Biliary

Question 1

tx for type 1 choledochal cyst?

Answer 1

cystectomy, cholecystectomy, hepatocoenterostomy

high malignancy potential

Question 2

charcot triad

Answer 2

fever, jaundice, abdominal pain

Question 3

Reynold’d pentad

Answer 3

fever, jaundice, abdominal pain, hypotension, altered mental status

Question 4

diagnostic criteria of functional sphincter of odd disorder

Answer 4

1. criteria for biliary pain
2. elevated LAE or dilated bile duct, but not both
3. absence of bile duct stones or other structural abnormalities

Question 5

how can ERCP w/ manometry help in the management of suspected sphincter of oddi disorder?

Answer 5

abnormal biliary manometry is predictive of response to biliary sphincterotomy

Question 6

a pt is diagnosed w/ PSC. what is the next step?

Answer 6

colonoscopy w/ biopsies

Question 7

what is the prevalence of IBD in pts w/ PSC?

Answer 7

60-80%

Question 8

if a pt is diagnosed w/ both PSC and IBD, what is the colonoscopy interval?

Answer 8

q1yr

Question 9

if a pt has PSC but not IBD, what is the colonoscopy interval?

Answer 9

q5yr

Question 10

how does a duodenal perforation present?

how do you diagnose it?

Answer 10

it is a rare complication of cholecystectomy

retroperitoneal fluid collection w/ elevated amylase and bilirubin

pt should get an upper GI series w/ gastrografin to localize the site of the leak

EGD is a relative contraindication, and upper GI series should be done first

Question 11

what is the sensitivity of RUQUS in detecting choledocholithiasis?

Answer 11

50%

Question 12

risk factors for cholangiocarcinoma

Answer 12

PSC
choledochal cyst
obesity
chronic liver disease
toxins
liver flukes (Opisthorchis and Clonorchis)

Question 13

what is the risk of recurrent biliary event (biliary colic, recurrent gallstone pancreatitis, choldecholithiasis) if cholecystectomy is delayed beyond the initial hospitalization?

Answer 13

18-40%

Question 14

what are the types of gallbladder polypoid lesions

Answer 14

pseudopolyps vs true polyps

pseudopolyps:

• cholesterol polyp
• inflammatory polyp
• adenomyoma (benign)

true polyp:

• adenoma (has malignant potential)
• adenocarcinoma

Question 15

what is the management of gallbladder polyps?

Answer 15

if >= 10mm, cholecystectomy

if <10mm:

 - if symptomatic, cholecystectomy
 - if asymptomatic, ultrasound surveillance

Question 16

most common presentation of HIV cholangiopathy?

typical epidemiology?

Answer 16

most common presentation of HIV cholangiopathy: papillary stenosis

• rare
• 80% of cases present w/ advanced HIV (CD4 <100)
• marked ALP elevation

Question 17

pancreaticobiliary malfunction increase the risk of developing which types of cancers?

Answer 17

most common - gallbladder cancer

also increases risk of cholangiocarcinoma

Question 18

gastric outlet obstruction w/ pneumobilia

Answer 18

Bouveret’s syndrome

rare cause of gallstone ileus where there is a cholecystoduodenal fistula

tx: start w/ EGD, but this is only successful in 9%. often require surgery (give them a heads up)

surgical intervention carries 12% mortality rate

Question 19

what is a choledochocele?
most common presentation?
tx?

Answer 19

choledochocele is synonymous with type III choledochal cyst (distal CBD dilation at the ampulla)

most common presentation is acute pancreatitis, followed by obstructive jaundice, and cholangitis.

for all the other types of choledochal cysts, the most common presentations are: cholangitis (MC), obstructive jaundice, then pancreatitis.

compared to other choledochal cysts, choledochoceles (Type III choledochal cysts) have low risk for malignancy and are the only type that can be managed w/ ERCP (snare resection vs sphincterotomy)

Question 20

what is the sensitivity of conventional cytology in diagnosing malignant biliary strictures? (low, medium, or high)

Answer 20

low (15-38%)

supplementation w/ FISH studies increases the sensitivity in diagnosing malignancy

Question 21

True or False

when there is risk of cholangiocarcinoma, you should get a percutaneous or EUS-guided biopsy to definitively diagnose

Answer 21

False. percutaneous or endoscopic sampling a suspicious biliary stricture has risk of peritoneal seeding

Question 22

what is the commonly used CA 19-9 cutoff value for PSC

Answer 22

CA 19-9 value of 129 has a sensitivity and specificity of 79% and 98% respectively for the dx of PSC

Question 23

what is Caroli disease?

Answer 23

aka type 5 choledochal cyst
congenital segmental saccular and fusiform intrahepatic ductal dilations w/ hepatic fibrosis and portal hypertension

often associated w/ auto recessive polycystic kidney disease

Question 24

2 months after liver transplant, pt presents for fever and jaundice. ERCP reveals multiple intrahepatic strictures

what’s the next step?

Answer 24

ultrasound w/ doppler to assess for hepatic artery thrombosis

post-transplant biliary strictures are categorized as either anastomotic or non-anastomotic

anastomotic strictures:

non-anastomotic strictures:

• usually at the hilum or intrahepatic
• from ischemic injury (hepatic artery thrombosis or stenosis, prolonged ischemic) or immune-mediated (ABO-incompatible graft or chronic ductupenic rejection)
• hepatic artery complications is the most common cause of non-anastomotic strictures

Question 25

PBC

• how to dx
• biopsy findings
• percent of pts w/ negative AMA
• tx options

Answer 25

can be dx’d w/ positive AMA and elevated ALP

If negative AMA (5% of PBC pts have negative AMA), must get liver bx to secure the dx

biopsy: florid duct lesions and mononuclear inflammatory infiltrate surrounding bile ducts

tx:
1st line - ursodeoxycholic acid 13-15mg/kg/day
2nd line (if not responding to UDCA) obeticholic acid (AE: pruritus)