Diseases of the Gallbladder

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what is the size of the gallbladder?

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10 cm

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the gallbladder is capable of holding ______ of bile

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50 ml

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59 Terms

1
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what is the size of the gallbladder?

10 cm

2
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the gallbladder is capable of holding ______ of bile

50 ml

3
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what is the function of the gallbladder?

receive, store & concentrate bile

- stimulated by cholecystokinin, usually over 10-15 mins

4
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what is cholelithiasis?

presence of gallstones w/i the gallbladder

5
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what is cholecystitis?

inflammation of the gallbladder

- potentially w/ or w/o stones

6
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what is choledocholithiasis?

presence of gallstones in the common bile duct

7
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what is cholangitis?

inflammation of the bile duct(s)

- potentially affecting the entire biliary tree

8
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what is included in liver function tests (LFTs)?

- alanine aminotransferase (ALT)

- aspartate aminotransferase (AST)

- gamma glutamyl transpeptidase (GGT)

- alkaline phosphatase (ALP)

- bilirubin

9
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elevated AST, ALT & GGT suggest ________ injury

hepatic (liver)

- commonly due to: hepatitis, toxin/drug injury, alcohol, fatty liver, or hemochromatosis

10
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elevated ALP & bilirubin suggest ___________ obstruction

biliary

11
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gallstones do not just appear. how do they start?

supersaturation

- imbalance in the chemical constituents of bile that results in precipitation of >/= 1 of the components (biliary sludge)

12
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what are the types of gallstones?

- cholesterol & mixed

- pigmented

13
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which are more common:

cholesterol & mixed or pigmented gallstones?

cholesterol & mixed (90%)

14
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cholesterol & mixed gallstones

most common

- characterized by their yellowish green color & soft texture

15
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pigmented gallstones

not common (10%)

- characterized by their darker color & grain-like texture

- composed of calcium bilirubinate

- sometimes detectable on plain films

16
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complications/clinical presentations of gallstones:

- biliary colic

- acute cholecystitis

- acute cholangitis

- acute biliary pancreatitis

- perforation of GB

- small bowel ileus

17
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biliary colic is a ___________ obstruction of the cystic or common bile duct

transient

1 multiple choice option

18
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clinical presentation of biliary colic

may start w/ mild, sporadic, or nonspecific complaints

- sudden onset: epigastric pain (most common), then RUQ pain which plateaus in 15 mins & usually lasts 1-4 hrs

- may refer to shoulder, chest, or back

- pain often develops 15 mins to 2 hrs after eating (nocturnal pain is common)

19
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5 Fs (risk factors) of cholecystitis:

- female (2-3 x > male)

- forty/40 y/o (age)

- fat (obesity)

- fertile (multiparity)

- fair (caucasian)

20
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clinical presentation of acute cholecystitis

- local inflammation

- RUQ mass, pain, fever, N/V, leukocytosis

- hx of previous episodes

- lasts > 8 hrs

- shifts from epigastrium to RUQ

- murphy's sign

- jaundice

- acalculous disorder

21
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what is murphy's sign?

acute pain and inspiratory arrest elicited by palpation of the RUQ during inspiration

- sign of: cholecysitis

22
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what is acalculous disorder/cholecystitis?

inflammation of the gallbladder (probably due to bile stasis) w/o stones

- more common in older, male, critically ill, TPN, surgery or trauma patients

- higher rate of complications

23
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how can you tell the difference between biliary colic & cholecystitis?

biliary colic

- upper abdomen or RUQ pain (may refer to shoulder, chest or back)

- < 8 hrs

- may have N/V

- no TTP in RUQ

- no inflammatory signs

cholecystitis

- usually localizes as RUQ pain

- > 8 hrs

- more frequent N/V

- TTP in RUQ

- inflammatory signs

24
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how is acute cholecystitis treated?

- NPO

- IV fluids

- NG tube (low, intermittent suction if significant vomiting)

- pain control (NSAIDs [IV ketorolac], opioids if no relief)

- antibiotics (gram - & anaerobes)

- consider severity & whether healthcare associated infection

25
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what is acute ascending cholangitis?

bacterial infection of the biliary tract

- suppurative (to form or discharge pus usually in response to bacterial infections) condition

26
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clinical presentation of acute ascending cholangitis

- charcot's triad (RUQ pain, fever/chills, jaundice)

- signs of sepsis (altered mentation, hypotension, shock)

27
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what is charcot's triad?

sign of acute ascending cholangitis

- RUQ pain

- jaundice

- fever/chills

28
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what are the typical organisms in acute ascending cholangitis?

- e. coli

- klebsiella

- pseudomonas

- anaerobes

29
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is acute ascending cholangitis a surgical emergency?

