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OBG > Biliary > Flashcards

Biliary Flashcards

1
Q 
RUQ pain radiating to the back after fatty meals
resolves within a few hours 
female
multigravida
obese
A

Cholelithiasis

Gallstones

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2
Q

RUQ pain radiating to back +/− scapular pain,
persistent (4–6+ hours)
fever
Leukocytosis
tachycardia
Murphy’s sign (too painful to breath with palpation)

A 
Acute cholecystitis
(Gallbladder infection 2/2 cystic duct obstruction)
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3
Q

RUQ pain with jaundice but no systemic inflammatory signs
(no fever or leukocytosis)
Abnormal Bilirubin/ ALP levels

A

Choledocholithiasis

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4
Q

Episodic RUQ pain aggravated by opioids

A

Sphincter of Oddi dysfunction

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5
Q

Persistent RUQ pain
fever
jaundice

(Charcot’s triad)

A

Acute cholangitis

abnormal bili/ALP

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6
Q

Severe epigastric pain
radiating straight through to back
(2/2 cholelithiasis, alcohol abuse, CF)
Abnormal lipase/amylase

A

Acute Pancreatitis

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7
Q

a positive Murphy’s sign, fever, tachycardia, and elevated white blood cell (WBC) count,

Most likely diagnosis is:

A

acute cholecystitis

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8
Q

Symptomatic cholelithiasis (gallstones) is usually managed as an outpatient, with eventual elective

A

laparoscopic cholecystectomy

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9
Q

Acute cholecystitis requires hospital admission, intravenous (IV) antibiotics, and urgent

A

cholecystectomy

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10
Q

U/S reveals:

Gallstones
gallbladder wall thickening >4 mm
pericholecystic fluid
+ sonographic Murphy’s

A

acute cholecystitis

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11
Q

Fatty food ingestion triggers the release of ___, which leads to contraction of the gallbladder.

A

cholecystokinin (CCK)

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12
Q

Main Risk Factors for Developing Cholesterol Gallstones?

Lithogenic bile
Obesity
High-fat diet
Hyperlipidemia
Hispanic

(6-7)

A

Increased estrogen
(females, pregnancy, OCPs)

Crohn’s disease
terminal ileal resection
Rapid weight loss after gastric surgery
Vagotomy (cutting vagal n. for PUD)
Statins
Total parenteral nutrition
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13
Q

Black stones are often associated with

A

Hemolytic diseases such as:
Hereditary spherocytosis
Sickle cell disease
G6PD deficiency

(2/2 increased unconjugated bilirubin)

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14
Q

Brown stones most often form within the bile ducts & are associated with

A

bacterial infection or parasites

ex: Chinese liver fluke
* brown stone common in asians

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15
Q

Transient obstruction of the cystic duct →
visceral peritoneal stretch →
RUQ pain

A

Symptomatic cholelithiasis

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16
Q 
Persistent obstruction of the cystic duct → 
visceral peritoneal stretch → 
inflammation of the gallbladder → 
bacterial overgrowth → 
infection of the gallbladder → 
parietal peritoneum inflammation
A

Acute Cholecystitis

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17
Q

Obstruction of the common bile duct (CBD)

A

Choledocholithiasis

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18
Q 
Obstruction of the CBD → 
bacterial overgrowth → 
infection of the entire biliary tree → 
ascends into the liver →
cholestasis
A

Acute Cholangitis

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19
Q

Obstruction of the CBD and pancreatic duct (often at the ampulla of Vater) →
pancreatic enzyme release →
autodigestion/inflammation of pancreas →
cholestasis

A

Acute gallstone pancreatitis

Obstruction usually distal to pancreatic duct

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20
Q

Large stone erodes into the duodenum →
gallbladder-duodenal fistula →
stone travels down the GI tract →
small bowel obstruction (not ileus!)

A

Gallstone ileus

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21
Q

Large gallstone lodged in the cystic duct or in the neck of the gallbladder causing→
external compression of the common HEPATIC duct

A

Mirizzi’s syndrome

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22
Q

Gallstone ileus is a mechanical small bowel obstruction,
typically as a result of the gallstone trapped at the _____

Patients present with a tumbling obstruction with transient episodes of diffuse abdominal pain and nausea and air in the biliary tree (from the cholecystoduodenal fistula).

A

terminal ileum

near the ileocecal valve

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23
Q

A mechanical small bowel obstruction 2/2 gallstone trapped in the terminal ileum (near the ileocecal valve)

A

Gallstone ileus

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24
Q

Patients present with:
transient episodes of diffuse abdominal pain
nausea
air in the biliary tree (from the cholecystoduodenal fistula)

A

Gallstone ileus

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25
Q

Ultrasound Demonstrates Gas Bubbles in the Gallbladder Wall

A

emphysematous cholecystitis

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26
Q

Emphysematous cholecystitis, an infection due to gas-forming organisms.

