treatment for biliary atresia?
Roux-en-Y choledochojejunostomy or the Kasai procedure (hepatic portoenterostomy).
## Footnote
Approximately 10% of cases are treatable with Roux-en-Y choledochojejunostomy.
164
What are choledochal cysts?
Cystic dilatation of the CBD or diverticulum formation in the intraduodenal segment.
## Footnote
Chronic reflux of pancreatic juice can lead to inflammation and stenosis of the extrahepatic bile ducts.
165
What is the classic triad of symptoms for choledochal cysts?
1. Abdominal pain
2. Jaundice
3. Abdominal mass.
166
What is postcholecystectomy diarrhea?
Diarrhea classified as three or more watery movements per day occurring in 5-10% of patients after elective cholecystectomy.
## Footnote
Caused by changes in gut transit and bile acid composition.
167
What are the clinical manifestations of Caroli's disease?
Recurrent cholangitis, abscess formation, and brown pigment gallstone formation.
## Footnote
It involves cystic dilatation of intrahepatic bile ducts.
168
What characterizes hyperplastic cholecystoses?
Excessive proliferation of normal tissue components in the gallbladder.
169
What is adenomyomatosis in the gallbladder?
A benign proliferation of gallbladder surface epithelium with glandlike formations and extramural sinuses.
170
What percentage of patients with cholelithiasis experience passage of gallstones into the CBD?
10-15%.
171
What increases the incidence of common duct stones?
Increasing age
## Footnote
The alkaline phosphatase level usually falls slowly, lagging behind the decrease in serum bilirubin.
172
What percentage of elderly patients may have calculi in the common duct at the time of cholecystectomy?
Up to 25%
## Footnote
Undetected duct stones are left behind in ~1-5% of cholecystectomy patients.
173
What is the most common associated entity discovered in patients with nonalcoholic acute pancreatitis?
Biliary tract disease
174
What type of stones are the overwhelming majority of bile duct stones?
Cholesterol stones
175
Where do cholesterol stones form before migrating into the extrahepatic biliary tree?
In the gallbladder
176
What are primary calculi that arise de novo in the ducts usually classified as?
Brown pigment stones
177
What conditions may lead to the development of primary calculi?
* Hepatobiliary parasitism
* Chronic, recurrent cholangitis
* Congenital anomalies of the bile ducts
* Dilated, sclerosed, or strictured ducts
* MDR3 (ABCB4) gene defect
178
What symptoms may suggest coexisting pancreatitis in patients with cholecystitis?
* Back pain
* Prolonged vomiting with paralytic ileus
* Pleural effusion, especially on the left side
179
What is the surgical treatment of gallstone disease usually associated with?
Resolution of pancreatitis
180
What may complicate prolonged or intermittent duct obstruction?
Secondary biliary cirrhosis
181
What is the characteristic presentation of acute cholangitis?
* Biliary pain
* Jaundice
* Spiking fevers with chills (Charcot's triad)
182
What is the typical finding in blood cultures for patients with acute cholangitis?
Positive cultures in ~75% of patients
183
What is the most common type of acute cholangitis?
Nonsuppurative acute cholangitis
184
What leads to severe toxicity in suppurative acute cholangitis?
The presence of pus under pressure in a completely obstructed ductal system
185
How is the diagnosis of choledocholithiasis made?
Cholangiography
186
What is the preferred approach for managing CBD stones prior to laparoscopic cholecystectomy?
Preoperative ERCP with endoscopic papillotomy and stone extraction
187
What should be suspected in gallstone patients with a history of jaundice or pancreatitis?
CBD stones
188
What may be a characteristic of painless jaundice in patients with choledocholithiasis?
It is much more characteristic of biliary obstruction secondary to malignancy
189
What causes the absence of a palpable gallbladder in patients with biliary obstruction?
Biliary obstruction from stones
190
What is the common cause of benign strictures of the extrahepatic bile ducts?
