biliary disease Flashcards

1
Q

Cholelithiasis

pain presents where?

more in women or men??

A

Gallstones are usually asymptomatic in most patients and often found incidentally on imaging studies for other issues

Classic pain presentation is RUQ with radiation to the R shoulder and infrascapular area

-more common in women with 8.6% prevalence vs. men with 5.5% prevalence

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2
Q

Gallstones are classified according to ??

symptoms will develop in how many pts??

A

chemical composition

Majority are cholesterol stones in the US
less than 20% are composed of calcium bilirubinate

Symptoms will develop in 10-25% of patients over time

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3
Q

gallstone on US

A

opaque

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4
Q

Gallstone/pain tx

A

NSAIDs
Laparoscopic cholecystectomy for symptomatic disease
Ursodeoxycholic acid

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5
Q

Laparoscopic cholecystectomy for what pts??

Only done in asymptomatic if ??

A

symptomatic disease

-if porcelain gallbladder, stones >3cm, or if a patient is a candidate for bariatric surgery or cardiac transplant

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6
Q

what is Ursodeoxycholic acid ??

do gallstones recur?

A

A bile salt given orally for up to 2 years which can help dissolve some cholesterol stones in patients who are unable to have or refuse to have surgery (elderly, other risk factors)

Gallstones usually reoccur by 5 years after medication is stopped

also given to liver failure/transplant/cirrhotic pts, eliminates itching in skin

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7
Q

porcelain GB on XR

caused by ??

removed??

A

rim enhancing

continued insult to GB over time, pancreatic/GB/GI cancer

not all need to be removed, but indication for removal esp. with symptoms

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8
Q

case: N/V 30 min after eating, steady RUQ tenderness and epigastric pain, low grade temp 100F

A

probably not E.coli, too quick of presentation (usually takes 24 hrs)

S. aureus, B. cereus: more acute FBI

has this happened before?

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9
Q

?? is associated with gallstones 90% of the time

A

Cholecystitis

Often precipitated by a fatty meal (burger)
Vomiting may give temporary relief

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10
Q

Acute Cholecystitis: physiology

A

a stone becomes impacted in the cystic duct and inflammation develops around the obstruction

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11
Q

When not caused by stones acute cholecystitis could be caused by ??

A

CMV, cryptosporidiosis or microsporidiosis in advanced HIV patients; or by vasculitis

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12
Q

acute cholecystitis labs

A

WBCs often elevated, LFTs and bilirubin can be elevated, serum amylase may also be mildly elevated

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13
Q

other cholecystitis pain

A

stones may hang around, or stones may have caused hepatic problems so have pain even after removal

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14
Q

Murphy’s sign

A

positive when you palpate the RUQ and ask the patient to breathe deeply
POSITIVE if patient develops pain that radiates to the R infrascapular area or if patient’s inspiration stops short

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15
Q

Sonographic Murphy’s sign

A

positive when a patient reports maximum discomfort when the ultrasound probe is over the gallbladder

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16
Q

U/S may show ??

A

gallstones, biliary sludge, biliary ductal dilation, gallbladder wall thickening, pericholecystic fluid (around GB), and/or a positive sonographic Murphy’s sign

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17
Q

If ultrasound is not convincing, next step would be to do a ??

Test most reliable when ??

A

hepatic iminodiacetic acid scan (HIDA)

when bilirubin is under 5mg/dL

positive when GB does not light up but cystic bile duct does?? listen 15 min

18
Q

Gangrene of the gallbladder

A

Symptoms of acute cholecystitis severe and lasting 24-48h
Due to ischemia from splanchnic vasoconstriction
Could lead to perforation, abscess
Obese, elderly, diabetics at higher risk (can’t perceive pain as much)

19
Q

Acalculous cholecystitis

What can be done if patient too unstable for cholecystectomy?

A

Should be considered if fever and RUQ pain 2-4 weeks after major surgery or in critically ill ICU patients

drain GB (loaded with sludge) cholecystotomy drain placed (can have in for a longer than year!) 
to avoid sepsis
sometimes a bridge to sx
20
Q

Chronic Cholecystitis Results from ??

