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79 Cards in this Set

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What is the volume of hepatic bile secretion?


What are the components of bile?


Where are they stored?


What does the gall bladder do following a meal?

What are the three different types of stones?

Pure and mixed cholesterol stones
Pigmented stone: brown
Pigmented stone: black

Pure and mixed cholesterol stones


Pigmented stone: brown


Pigmented stone: black

- Most frequent type of stone
- Yellowish-white
- Monohydrate cholesterol crystals
- Matrix of mucin glycoprotein
- Calcium salts of unconjugated bilirubin
- Only occasionally seen by x-ray



Which type of stone?

Pure and mixed cholesterol stones

- Calcium salts and deconjugated bilirubin , cytoeskeleton of bacteria
- Frequent in patient with previous surgery, patients with duodenal diverticula


Which type of stone?

Pigmented Stone brown

- Black pigmented: seen more in patients with liver disease, hemolysis, older age
- Pure calcium bilirubinate, calcium copper, mucin glycoprotein


Which type of stone?

Pigmented stone black

Draw out the pathway of cholesterol metabolism.



What are the three components of the total body pool of cholesterol?



What happens when cholesterol is secreted?

What are the three components of the total body pool of cholesterol?



What happens when cholesterol is secreted?

What is the rate limiting enzyme in bile acid synthesis?

7-a-hydroxylase

7-a-hydroxylase

Draw the pathway of enterhepatic circulation.



How many times per day does this occur?


Where is storage? Low absorption? Active and passive absorption?

Gall bladder = storage
Jejunum = low absorption
Ileum = active and passive absorption

Gall bladder = storage


Jejunum = low absorption


Ileum = active and passive absorption

What is the pathophysiology of cholesterol stone formation (3 major components)?

Identify the causes of each:

Identify the causes of each:

How do each of these cause cholesterol hyper secretion?



Age


Marked weight reduction


Ileal disease, bypass, or resection

Are cholesterol molecules soluble in water? How are bile acids able to solubilize cholesterol or phospholipid?

Cholesterol molecules are insoluble in water
Amphipathic properties.

Cholesterol molecules are insoluble in water


Amphipathic properties.

What is the cholesterol saturation index (CSI)?



What is the CSI of bile?

Ratio of the amount of cholesterol in a given bile sample to the maximal cholesterol micellar-holding capacity of that sample in vitro.



CSI of bile > 1 = supersaturated

How can cholesterol be found in bile? What are the components of each?



Mixed micelle


Simple micelle


Vesicles


Multilamelar vesicles

Mixed micelle: bile acids, cholesterol, bilirubin, PC
                                             
Simple micelle: bile acids, cholesterol, bilirubin
                                             
Vesicles: 10 times larger, no bile salts
         ...

Mixed micelle: bile acids, cholesterol, bilirubin, PC


Simple micelle: bile acids, cholesterol, bilirubin


Vesicles: 10 times larger, no bile salts


Multilamelar vesicles: unstable and permit crystals formation

Crystal formation
Crystal generation

Crystal formation


Crystal generation

Formation = aggregation process by which crystal particle is formed from supersaturated bile



Generation = vesicular fusion and aggregation

Look over inhibitors and promotors of crystal formation. 
 
The gallbladder mucosa concentrates bile and secretes mucin glycoprotein/ changes in composition of bile (such as high cholesterol saturation and an increased deoxycholate content all enh...

Look over inhibitors and promotors of crystal formation.



The gallbladder mucosa concentrates bile and secretes mucin glycoprotein/ changes in composition of bile (such as high cholesterol saturation and an increased deoxycholate content all enhance what?

Several factors have been identified that either promote or inhibit the kinetics of cholesterol crystal formation. The
gallbladder mucosa concentrates bile and secretes mucin glycoprotein, both of which increases cholesterol crystal formation. Changes in the composition of bile, including high cholesterol saturation and an increased deoxycholate content all enhance cholesterol crystallization.

Patients with gall-stones have a delay in gallbladder emptying. True or false?

True

True

Defective acidification of gallbladder bile


> pH higher precipitation of calcium salts


Gallbladder stasis can produce increase of mucin and interfere with mechanical emptying


Decreased response to CCK



What are these all risk factors for?

Gallstone formation

Gallstone formation

Draw out the pathophysiology of gallstone formation.

Draw it out again...

Hemolysis
Advancing age
Long term TPN
Cirrhosis
What are these all risk factors for?

Black stones

Black stones

What are some clinical risk factors for black pigment gallstone disease?

Bacterial infection
Decreasing biliary secretory IgA


High activity of B-glucuronidase



What do all these cause?

Brown stones



(In heart patients?)

Draw the pathophysiology of brown pigment gallstone formation.

What is a cholelith?


What is more than 95% of all gallbladder disease?

What percent of people have cholelithiasis?


What countries have highest rates? Lowest?