Surgical trauma
191
What is the maximum bilirubin level seldom exceeding in patients with choledocholithiasis?
256.5 umol/L (15.0 mg/dL)
192
What serum bilirubin level should suggest the possibility of neoplastic obstruction?
≥342.0 umol/L (20 mg/dL)
193
What is almost always elevated in biliary obstruction?
Serum alkaline phosphatase level
194
What may follow traumatic or operative injury to the liver or bile ducts?
Hemobilia
195
What diagnostic procedure may be helpful in establishing the nature of biliary strictures?
Endoscopic brushing
196
What is the typical clinical finding in patients with biliary obstruction?
Jaundice accompanied by dark urine and light-colored stools
197
What are the diagnostic advantages of Ultrasound for bile ducts?
* Rapid
* Simultaneous scanning of GB, liver, bile ducts, pancreas
* Accurate identification of dilated bile ducts
* Not limited by jaundice, pregnancy
## Footnote
Bowel gas, massive obesity, and ascites can limit ultrasound's effectiveness.
198
What are the diagnostic limitations of Barium for bile ducts?
* Partial bile duct obstruction
* Poor visualization of distal CBD
## Footnote
Guidance for fine-needle biopsy is a potential advantage.
199
What are the advantages of Computed Tomography in bile duct diagnostics?
* Simultaneous scanning of GB, liver, bile ducts, pancreas
* Accurate identification of dilated bile ducts, masses
* Not limited by jaundice, gas, obesity, ascites
* High-resolution image
* Guidance for fine-needle biopsy
## Footnote
Extreme cachexia, movement artifact, and ileus can limit its effectiveness.
200
What is a key feature of Magnetic Resonance Cholangiopancreatography?
Noninvasive modality for visualizing pancreatic and biliary ducts
## Footnote
It has excellent sensitivity for bile duct dilatation, biliary stricture, and intraductal abnormalities.
201
What are the limitations of Magnetic Resonance Cholangiopancreatography?
* Cannot offer therapeutic intervention
* High cost
## Footnote
It can identify pancreatic duct dilatation or stricture, pancreatic duct stenosis, and pancreas divisum.
202
What is the primary advantage of Endoscopic Retrograde Cholangiopancreatography?
Best visualization of distal biliary tract
## Footnote
It allows for simultaneous pancreatography, bile or pancreatic cytology, and endoscopic sphincterotomy.
203
What are the contraindications for Endoscopic Retrograde Cholangiopancreatography?
* Pregnancy
* Acute pancreatitis
* Severe cardiopulmonary disease
* Uncorrectable coagulopathy
* Massive ascites
* Hepatic abscess
## Footnote
Gastroduodenal obstruction and Roux-en-Y biliary-enteric anastomosis can also limit its use.
204
What is the best use of Percutaneous Transhepatic Cholangiogram?
Best when bile ducts are dilated
## Footnote
It allows for percutaneous transhepatic drainage and may be used to obtain bile cytology/culture.
205
What is the primary advantage of Endoscopic Ultrasound?
Most sensitive method to detect ampullary stones and exclude pathology in the head of the pancreas
## Footnote
It is particularly useful for nondilated or sclerosed ducts.
206
What are the complications associated with Endoscopic Retrograde Cholangiopancreatography?
* Pancreatitis
* Cholangitis, sepsis
* Infected pancreatic pseudocyst
* Perforation (rare)
* Hypoxemia, aspiration
## Footnote
It is the procedure of choice for investigating possible biliary obstruction.
207
What are the clinical presentations of obstructive jaundice?
* Biliary pain
* Obstructive jaundice
* Melena or occult blood in stools
## Footnote
Diagnosis may involve cholangiographic evidence of blood clot in the biliary tree.
208
What is the cause of extrinsic compression of the bile ducts?
Partial or complete biliary obstruction due to external forces
## Footnote
This condition is relatively rare but occurs in inhabitants of southern China.
209
True or False: Hemobilia may resolve without intervention.
