BILIARY TRACT DISEASE Year 4 Internal Medicine Notes

BILIARY TRACT DISEASE Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / IMED 4.1 / ALEX / Gastroenterology -- Slide 1 BILIARY TRACT DISEASE DR.ALEX MOGERE CONSULTANT PHYSICIAN Slide 2 OVERVIEW Gallstones Bile Biliary tract tumours Other conditions Acute acalculous cholecystitis Primary Biliary Cirrhosis(PBC) Primary Sclerosing Cholangitis(PSC) Biliary tract cysts Biliary strictures Slide 3 BILE Bile = bile acids+phospholipids +cholesterol Primary bile acids- cholic and chenodeoxycholic acids, formed in liver from cholesterol and AAs Secondary bile acids- bacterial metabolites of primary bile acids formed in the colon(deoxycholate and lithocholate) Helps excrete cholesterol,aid in fat digestion,and fat absorption, cholesterol and fat soluble vitamins in the intestine Slide 5 BILIARY TRACT Part of the digestive system. Made up of: Intra hepatic ducts Extra hepatic ducts Gallbladder Common Bile Duct Slide 6 THE GALLBLADDER The gallbladder concentrates and stores bile. Bile: Secreted by the liver\nContains cholesterol, bile pigments and phospholipids Flows from the liver, through the hepatic ducts, into the gallbladder Exits the gallbladder via the cystic duct Flows from the cystic duct into the common bile duct, into the small intestine In the small intestine, aids digestion by breaking down fatty foods and fat-soluble vitamins Slide 7 GALLSTONES – PATHOPHYSIOLOGY If ratio of cholesterol, phospholipids, and bile salts altered, cholesterol crystals may form\n Gallstone formation involves a variety of factors: Cholesterol super-saturation Mucin hyper-secretion by the gallbladder mucosa creates a viscoelastic gel that fosters nucleation.\nBile stasis Occurs in diabetes, pregnancy, oral contraceptive use, and prolonged fasting in critically ill patients on total parenteral nutrition. Slide 8 GALLSTONES – FREQUENCY Gallstone disease is one of the most common and costly of all digestive diseases 9% of those 60 years In USA, 6.3 million men and 14.2 million women aged 20-74 years have gallbladder disease Incidence of gallstones is 1 million new cases per year Prevalence is 20 million cases in USA Slide 10 GALLSTONES – TYPES Two main types: Cholesterol stones (85%):\n2 subtypes—pure (90-100% cholesterol) or mixed (50-90% cholesterol).\nPure stones often are solitary, whitish, and larger than 2.5 cm in diameter.\nMixed stones usually are smaller, multiple in number, and occur in various shapes and colours.\nPigment stones (15%) occur in 2 subtypes—brown and black.\nBrown stones are made up of calcium bilirubinate and calcium-soaps. Bacteria involved in formation via secretion of beta glucuronidase and phospholipase\nBlack stones result when excess bilirubin enters the bile and polymerizes into calcium bilirubinate (patients with chronic haemolysis) Slide 11 GALLSTONES – NATURAL HISTORY 80% of patients, gallstones are clinically silent 20% of patients develop symptoms over 15-20 years About 1% per year Almost all become symptomatic before complications develop Biliary-type pain due to obstruction of the bile duct lumen Slide 12 GALLSTONES – DIVERSE SYMPTOMS Abdominal pain Aching or tightness, typically severe and located in the epigastrium,more at night, esp after fatty meal May develop suddenly, last for 15 minutes to several hours, and then resolve suddenly Referred pain – posterior scapula or right shoulder area Nausea and vomiting Jaundice\nPruritus: typically worse at night.\nFatigue Weight loss Miscellaneous:\nFatty food intolerance Gas Bloating Dyspepsia Slide 13 COMPLICATIONS OF GALLSTONES In the gallbladder Biliary colic Acute and chronic cholecystitis Empyema Mucocele Carcinoma In the bile ducts Obstructive jaundice Pancreatitis Cholangitis In the Gut Gallstone ileus Slide 14 OBSTRUCTIVE JAUNDICE Blockage of the biliary tree by gallstones Symptoms Pain, Jaundice, dark urine, pale stools Signs Jaundice.\nInvestigations Bloods – U&E, FBC, LFT, Amylase, CRP, Hepatitis screen, Coagulation screen Ultrasound of abdomen Treatment\nEndoscopic Retrograde Cholangio-pancreatogram Slide 15 ASCENDING CHOLANGITIS Obstruction of biliary tree with bile duct infection Symptoms Unwell, pain, jaundice, dark urine, pale stools Charcot triad (ie, fever, right upper quadrant pain, jaundice) occurs in only 20-70% of cases Signs Sepsis (Fever, tachycardia, low BP), Jaundice.\nInvestigations Bloods – U&E, FBC, LFT, Amylase, CRP, Coagulation screen Ultrasound of abdomen Treatment\nIntravenous antibiotics Endoscopic Retrograde Cholangio-Pancreatogram (ERCP) Slide 16 GALLSTONE ILEUS Obstruction of the small bowel by a large gallstone A stone ulcerates through the gallbladder into the duodenum and causes obstruction at the terminal ileum Symptoms Small bowel obstruction (vomiting, abdominal pain, distension, nil PRr) Signs Abdominal distension, obstructive bowel sounds.\nInvestigations Bloods – U&E, FBC, LFT, Amylase, CRP, Hepatitis screen, Coagulation screen Plain film of abdomen – Air in CBD, small bowel fluid levels an