What are the two major types in the US?

Review

Review

What are the clinical manifestations of each?



Biliary colic


Acute cholecystitis


Choledocholithiasis with cholangitis


Biliary pancreatitis

Choledocholithiasis = also have pain in RUQ

What is the most common elective abdominal operation?



What is found in 12%-15% of patients who undergo cholecystectomy?

What is the arrow pointing to?

What is the arrow pointing to?

biliary obstruction,
acute or chronic pancreatitis,
acute or chronic cholangitis,
acute or chronic cholecystitis
(if in cystic duct),
liver abscess,
chronic liver disease,
secondary biliary cirrhosis.


What are these all complications of?



What is cholelithiasis?

Identify cholelithiasis and choledocholithiasis

Identify cholelithiasis and choledocholithiasis

What is the organ?
Normal or abnormal?
What does it secrete into what?

What is the organ?


Normal or abnormal?


What does it secrete into what?

What is inflammation of the biliary tree (often with infection)?



What is is almost always caused by?



What are some uncommon causes?

What is the diagnosis? How do you know? What is casting the shadow?

What is the diagnosis? How do you know? What is casting the shadow?

Stone disease



Hyperechoic (white) structures within the gall-bladder with a shadow. This is the typical appearance of cholelithiasis by ultrasound
Abdominal ultrasound is the most sensitive test for the diagnosis of gallstone

What is the diagnosis? How do you know?

What is the diagnosis? How do you know?

Emphysematous cholecystitis



The presence of air at the gallbladder wall is a radiologic finding highly suggestive of acute cholecystitis

What is the procedure? What does it show? 
 
What percent of patients with cholelithiasis will have this?

What is the procedure? What does it show?



What percent of patients with cholelithiasis will have this?

Endoscopic rethrograde cholangiography (ERCP). This cholangiogram shows filling defects consistent with choledocholithiasis
10 % of patients with cholelithiasis will have choledocholithiasis

Acute cholecystitis:



Common or uncommon?
Ages?


What percent have gallstones obstructing the neck of the gallbladder or cystic duct



What are the symptoms? Location?



What are the signs?

Acute cholecystitis:



While palpating the area of the gallbladder, patient is asked to inspire deeply, causing increased pain
(sensitivity 97% and specificity 48%)



What sign is this?



What two labs will you see?


What are two complications?


What is the treatment?

What percent of gallbladders removed for acute cholecystitis contain no gallstones?



What is the term for this?



What are four types of patients who may have this procedure?



What are the two major etiological factors?

What is the diagnosis?

What is the diagnosis?

Describe. What is the diagnosis?

Describe. What is the diagnosis?

Chronic cholecystitis:



Associated with what two things?


What are the symptoms?


How do you diagnosis it?


What is the treatment?

gray-tan wall thickened with fibrosis, 3 stones (one obstructing cystic duct, arrow), and
tan mucosa,
with yellowish
areas that
may have
cholesterol-
laden
macrophages
(feature
 called 
“cholesterol-
  osis”, some-
 times bright
 yellow)
 
Wha...

gray-tan wall thickened with fibrosis, 3 stones (one obstructing cystic duct, arrow), and
tan mucosa,
with yellowish
areas that
may have
cholesterol-
laden
macrophages
(feature
called
“cholesterol-
osis”, some-
times bright
yellow)



What is the diagnosis?

Chronic cholecystitis

gray-tan wall thickened with fibrosis, one large and numerous small stones
mixed with gray mucus, tan exudate and red blood
in the lumen (yuck), and congested fibrotic serosa
 
What is the diagnosis?

gray-tan wall thickened with fibrosis, one large and numerous small stones
mixed with gray mucus, tan exudate and red blood
in the lumen (yuck), and congested fibrotic serosa


What is the diagnosis?

Chronic cholecystitis

infiltration of the wall by lymphocytes, in this case with mucosal edema, congestion and hyperplasia combining to throw
the mucosa up into papillary projections.
 
Diagnosis?

infiltration of the wall by lymphocytes, in this case with mucosal edema, congestion and hyperplasia combining to throw
the mucosa up into papillary projections.


Diagnosis?

Chronic cholecystitis

What is the term for this microscopic hernitation of gallbladder mucosa though the muscular wall? Is this cancer? 
 
What is the diagnosis?

What is the term for this microscopic hernitation of gallbladder mucosa though the muscular wall? Is this cancer?



What is the diagnosis?

Chronic cholecystitis

What can cholestasis be the result of?



What are the intrahepatic and extra hepatic causes?

What are these all causes of?

What are these all causes of?

Mechanical cholestasis

How often do biliary complications occur after liver transplantation? 
 
What do patients present with? 
 
How is the diagnosis made?

How often do biliary complications occur after liver transplantation?



What do patients present with?



How is the diagnosis made?