True
## Footnote
However, arteriography and transcatheter embolization or surgical ligation may be required for severe cases.
210
Fill in the blank: The initial procedure of choice in investigating possible biliary tract obstruction is _______.
[Endoscopic Retrograde Cholangiopancreatography]
211
What are the indications for Percutaneous Transhepatic Cholangiogram?
* Drainage of obstructed and infected ducts
* When ERCP is contraindicated or has failed
* Excellent for detecting choledocholithiasis
## Footnote
It is the cholangiogram of choice if intervention is needed for choledocholithiasis or biliary stricture.
212
What are the diagnostic advantages of Ultrasound for bile ducts?
* Rapid
* Simultaneous scanning of GB, liver, bile ducts, pancreas
* Accurate identification of dilated bile ducts
* Not limited by jaundice, pregnancy
## Footnote
Bowel gas, massive obesity, and ascites can limit ultrasound's effectiveness.
213
What are the diagnostic limitations of Barium for bile ducts?
* Partial bile duct obstruction
* Poor visualization of distal CBD
## Footnote
Guidance for fine-needle biopsy is a potential advantage.
214
What are the advantages of Computed Tomography in bile duct diagnostics?
* Simultaneous scanning of GB, liver, bile ducts, pancreas
* Accurate identification of dilated bile ducts, masses
* Not limited by jaundice, gas, obesity, ascites
* High-resolution image
* Guidance for fine-needle biopsy
## Footnote
Extreme cachexia, movement artifact, and ileus can limit its effectiveness.
215
What is a key feature of Magnetic Resonance Cholangiopancreatography?
Noninvasive modality for visualizing pancreatic and biliary ducts
## Footnote
It has excellent sensitivity for bile duct dilatation, biliary stricture, and intraductal abnormalities.
216
What are the limitations of Magnetic Resonance Cholangiopancreatography?
* Cannot offer therapeutic intervention
* High cost
## Footnote
It can identify pancreatic duct dilatation or stricture, pancreatic duct stenosis, and pancreas divisum.
217
What is the primary advantage of Endoscopic Retrograde Cholangiopancreatography?
Best visualization of distal biliary tract
## Footnote
It allows for simultaneous pancreatography, bile or pancreatic cytology, and endoscopic sphincterotomy.
218
What are the contraindications for Endoscopic Retrograde Cholangiopancreatography?
* Pregnancy
* Acute pancreatitis
* Severe cardiopulmonary disease
* Uncorrectable coagulopathy
* Massive ascites
* Hepatic abscess
## Footnote
Gastroduodenal obstruction and Roux-en-Y biliary-enteric anastomosis can also limit its use.
219
What is the best use of Percutaneous Transhepatic Cholangiogram?
Best when bile ducts are dilated
## Footnote
It allows for percutaneous transhepatic drainage and may be used to obtain bile cytology/culture.
220
What is the primary advantage of Endoscopic Ultrasound?
Most sensitive method to detect ampullary stones and exclude pathology in the head of the pancreas
## Footnote
It is particularly useful for nondilated or sclerosed ducts.
221
What are the complications associated with Endoscopic Retrograde Cholangiopancreatography?
* Pancreatitis
* Cholangitis, sepsis
* Infected pancreatic pseudocyst
* Perforation (rare)
* Hypoxemia, aspiration
## Footnote
It is the procedure of choice for investigating possible biliary obstruction.
222
What are the clinical presentations of obstructive jaundice?
* Biliary pain
* Obstructive jaundice
* Melena or occult blood in stools
## Footnote
Diagnosis may involve cholangiographic evidence of blood clot in the biliary tree.
223
What is the cause of extrinsic compression of the bile ducts?
Partial or complete biliary obstruction due to external forces
## Footnote
This condition is relatively rare but occurs in inhabitants of southern China.
224
True or False: Hemobilia may resolve without intervention.
True
## Footnote
However, arteriography and transcatheter embolization or surgical ligation may be required for severe cases.