YES!

1 multiple choice option

30
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what is the imaging modality of choice for assessing an issue w/ gallbladder?

ultrasound

- although less sensitive for common duct stones

31
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will plain films (radiographs/XRs) visualize cholesterol stones?

NO

- you should NOT be able to see the gallbladder on XR, if you can: beware of "porcelain gallbladder"
- porcelain gallbladder = gallbladder calcification

32
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what is "porcelain gallbladder?"

calcium depositions in the gallbladder

- cancer until proven otherwise

- should prompt investigation

33
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why are CT or MRI not commonly done to diagnose a disease of the gallbladder?

expensive & time consuming

34
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what is a hepatobiliary or cholescintigraphy (HIDA scan)?

technetium labeled HIDA is injected, taken up by hepatocytes & excreted into bile

- used when looking for obstruction of cystic duct & to assess gallbladder function

35
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____ is best for finding choledocholithiasis & can be both diagnostic & therapeutic

ERCP

36
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will uncomplicated biliary colic show any lab abnormalities?

no

1 multiple choice option

37
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lab abnormalities for acute cholecystitis & ascending cholangitis

- leukocytosis w/ "left shift"

- elevated liver enzymes (ALP & bilirubin)

- elevated amylase (acute pancreatitis)

38
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ascending cholangitis may also have positive (+) ________________

blood cultures

39
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Gallstones present but pt is asymptomatic … treatment =

none (w/ exceptions)

40
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treatment in an acute episode =

- NPO

- analgesics

- antibiotics

- consider surgery (2-3 days)

41
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oral dissolution therapy =

ursodiol (Actigall)

- last ditch effort; usually a poor surgical candidate; 50% recurrence rate

42
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what are the surgical treatment options?

- laparoscopic cholecystectomy

- open subcostal incision

43
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if there is a slightly higher incidence of bile duct injury w/ laparoscopic cholecystectomy, why is it the preferred surgical treatment option?

- reduced postop pain & recovery

- looks better cosmetically

44
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atypical symptoms:

- chest pain

- epigastric pain

- nonspecific abdominal pain

- early satiety

- abdominal distention/bloating

- nausea

45
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what is cholangiocarcinoma?

cancer of the biliary tree

- can be intrahepatic, extrahepatic or both

- periductal or intraductal

46
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s/s of cholangiocarcinoma:

depends on location of tumor

47
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is most cholangiocarcinoma extrahepatic or intrahepatic?

extrahepatic

1 multiple choice option

48
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s/s of extrahepatic cholangiocarcinoma

- constant, dull RUQ ache

- weight loss

- sx of biliary obstruction:

*jaundice

*pruritis

*clay colored stools

*dark urine

49
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s/s of intrahepatic cholangiocarcinoma

- constant, dull RUQ ache

- weight loss

- elevated ALP

- jaundice less likely

50
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how is cholangiocarcinoma diagnosed?

- labs (serum transaminases [AST, ALT, ALP, GGT], bilirubin [total, direct & indirect])

- RUQ ultrasound (US)

- GI referral (MRCP/ERCP)

51
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what finding on RUQ ultrasound is concerning for cholangiocarcinoma?

ductal dilation w/o stones

52
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what is primary sclerosing cholangitis?

autoimmune, fibrous obliteration of intra or extrahepatic bile ducts

- s/s: malaise, fatigue, pruritis

- may be idiopathic or autoimmune

- 50% will also have IBD

- 10-20% will develop cholangiocarcinoma

- tx: transplant

53
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what is primary biliary cholangitis (biliary cirrhosis)?

autoimmune destruction of interlobular bile ducts

- middle aged women

- women > men (15:1)

- insidious onset over decades

- s/s: pruritis, hepatomegaly, abnormal lipid metabolism; + antimitochondrial antibody

54
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does biliary colic have any systemic sx?

no

1 multiple choice option

55
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in general, how is acute cholecystitis treated?

- admit

- broad spectrum abx

- surgical consult

56
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what is charcot's triad associated w/?

ascending cholangitis

- which is a surgical emergency

57
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if GB can be seen on plain xray:

evaluate

- this is NOT normal

58
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which of these is an autoimmune, fibrous obliteration of intra or extrahepatic bile ducts?

a. primary sclerosing cholangitis (PSC)

b. primary biliary cholangitis (PBC)

a. primary sclerosing cholangitis (PSC)

- assoc. w/ IBD & cholangicarcinoma

59
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which of these is an autoimmune destruction of interlobular bile ducts?

a. primary sclerosing cholangitis (PSC)

b. primary biliary cholangitis (PBC)

b. primary biliary cholangitis (PBC)

- will also see a positive (+) antimitochondrial antibody