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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
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?
Acute calculous cholecystitis
26
What will the labs for pt w/ acute calculous cholecystitis show?
- Leukocytosis w/ left shift | - +/- elevated AST/ALT
27
Are total bili and alk phos typically elevated w/ acute calculous cholecystitis?
No. | If elevated should be concerning for biliary obstruction
28
What imaging is preferred for evaluated of acute calculous cholecystitis? What are suggestive findings?
US - Gallstones - Wall thickening - Pericholecystic fluid - Positive "sonographic" Murphy's sign
29
What test should be ordered if Acute calculous cholecystitis is uncertain after US?
HIDA | * Positive test = failure to visualize GB (b/d cystic duct obstruction)
30
What is the top 3 common complication of acute calculous cholecystitis?
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
What is the tx for acute calculous cholecystitis?
Admit (NPO, IV fluids/pain meds/abx) | Cholecystectomy
32
What disease is characterized as chronic inflammation of the gallbladder?
Chronic cholecystitis
33
T or F: Chronic cholecystitis is ALWAYS associated w/ gallstones?
TRUE
34
How do pts w/ chronic cholecystitis often present?
Minimal sx due to chronic progression of disease
35
What disease is characterized as acute neoinflammatory disease of the gallbladder in the absence of gallstones due to GB stasis and ischemia?
Acute ACALCULOUS cholecystitis
36
Acute acalculous cholecystitis is common in what pt populations?
Hospitalized and critically ill pts
37
Critically ill pt w/ sepsis w/o clear source or jaundice is concerning for what disease?
Acute acalculous cholecystitis *also in pts w/ postop jaundice
38
What is the work up for pt w/ suspected acute acalculous cholecystitis?
US | Liver tests, CBC, lytes, pancreatic enzymes, UA, CXR
39
Prompt tx of acute acalculous cholecystitis is important to prevent GB gangrene or perf. What is the management?
Cultures then ABX | Cholecystectomy vs GB drainage
40
What disease is due to gallstones in the common bile duct?
Choledocholithiasis
41
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?
Choledocholithiasis
42
What are the labs for pt w/ Choledocholithiasis?
NO leukocytosis | Elevated AST/ALT (early course) vs. elevated serum bili, alk. phos and GGT (late course)
43
What is the initial imaging for choledocholithiasis?
US | - Will show cholelithiasis, CBD stone, CBD dilation > 6 mm
44
If dx of Choledocholithiasis is still uncertain after US, what is your next step?
MRCP (will confirm DX of CBD stone) or endoscopic US (EUS)
45
What is the tx for choledocholithiasis?
ERCP (remove CBD stone) ID and tx complications (acute cholangitis, acute pancreatitis) +/- Cholecystectomy
46
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)?
Acute cholangitis
47
Is acute cholangitis a surgical emergency?
YES if supprative infection ("Pus under pressure")
48
What is charcot's triad and what disease is it associated with?
Charcot's triangle: Fever, abdominal pain, jaundice Acute cholangitis
49
What is charcot's triangle + mental status changes and hypotension?
Reynolds Pentad
50
What are the labs for pt w/ acute cholangitis?
``` Leukocytosis w/ left shift Elevated CRP/ESR Increased bili, alk, phos, GGT, +/- AST/ALT Serum amylase increased 3-4x normal + blood cultures ```
51
What imaging is recommended for acute cholangitis?
1. US | 2. MRCP or EUS if CBD dilation or CBD stone
52
What is the tx for acute cholangitis?
1. Admit 2. Monitor for/tx sepsis 3. Emergent GI/Surgery consults 4. Biliary drainage (ERCP w/ sphincterotomy) + ABX 5. +/- cholecystectomy
53
Primary biliary cholangitis is more common in W or m?
WOMEN
54
What is the cause of primary biliary cholangitis?
Autoimmune destruction of bile ducts resulting in cholestasis
55
Pt w/ hx of Sjorgren's syndrome presents w/ fatigue and prurtitis w/o rash. ON exam you note skin hyperpigmentation and jaundice.
Primary biliary cholangitis
56
What are the labs for Primary biliary cholangitis ?
AMA +/- ANA Elevated liver tests (alk phos, ALT/AST, bili) Hyperlipidemia
57
How is Primary biliary cholangitis diagnosed?
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
Primary sclerosing cholangitis is more common in women or men?
MEN
59
Pts w/ Primary sclerosing cholangitis often have what other disease?
IBD (CD > UC)
60
Primary sclerosing cholangitis will lead to what complications?
Cholestasis and end stage liver disease
61
What is Primary sclerosing cholangitis?
Sclerosing inflammatory obliterative process involving the intrahepatic or extrahepatic biliary tree
62
Pt presents w/ fatigue, pruritis and jaundice. Labs show cholestatic pattern and AMA is NEGATIVE. What is your suspected dx?
Primary sclerosing cholangitis
63
How is Primary sclerosing cholangitis dx?
1. Abn liver tests 2. Cholangiography (MRCP/ERCP) - multifocal strictures and dilation of intra or extrahepatic bile ducts 3. Liver bx (rarely dx)
64
What is the tx for primary biliary cholangitis?
GI referral & med management
65
Primary sclerosing cholangitis can lead to what complications?
ESLD Hepatobiliary CA Colon CA (pts w/ UC)
66
What is the tx for Primary sclerosing cholangitis?
GI referral
67
What inherited disease will typically presents in man post puberty will mild intermittent episodes of jaundice and unconjugated hyperbilirubinemia?
Gilbert Syndrome (no specific tx required)
68
What GB malignancy is the most common CA of the biliary tract, highly fatal and has a RF of porcelain gallbladder?
GB CA
69
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?
Cholangiocarcinoma (bile duct CA)
70
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?
Ampullary Carcinoma

1. Clin Med III (29 decks)

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