Biliary colic

Question 1

Pain in biliary colic

Answer 1

1. After fatty meal
2. Inc intensity
3. Radiating to back
4. Min to hrs
5. Variable
6. Better with analgesics
7. A/w nausea, vomit, bloating

Question 2

Gall stones r/f

Answer 2

1. Female
2. Fertile
3. Fat
4. Forty
5. Ethinicity - Native american/Scandinavian

Drugs: Ceftriaxone*, post meno - estrogen, TPN

Question 3

Acute cholecystitis

Answer 3

Stone ..
permanent obstruction of ciliary duct…
Infl of GB

1. pain a/w raised temperature,
2. tachycardia
3. tenderness in the right upper quadrant (especially on inspiration)

Mx -
Early Cholecystectomy

Pain = +
Fever/WBC = raised
Jaundice = no

Question 4

Biliary colic

Answer 4

Stone …
On and off obstruction of ciliary duct

Pain = +
Fever/WBC = no
Jaundice = no

Question 5

Cholangitis

Answer 5

Stone..
obstruction @ ciliary/common bile duct..
Infection..
DEADLY

Pain = +
Fever/WBC = raised
Jaundice = present
CHARCOTs triad

Rx:
1. Iv fluids and antibiotics
… not better …
2. Urgent ERCP to drain GB/biliary system
3. Cholecystectomy

Question 6

Acalculous cholecystitis

Answer 6

1. Distention and ischemia of GB, a/w fasting?NBM*
2. USG - sludge/polyp/inflammation
   If negative
   Nuclear medicine GB excretion study
   -evaluate if cholecystectomy beneficial or no
3. Mx: Cholecystectomy

Question 7

ERCP, uses

Answer 7

Endoscopic retrograde cholangipancreaticography

Diagnostic use:
1. Obstructive jaundice
2. Chr pancreatitis
3. Ampullary/periampullary CA
4. Unexplained jaundice

Therapeutic use:
1. Gall stone removal
2. Sphincterotomy
3. Stricture dilation

Question 8

ERCP C/I in

Answer 8

Acute pancreatitis without features of obstriction - cholangitis/choledochal cyst

Causes PEP- Post ERCP pancreatitis d/t irritation of pancreatic duct

Question 9

Signs and diagnosis on ERCP

Answer 9

1. Double duct sign - pancreatic CA
2. Chain of lakes - Chr pancreatitis
3. Linear filling defect - Ascariasis
4. Fish eye - IpMN (Intraductal papillary mucinous neoplasms)

Question 10

MRCP, benefits

Answer 10

Magnetic resonance cholangiopancreaticography

1. No contrast needed
2. No radiation
3. Faster
4. Less operator dependant
5. *NO RISK OF PANCREATITIS

Question 11

ERCP vs MRCP

Answer 11

MRCP better than ERCP in
1. Choledocholithiasis

ERCP better than MRCP
1. Ampullary lesions
2. Primary sclerosing cholangitis
3. Therapeutic uses

Question 12

Mirrizzi syndrome

Answer 12

Stone @ GB neck..
compresses/erodes into
COMMON HEPATIC DUCT

Rx: ERCP - stenting, antibiotics
SX

Question 13

Porcelain GB

Answer 13

Precancerous
Remove

Question 14

Asymptomatic gallstones Mx

Answer 14

Left alone
Can rarely remove in DM, pre-cancerous

Question 15

GB polyps

Answer 15

1. Risky in
   >10mm
   Wide base
   Distorting GB
   With gall stones
   Focal thickening
2. <10mm - USG every 6 mo for 2yrs
3. > 10mm OR
   5mm in primary sclerosing cholangitis or inflammatory bowel disease
   =Cholecystectomy

Question 16

Mx scheme for gall stones

Answer 16

Rt upper quadrant pain..
USG..
Gall stones + = cholecystectomy

No symp but
1. >2cm in immunocomp
2. >1.5cm in polyp GB
3. Porcelain GB
4. DM
5. Elderly (65yrs) with life expectancy >20 yrs
- Prophylactic Cholecystectomy

Gall stones -ve = exclude other path
*Hepatobiliary iminodiacetic scan
=GB ejection <30% = cholecystectomy

Murphys sign+ in gall stones

Question 17

Lap cholecystectomy - antibiotics

Answer 17

Single dose before sx only