This diagnosis is common in

A

older men, often with diabetes mellitus

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27
Q

Emphysematous cholecystitis complications

gallbladder needs to be SAPeD off

A

Sepsis
Abscess (intra-abdominal)
Perforation (gallbladder)
Death

Bile cultures will often grow:
Clostridium or E. coli

Treat with: IV ABx & cholecystectomy

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28
Q

Pneumobilia (air in biliary tree)

MCC (2)

A

recent instrumentation
gallstone ileus

(NOT emphysematous cholecystitis that is GAS not AIR)

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29
Q

__ may be negative for gallstones due to radiolucent. stones

A

CT

get an U/S

30
Q

Significantly elevated ALP and GGT out of proportion to AST and ALT

suggest what primary pathology?

A

Biliary

*Gamma-glutamyl transferase (GGT)

31
Q

Significantly elevated AST and ALT out of proportion

to ALP and GGT suggest what primary pathology?

A

Hepatocellular

like hepatitis

32
Q

__ (lab) is the test of choice to rule out pancreatitis.

A

Lipase

Lipase = higher sensitivity for pancreatitis than amylase

33
Q

RUQ pain in critically ill patients who are:

hospitalized (for other reasons)
or
fasting for prolonged periods (on total peripheral nutrition)

A

Acalculous cholecystitis

34
Q

Ultrasound will typically demonstrate a thickened gallbladder wall or pericholecystic fluid without stones.

A

Acalculous cholecystitis

If U/S is negative, a HIDA scan is obtained

35
Q

Acalculous cholecystitis

Treatment: IV antibiotics & emergent cholecystectomy

If the patient is UNSTABLE:
______ is performed followed by cholecystectomy
once the patient is medically stable.

A

Percutaneous cholecystostomy

tube to drain the gallbladder

36
Q

Post- cholecystectomy
cystic duct stump leak is treated with:

_____ & stenting of the sphincter of Oddi.

A

Endoscopic-retrograde cholangiopancreatography
(ERCP)

HIDA scan is obtained to r/o a bile leak and/or a bile duct injury

37
Q

Suspected Common Bile Duct injury s/p cholecystectomy management:

A
  1. HIDA scan
    (obtained to r/o a bile leak or a bile duct injury)
  2. Hepatico-jejunostomy
    (if injury is present)
38
Q

Gallbladder infection antibiotic of choice:

A

1st line:
Cefoxitin (2º ceph; covers anaerobes)

Alternatives:
(piperacillin/ tazobactam)
(ampicillin/sulbactam)

In severe cases:
3rd & 4th gen cephalosporins

39
Q 
Calcified gallbladder (porcelain) = increased
risk of \_\_\_\_\_

Tx: _____

A

malignancy

cholecystectomy

40
Q

Postcholecystectomy syndrome is persistent abdominal pain or dyspepsia either postoperatively (early) or months to years (late) after cholecystectomy.

U/S followed by ______
is the next best step

A

direct visualization via

endoscopic retrograde cholangiopancreatography (ERCP)
or
magnetic resonance cholangiopancreatography (MRCP)

41
Q 
Biliary cyst
presents with:
RUQ-pain
Fever
Juandice
elevated LFTs & WBCs

Treatment:

A

Treatment:
Cyst resection (to ↓ risk of malignancy)
± Roux-en-Y hepaticojejunostomy (percutaneous drainage)

Diagnosis: Ultrasound ± CT scan or MRCP

Complications: 
Cholangiocarcinoma (malignancy)
Acute cholangitis (infection)
Pancreatitis
Stone formation
42
Q

Cholangiocarcinoma is a biliary tract epithelial malignancy.

Most often occurs in those who have:

fibropolycystic liver disease
or
____ 2/2 ____

A

primary sclerosing cholangitis
2/2
ulcerative colitis

(↑CEA & ↑CA 19-9)

43
Q

Porcelain gallbladder usually shows a calcified rim in the gallbladder wall with a central bile-filled dark area.

It is associated with an increased risk for ____ and requires cholecystectomy.

A

gallbladder adenocarcinoma

44
Q

gallstone pancreatitis complicated by acute cholangitis in a hypotensive pt w/ altered mental status ( aka unstable)

Next best step in management:

A

Endoscopic retrograde cholangiopancreatography
(ERCP)

(to relieve the biliary obstruction/stone)

45
Q

A HIDA scan is used to diagnose____ in patients with equivocal ultrasound findings

A

Acute Cholecystitis
______________________
HIDA INTERPRETATION

HIDA scan used to assess function or integrity of biliary tract.

acute cholecystitis: No GB visualization in 1hr

acute acalculous cholecystitis: no GB in 1hr visualization w/o stones or partial filling of GB

chronic cholecystitis: ↓ GB ejection fraction + stones

chronic acalculous cholecystitis (GB dyskinesia) : ↓ GBEF w/o stones

46
Q

Biliary dilation suggests ____

A

cholangitis

Infection/Obstruction of the common bile duct

47
Q

A ___ is used to diagnose cholecystitis in patients with equivocal ultrasound findings

A

HIDA scan

48
Q

A rare complication of hepatic or bilio-pancreatic procedures.

