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1. Clin Med III > 2- Biliary disease > Flashcards

2- Biliary disease Flashcards

1
Q

What is inflammation of the GB?

A

Cholecystitis

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2
Q

What is stones in the GB?

A

Cholelithiasis

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3
Q

What is inflammation of the bile ducts?

A

Cholangitis

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4
Q

What is disruption of bile flow?

A

Cholestasis

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5
Q

What is stones in the common bile duct?

A

Choledocholithiasis

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6
Q

What are the 4 F’s of cholelithiasis?

A

RFs:

  • Female
  • 40
  • Fluffy
  • Fertile
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7
Q

What are the 4 types of GB stones? What is the most common?

A
  1. Cholesterol stones (most common)
  2. Pigment stones
  3. Black pigment stones (hemolytic anemia)
  4. Brown pigment stones (parasitic/infection)
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8
Q

How do the majority of pts w/ cholelithiasis present?

A

Asx. Gallstones are an incidental finding

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9
Q

What is the initial test of choice for assessing cholelithiasis?

A

US

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10
Q

What is the tx for pts w/ asymptomatic (incidental) gallstones?

A

No tx

Referred for cholecystectomy if sx develop (except if risk of gallbladder cancer or hemolytic disease)

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11
Q

Uncomplicated gallstone disease is AKA what?

A

Biliary colic (no inflammation of the gallbladder)

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12
Q

Describe biliary-type pain

A
  • RUQ pain +/- radiation to right shoulder
  • 30 min- 5/6 hrs of constant pain (plateaus at 1 hr)
  • Postprandial pain (fatty, greasy foods)
  • N/V + diaphoresis
  • Not exacerbated by movement or relieve w/ BM
  • Nocturnal pain
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13
Q

Pt presents with classic biliary-type pain. On exam pt has normal vitals, no evidence of jaundice, and negative Murphy’s sign. What is you suspected dx?

A

Biliary colic

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14
Q

Pt w/ biliary colic/uncomplicated gallstone disease will have what expected lab values & US findings?

A

NORMAL labs (CBC, liver test, amylase, lipase)

US w/ gallstones/sludge. NO inflammation

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15
Q

What is the tx for pt w/ uncomplicated gallstone disease w/ + gallstones on US?

A

Cholecystectomy recommended to prevent recurrent sx and complications

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16
Q

What is characterized by biliary type pain in the absence of gallstones, sludge, microlithiasis or microcrystal disease?

A

Functional gallbladder disorder

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17
Q

Functional gallbladder disorder is thought to be due to what?

A

Gallbladder dysmotility

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18
Q

How is functional gallbladder disorder dx?

A

Diagnosis of EXCLUSION.

If no cause of biliary pain identified follow Rome IV criteria

  • Biliary pain
  • Absence of gallstones or other structural pathology
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19
Q

What is the Rome IV criteria for functional gallbladder disorder?

A

Biliary pain

Absence of gallstones or other structural pathology

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20
Q

What tests are supportive of functional gallbladder disorder by not required?

A

CCK w/ low ejection fraction (<35-40%)

Normal liver enzymes, conjugated bilirubin, amylase/lipase

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21
Q

When is a cholecystectomy recommended for a pt w/ functional gallbladder disorder?

A

Biliary type pain + GB efection fraction < 40&

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22
Q

What disease is characterized by acute inflammation of the gallbladder is predominantly a complication of gallstone disease?

A

Acute cholecystitis

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23
Q

Acute calculous cholecystitis usually occurs as a result of what?

A

Cystic duct obstruction

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24
Q

How does a pt w/ acute calculous cholecystitis present?

A 
Progressively worsening biliary pain 
Prolonged severe RUQ/epigastric pain > 4-6 hrs
\+/- radiation to R shoulder or back
Fever
Hx of fatty food ingestion
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25
Q

Pt presents with severe RUQ pain > 5 hrs. Vitals show fever and tachycardia. On exam pt is ill appearing w/o jaundice, RUQ tenderness and positive Murphy’s sign. What is your suspected dx?

A

Acute calculous cholecystitis

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26
Q

What will the labs for pt w/ acute calculous cholecystitis show?

A
  • Leukocytosis w/ left shift

- +/- elevated AST/ALT

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27
Q

Are total bili and alk phos typically elevated w/ acute calculous cholecystitis?

A

No.

If elevated should be concerning for biliary obstruction

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28
Q

What imaging is preferred for evaluated of acute calculous cholecystitis? What are suggestive findings?

A

US

  • Gallstones
  • Wall thickening
  • Pericholecystic fluid
  • Positive “sonographic” Murphy’s sign
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29
Q

What test should be ordered if Acute calculous cholecystitis is uncertain after US?

A

HIDA

* Positive test = failure to visualize GB (b/d cystic duct obstruction)

30
Q

What is the top 3 common complication of acute calculous cholecystitis?

A
  1. Gangrene (20%)
  2. Perforation (10%) - often after development of gangrene
  3. Mirizzi syndrome - gallstone impacted in distal cystic duct causing extrinsic compression on common bile duct)
31
Q

What is the tx for acute calculous cholecystitis?

A

Admit (NPO, IV fluids/pain meds/abx)

Cholecystectomy

32
Q

What disease is characterized as chronic inflammation of the gallbladder?

A

Chronic cholecystitis

33
Q

T or F: Chronic cholecystitis is ALWAYS associated w/ gallstones?

A

TRUE

34
Q

How do pts w/ chronic cholecystitis often present?

A

Minimal sx due to chronic progression of disease

35
Q

What disease is characterized as acute neoinflammatory disease of the gallbladder in the absence of gallstones due to GB stasis and ischemia?

A

Acute ACALCULOUS cholecystitis

36
Q

Acute acalculous cholecystitis is common in what pt populations?