Primary sclerosing cholangitis:
 
Chronic cholestatic disease of the which bile ducts?
Most frequent in which sex?
80% have what associated condition? 
Any risk for malignancy?
How do you treat?
Does HIV cholangiopathy present a similar finding?

Primary sclerosing cholangitis:



Chronic cholestatic disease of the which bile ducts?


Most frequent in which sex?


80% have what associated condition?


Any risk for malignancy?


How do you treat?


Does HIV cholangiopathy present a similar finding?

Chronic cholestatic disease of the intrahepatic and extrahepatic bile ducts
Six to eight cases per 100,000 persons.
Most frequent in men
80% of patients with Primary Sclerosing Cholangitis have concomitant inflammatory bowel disease
Patients with PSC are on risk for developing bile duct malignancy (cholangiocarcinoma)
Clinical presentation ad chronic cholestasis
Treatment with liver transplantation
HIV cholangiopathy presents in a similar radiologic findings

What is the probably pathogenesis of primary sclerosing cholangitis?


Associated with which disease? Age? Sex?

What is the diagnosis?

What is the diagnosis?

Primary sclerosing cholangitis

What three things does primary sclerosis cholangitis usually present with?



What do patients also commonly have (characteristic "beading" of bile ducts due to strictures and dilatations).

20% of patients with chronic pancreatitis will present with what?


What is the clinical presentation?


What is the treatment?

What is the term for blood from biliary tree?


What are some things that can cause it?


What three things do patients usually present with?



What is the treatment?

What are these all other causes of? What does malignancy usually present with?

What are these all other causes of? What does malignancy usually present with?

Mechanical cholestasis



Malignancy => progessive painless jaundice and weight loss

Gallbladder carcinoma:



Which sex? Two races?


What is the risk factor?

Diagnosis? Type of growth pattern?

Diagnosis? Type of growth pattern?

Gallbladder carcinoma



Exophytic

Diagnosis? Growth pattern?

Diagnosis? Growth pattern?

Gallbladder carcinoma


Infiltrating

What is happening here?

What is happening here?

Gallbladder carcinoma invading the liver

What type of cancer is gallbladder carcinoma? What is it lined by? Similar to what carcinoma?

What type of cancer is gallbladder carcinoma? What is it lined by? Similar to what carcinoma?

Gallbladder carcinoma:



Age of presentation?


Symptoms?


Sign? (sometimes)



How do you diagnose? Is surgery an option?


What is the prognosis?

What percent of all GI malignancies?
Age and sex? What are some risk factors? 
Two things it commonly presents with? What will labs suggest? What tumor marker is sometimes present?

What percent of all GI malignancies?


Age and sex? What are some risk factors?


Two things it commonly presents with? What will labs suggest? What tumor marker is sometimes present?

3 % of all GI malignancies Most frequent in men at 50-70 years old
Risk factors include Primary sclerosing cholangitis, Hepatitis C related cirrhosis, toxin exposure, infection with liver flukes (clonorchis) and other
Commonly present with biliary obstruction causing painless jaundice
Laboratory studies suggest biliary obstruction: elevated total bilirubin, elevated alkaline phosphatase, 5’-nucleotidase and GGT.
Patients may have high tumor markers as Ca 19-9
Diagnosis: endoscopic retrograde cholangiography, magnetic resonance cholangiography
Treatment: surgery, endoscopic palliation

What are some common symptoms of EXTRAHEPATIC cholangiocarcinoma? Three signs? What labs will be high?

Extrahepatic cholangiocarcinoma. Identify what is indicated by the arrows.

Extrahepatic cholangiocarcinoma. Identify what is indicated by the arrows.

What is the disease? How do you know?

What is the disease? How do you know?

What is the most common cause of biliary obstruction by malignancy? When does it occur (location)?



Two clinical presentations?

Is ampullary malignancy common? Fast or slow growing? Treatment?

It’s not frequent
Slow growth
Treatment: surgery and/or stent placement

It’s not frequent
Slow growth
Treatment: surgery and/or stent placement

44 yo black female, history of sickle cell disease, mother of four, history of obesity, alcohol, and tobacco use => tries weight loss



Following a meal she experiences RUQ abdominal pain radiating to her right shoulder. She developed anorexia progressing to nausea and vomiting associated with mild fever, sweating, and tachycardia. What is the most likely cause of her symptoms?

Acute cholecystitis

Which is not a risk factor for acute cholecystitis?



Age


Alcohol use


Female gender


Hemolysis


Obesity


Prolonged fasting

What do the risk factors for the development of gallstones include?



Decelerated cholesterol crystal nucleation


Decreased hemoglobin breakdown


Hypomotility of the gallbladder


Hyposaturation of bile with cholesterol


Hyposecretion of mucus in the gallbladder

Hypomotility of the gallbladder

Pigmented gallstones are more common in:



Alcoholics


Female


Hemolysis


Obesity


Pregnency

Hemolysis