Presents with:
RUQ pain
Jaundice &
Upper gastrointestinal bleeding (aka Melena)

A

Hemobilia

bleeding into the biliary tract

49
Q

Dyskinesia or stenosis of the sphincter leading to cholestasis

worsened with opioids

A

Sphincter of Oddi dysfunction

50
Q 
Most likely diagnosis:
RUQ pain
jaundice
fever, hypotension
leukocytosis
hyperbilirubinemia
elevated alkaline phosphatase (ALP)
\+/- altered mental status
A

acute cholangitis

2/2 gallstone impaction (CBD)

51
Q

Pale/white (acholic) poop is due to:

A

prolonged biliary obstruction

would not be expected in patients with acute gallstone cholangitis

52
Q

Acute biliary obstruction can lead to an increased level of _____ which may cause dark (Coca-Cola-colored) urine.

A

conjugated bilirubinemia

53
Q

Acute biliary obstruction can lead to an increased level of conjugated bilirubinemia which may cause ___ urine.

A

dark (Coca-Cola-colored)

54
Q

Charcot’s triad consists of _____

Classically associated with Cholangitis

A

fever
RUQ pain
jaundice (not always seen on PE)

55
Q

Reynold’s pentad implies cholangitis with septic shock.

It includes Charcot’s triad plus ______ & ______.

A

hypotension
&
altered mental status

56
Q

Reynold’s pentad implies cholangitis with ____.

A

septic shock

Fever, RUQ pain, Juandice (Charcot’s triad) + AMS, Hypotension

57
Q

Once the Patient is Fluid resuscitated, started on Antibiotics, and the diagnosis of Cholangitis is established via U/S & blood cultures

What is the next step in treatment:

A

ERCP
(drain the infected bile/ biliary decompression)

If ERCP is unsuccessful → PTC

ERCP
a scope is inserted through the mouth to the sphincter of Oddi → sphincterotomy → wire is
passed through ampulla → stone removed/bile drained into duodenum → place stent.

Percutaneous Transhepatic drainage (PTC)
The bile is drained via a catheter inserted directly into the liver.

58
Q

Once the patient’s sepsis 2/2 cholangitis has completely RESOLVED

Next, step in management

A

Cholecystectomy

59
Q

Bloody diarrhea in a patient who presents with

cholangitis is suggestive of ulcerative colitis with

A

primary sclerosing cholangitis (PSC)

60
Q

Characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts.

Cholangiography shows multifocal areas of alternating stricturing and dilation of intrahepatic and/or extrahepatic bile ducts

(“pearls on a string”)

A

primary sclerosing cholangitis (PSC)

2/2 ulcerative colitis (IBD)

61
Q 
If a patient (generally a middle-aged woman) presents with:
pruritus, fatigue, 
mildly elevated ALP, 
normal AST/ALT,
normal RUQ U/S

then suspect a diagnosis of

A

primary biliary cholangitis (PBC)

Patients test positive for the anti-mitochondrial antibody (AMA).

Complications:
cirrhosis, hepatobiliary cancers, malabsorption, &
osteopenia.

62
Q

Suppurative cholangitis

aka

A

acute cholangitis complicated by septic shock

63
Q

Think ____ if pt also having symptoms of IBD (bloody diarrhea)

A

sclerosing cholangitis

64
Q 
Suspect \_\_\_\_\_\_ if there is:
pruritis
elevated ALP
no duct dilatation
(+) Anti Mito-Ab
A

primary biliary cholangitis

65
Q

Epigastric pain radiating straight through to the back
bilious vomiting/ nausea
hypoactive bowel sounds

imaging = gas in the small & large bowel.
Focal dilated loop of proximal small bowel w/o air fluid levels.

A

Acute pancreatitis

MCC 2/2 cholelithiasis (gallstones)

*Treatment is supportive if not 2/2 to gallstones

66
Q

Criteria for the diagnosis of acute pancreatitis:
Require 2 of 3:

  1. Sudden/Persistent epigastric pain radiating to
    the back
  2. Elevated Lipase or Amylase 3x> normal
3. Characteristic findings of acute pancreatitis on imaging
such as (3-4)
A

enlarged pancreas

sentinel loops
[dilated loops of proximal small bowel in the
LUQ on XR]

colon cutoff sign
[distended proximal colon with abrupt collapse in the LUQ at the splenic flexure]

67
Q

Criteria for the diagnosis of acute pancreatitis:

Require 2 of 3:

A
  1. Epigastric pain radiating to the back
  2. Elevated Lipase or Amylase (3x normal)
  3. sentinel loops [dilated small bowel] or gas
    on imaging
68
Q

Main Pulmonary Complications of Acute Pancreatitis?

A

Pleural Effusions (mostly on the left side)
&
acute respiratory distress syndrome (ARDS)
-diffuse bilateral pulmonary infiltrates

*PE = severe pancreatitis

69
Q

__ & __ are the most common causes of

acute pancreatitis

A

Gallstones

Alcohol

70
Q

Most sensitive lab value for diseases of the liver or biliary.

Used to confirm hepatic origin of elevated ALP levels.

↑ with Cholestasis (obstructive or nonobstructive) & Alcohol use

A

Gamma-glutamyl transferase (GGT)

*Not elevated in bone disease (unlike, ALP)

OBG (8 decks)

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