A

Hospitalized and critically ill pts

37
Q

Critically ill pt w/ sepsis w/o clear source or jaundice is concerning for what disease?

A

Acute acalculous cholecystitis

*also in pts w/ postop jaundice

38
Q

What is the work up for pt w/ suspected acute acalculous cholecystitis?

A

US

Liver tests, CBC, lytes, pancreatic enzymes, UA, CXR

39
Q

Prompt tx of acute acalculous cholecystitis is important to prevent GB gangrene or perf. What is the management?

A

Cultures then ABX

Cholecystectomy vs GB drainage

40
Q

What disease is due to gallstones in the common bile duct?

A

Choledocholithiasis

41
Q

Pt presents with biliary type pain and reports of jaundice. On exam, vitals are WNL, pt is jaundiced and + courvoisier’s sign (palpable GB). What is your suspected dx?

A

Choledocholithiasis

42
Q

What are the labs for pt w/ Choledocholithiasis?

A

NO leukocytosis

Elevated AST/ALT (early course) vs. elevated serum bili, alk. phos and GGT (late course)

43
Q

What is the initial imaging for choledocholithiasis?

A

US

- Will show cholelithiasis, CBD stone, CBD dilation > 6 mm

44
Q

If dx of Choledocholithiasis is still uncertain after US, what is your next step?

A

MRCP (will confirm DX of CBD stone) or endoscopic US (EUS)

45
Q

What is the tx for choledocholithiasis?

A

ERCP (remove CBD stone)

ID and tx complications (acute cholangitis, acute pancreatitis)

+/- Cholecystectomy

46
Q

What disease is characterized by ascending inflammation of the biliary duct system most often caused by a bacterial infection in a pt w/ biliary obstruction (ex: choledocholithiasis)?

A

Acute cholangitis

47
Q

Is acute cholangitis a surgical emergency?

A

YES if supprative infection (“Pus under pressure”)

48
Q

What is charcot’s triad and what disease is it associated with?

A

Charcot’s triangle: Fever, abdominal pain, jaundice

Acute cholangitis

49
Q

What is charcot’s triangle + mental status changes and hypotension?

A

Reynolds Pentad

50
Q

What are the labs for pt w/ acute cholangitis?

A 
Leukocytosis w/ left shift
Elevated CRP/ESR
Increased bili, alk, phos, GGT, +/- AST/ALT
Serum amylase increased 3-4x normal
\+ blood cultures
51
Q

What imaging is recommended for acute cholangitis?

A
  1. US

2. MRCP or EUS if CBD dilation or CBD stone

52
Q

What is the tx for acute cholangitis?

A
  1. Admit
  2. Monitor for/tx sepsis
  3. Emergent GI/Surgery consults
  4. Biliary drainage (ERCP w/ sphincterotomy) + ABX
  5. +/- cholecystectomy
53
Q

Primary biliary cholangitis is more common in W or m?

A

WOMEN

54
Q

What is the cause of primary biliary cholangitis?

A

Autoimmune destruction of bile ducts resulting in cholestasis

55
Q

Pt w/ hx of Sjorgren’s syndrome presents w/ fatigue and prurtitis w/o rash. ON exam you note skin hyperpigmentation and jaundice.

A

Primary biliary cholangitis

56
Q

What are the labs for Primary biliary cholangitis ?

A

AMA +/- ANA
Elevated liver tests (alk phos, ALT/AST, bili)
Hyperlipidemia

57
Q

How is Primary biliary cholangitis diagnosed?

A
  1. No extrahepatic biliary obstruction
  2. No comorbidity affecting the liver
  3. 2 of the following:
    • Elevated Alk pho’s
      • AMA
    • Histologic evidence of PBC
58
Q

Primary sclerosing cholangitis is more common in women or men?

A

MEN

59
Q

Pts w/ Primary sclerosing cholangitis often have what other disease?

A

IBD (CD > UC)

60
Q

Primary sclerosing cholangitis will lead to what complications?

A

Cholestasis and end stage liver disease

61
Q

What is Primary sclerosing cholangitis?

A

Sclerosing inflammatory obliterative process involving the intrahepatic or extrahepatic biliary tree

62
Q

Pt presents w/ fatigue, pruritis and jaundice. Labs show cholestatic pattern and AMA is NEGATIVE. What is your suspected dx?

A

Primary sclerosing cholangitis

63
Q

How is Primary sclerosing cholangitis dx?

A
  1. Abn liver tests
  2. Cholangiography (MRCP/ERCP) - multifocal strictures and dilation of intra or extrahepatic bile ducts
  3. Liver bx (rarely dx)
64
Q

What is the tx for primary biliary cholangitis?

A

GI referral & med management

65
Q

Primary sclerosing cholangitis can lead to what complications?

A

ESLD
Hepatobiliary CA
Colon CA (pts w/ UC)

66
Q

What is the tx for Primary sclerosing cholangitis?

A

GI referral

67
Q

What inherited disease will typically presents in man post puberty will mild intermittent episodes of jaundice and unconjugated hyperbilirubinemia?

A

Gilbert Syndrome (no specific tx required)

68
Q

What GB malignancy is the most common CA of the biliary tract, highly fatal and has a RF of porcelain gallbladder?

A

GB CA

69
Q

What GB malignancy arises from the epithelial cells fo the bile ducts, is associated w/ Primary sclerosing cholangitis (sx: jaundice, prurtitis, weight loss) and has labs that show cholestasis?

A

Cholangiocarcinoma (bile duct CA)

70
Q

What GB malignancy will in the vicinity fo the ampulla of vater, has an increased incidence w/ familial adenomatous polyposis and presents w/ obstructive jaundice?

A

Ampullary Carcinoma

1. Clin Med III (29 decks)

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