225
Fill in the blank: The initial procedure of choice in investigating possible biliary tract obstruction is _______.
[Endoscopic Retrograde Cholangiopancreatography]
226
What are the indications for Percutaneous Transhepatic Cholangiogram?
* Drainage of obstructed and infected ducts
* When ERCP is contraindicated or has failed
* Excellent for detecting choledocholithiasis
## Footnote
It is the cholangiogram of choice if intervention is needed for choledocholithiasis or biliary stricture.
227
What organisms are most commonly involved in biliary tract infections?
Trematodes or flukes including Clonorchis sinensis, Opisthorchis viverrini, Opisthorchis felineus, and Fasciola hepatica.
228
What is the primary diagnostic method for biliary tract issues?
Cholangiography and stool examination for characteristic ova.
229
What is the treatment of choice when obstruction is present in biliary tract infections?
Laparotomy under antibiotic coverage, common duct exploration, and biliary drainage procedure.
230
What characterizes Primary Sclerosing Cholangitis (PSC)?
A progressive, inflammatory, sclerosing, and obliterative process affecting extrahepatic and/or intrahepatic bile ducts.
231
Which condition is PSC strongly associated with?
Inflammatory bowel disease, especially ulcerative colitis.
232
What is Immunoglobulin G4 (IgG4)-associated cholangitis?
A biliary disease of unknown etiology that presents with features indistinguishable from PSC.
233
What should all patients diagnosed with sclerosing cholangitis have checked?
Serum IgG4 level to rule out IgG4 disease as a cause of secondary sclerosing cholangitis.
234
What is the initial treatment of choice for IgG4-associated cholangitis?
Glucocorticoids.
235
What are common signs and symptoms of PSC?
RUQ abdominal pain, pruritus, jaundice, or acute cholangitis.
236
What might occur late in the course of PSC?
Complete biliary obstruction, secondary biliary cirrhosis, hepatic failure, or portal hypertension with bleeding varices.
237
How is the diagnosis of PSC established?
Finding multifocal, diffusely distributed strictures with intervening segments of normal or dilated ducts on cholangiography.
238
What are the cholangiographic techniques of choice in suspected PSC cases?
MRCP and ERCP.
239
What defines small duct PSC?
Chronic cholestasis and hepatic histology consistent with PSC in a patient with IBD but normal cholangiography findings.
240
What percentage of patients with PSC may have small duct PSC?
~5%.
241
What is a potential progression for patients with small duct PSC?
They may progress to classic PSC and/or end-stage liver disease requiring liver transplantation.
242
What biliary tract changes can be seen in patients with AIDS?
Intrahepatic bile duct involvement, ampullary stenosis, stricture of the CBD, and pancreatic duct involvement.
243
Which infectious organisms are associated with biliary tract lesions in AIDS?
Cryptosporidium, Mycobacterium avium-intracellulare, cytomegalovirus, Microsporidia, and Isospora.
244
What can ERCP sphincterotomy provide relief for in AIDS patients?
Significant pain reduction in patients with AIDS-associated papillary stenosis.
245
What is the proven medical therapy for PSC?
There is no proven medical therapy for PSC.
246
What therapies can be used to treat pruritus associated with PSC?
Cholestyramine, rifampin, and naltrexone.
247
When are antibiotics useful in the context of PSC?
When bacterial cholangitis complicates the clinical picture.
248
What supplementation may be needed for patients with PSC?
Vitamin D and calcium supplementation.
249
What organisms are most commonly involved in biliary tract infections?
Trematodes or flukes including Clonorchis sinensis, Opisthorchis viverrini, Opisthorchis felineus, and Fasciola hepatica.
250
What is the primary diagnostic method for biliary tract issues?
Cholangiography and stool examination for characteristic ova.
251
What is the treatment of choice when obstruction is present in biliary tract infections?
Laparotomy under antibiotic coverage, common duct exploration, and biliary drainage procedure.
252
What characterizes Primary Sclerosing Cholangitis (PSC)?
A progressive, inflammatory, sclerosing, and obliterative process affecting extrahepatic and/or intrahepatic bile ducts.
253
Which condition is PSC strongly associated with?
Inflammatory bowel disease, especially ulcerative colitis.
254
What is Immunoglobulin G4 (IgG4)-associated cholangitis?
A biliary disease of unknown etiology that presents with features indistinguishable from PSC.
255
What should all patients diagnosed with sclerosing cholangitis have checked?
Serum IgG4 level to rule out IgG4 disease as a cause of secondary sclerosing cholangitis.
256
What is the initial treatment of choice for IgG4-associated cholangitis?
Glucocorticoids.
257
What are common signs and symptoms of PSC?
RUQ abdominal pain, pruritus, jaundice, or acute cholangitis.
258
What might occur late in the course of PSC?
Complete biliary obstruction, secondary biliary cirrhosis, hepatic failure, or portal hypertension with bleeding varices.
259
How is the diagnosis of PSC established?
Finding multifocal, diffusely distributed strictures with intervening segments of normal or dilated ducts on cholangiography.
260
What are the cholangiographic techniques of choice in suspected PSC cases?
MRCP and ERCP.
261
What defines small duct PSC?
Chronic cholestasis and hepatic histology consistent with PSC in a patient with IBD but normal cholangiography findings.
262
What percentage of patients with PSC may have small duct PSC?
~5%.
263
What is a potential progression for patients with small duct PSC?
They may progress to classic PSC and/or end-stage liver disease requiring liver transplantation.
264
What biliary tract changes can be seen in patients with AIDS?
Intrahepatic bile duct involvement, ampullary stenosis, stricture of the CBD, and pancreatic duct involvement.
265
Which infectious organisms are associated with biliary tract lesions in AIDS?
Cryptosporidium, Mycobacterium avium-intracellulare, cytomegalovirus, Microsporidia, and Isospora.
266
What can ERCP sphincterotomy provide relief for in AIDS patients?
Significant pain reduction in patients with AIDS-associated papillary stenosis.
267
What is the proven medical therapy for PSC?
There is no proven medical therapy for PSC.
268
What therapies can be used to treat pruritus associated with PSC?
Cholestyramine, rifampin, and naltrexone.
269
When are antibiotics useful in the context of PSC?
When bacterial cholangitis complicates the clinical picture.
270
What supplementation may be needed for patients with PSC?
Vitamin D and calcium supplementation.
271
What may be used as initial therapy to help prevent the loss of bone mass in patients with chronic cholestasis?
May be used as initial therapy to help prevent the loss of bone mass
## Footnote
This refers to treatments or medications that are effective in maintaining bone density in patients suffering from chronic liver issues.
272
What is preferred over stenting in cases of high-grade biliary obstruction?
Balloon dilatation
## Footnote
Balloon dilatation is chosen due to the higher complication rates associated with stenting, such as pancreatitis and cholangitis.
273
What complications are associated with stenting in high-grade biliary obstruction?
Higher complication rate including:
* Pancreatitis
* Cholangitis
## Footnote
These complications can significantly affect patient outcomes and management strategies.
274
When is surgical intervention indicated in patients with biliary obstruction?
Only rarely
## Footnote
Surgical intervention is not commonly required and is typically reserved for specific cases.
275
What is the median survival of patients diagnosed with PSC?
12-18 years
## Footnote
This median survival is noted regardless of the therapy provided to the patients.
276
What four variables predict survival in patients with PSC?
The four variables are:
* Age
* Serum bilirubin level
* Histologic stage
* Splenomegaly
## Footnote
These variables are used to create a risk score for assessing patient prognosis.
277
What is a common indication for liver transplantation?
PSC (Primary Sclerosing Cholangitis)
## Footnote
PSC is a progressive liver disease that often necessitates transplantation due to its severe complications.
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