A

repeated episodes of acute cholecystitis or from chronic irritation of the gallbladder due to stones
Occasionally chronic inflammation creates polypoid changes inside the gallbladder giving the gallbladder a strawberry appearance

21
Q

chronic cholecystitis: Hydrops of the gallbladder can occur if ??

A

the cholecystitis subsides but the cystic duct obstruction persists generating a gallbladder filled with mucoid fuid

22
Q

cholecystitis tx

A

Acute cholecystitis can often improve with gut rest, pain medications, and antibiotics

A cephalosporin + metronidazole
Fluoroquinolone + metronidazole
Piperacillin/tazobactam
Carbapenem (imipenem, meropenem, ertapenem)

23
Q

chonic cholecystitis tx: Given high risk for recurrence, ?? can be planned when symptoms improve

A

interval cholecystectomy

don’t want to do when acute, risk of perforation and infection

24
Q

case 2: sclera icterus
some episodic N/V +/- epigastric pain

questions?

A

when N/V: sometimes after food
color: yellow/green stool
darker urine
itchy skin

recent travel?
some etOH

25
Choledocholithiasis and Cholangitis Cholangitis suspected if ??
Often a h/o epigastric pain accompanied by jaundice Sometimes patients present with painless jaundice as their chief complaint Cholangitis suspected if there are signs of sepsis Etiology is a stone in the bile duct which requires an ERCP for diagnosis and possible intervention
26
Charcot’s Triad
Frequently occurring attacks of RUQ abdominal pain Jaundice associated with RUQ pain Chills and fever
27
Reynold’s Pentad
The classic findings of Charcot’s triad for acute cholangitis PLUS: Altered mental status Hypotension Indicates probable supperative cholangitis and is an endoscopic emergency
28
Cholangitis: labs can demonstrate ?? CT??
striking increases in LFTs and hyperbilirubinemia Serum amylase may be elevated indicating a secondary pancreatitis CT may demonstrate dilated bile ducts
29
ERCP ??
ERCP provides the most accurate determination of the extent of the obstruction especially when bile duct diameter is >6mm, when ductal stones are seen on ultrasound, or when bilirubin is >4mg/dL Sphincterotomy with stone extraction or stenting can be done as needed during this procedure
30
cholangitis tx
Bile duct stones should be removed even in asymptomatic patients If a patient has concurrent cholecystitis, cholecystectomy is generally performed during the same hospital stay If no signs of cholecystitis, cholecystectomy can be done electively in 2 weeks
31
Cholangitis: Antibiotics targeted towards??
G- pathogens are often administered acutely via IV, and patients are sent home on ~2 weeks of p.o. agents Ciprofloxacin/metronidazole, cefuroxime/metronidazole, amoxicillin/clavulanate
32
case 3: 3 weeks post liver transplant for hepC w/ cirrhosis | itching/yellowing
Biliary Stricture
33
Biliary Stricture Benign biliary strictures are generally due to ?? what developments/common complications
injury around a surgical anastomosis ~95% of the time 5% of cases can be due to direct injury to the abdomen, pancreatitis, or prior endoscopic sphincterotomy Jaundice can develop rapidly if complete occlusion occurs Cholangitis is the most common complication of stricture Biloma or infected fluid collection/abscess could also arise
34
biloma
backup of bile fluid
35
MRCP vs. ERCP risk?
MRCP is valuable in demonstrating strictures ERCP permits biopsy to evaluate for possible malignancy, sphincterotomy to allow closure of a bile leak, and dilation/stent placement Risk of post-ERCP pancreatitis in challenging cases
36
ERCP
endoscope into mouth thru duodenum, up retrograde to GB
37
case 4: hx of UC, poor compliance with management yellow skin/eyes diffuse pruritis
yellow/green stools dark urine Upon further questioning, patient reports he hasn’t been eating well and had noticed the yellowing slowly over the past 2 months Patient also with fatigue and loose stools Labs reveal high direct and indirect bilirubin, elevated LFTs MRCP is performed
38
MRCP shows punctuated strictures: "string of pearls"
Primary Sclerosing Cholangitis
39
Primary Sclerosing Cholangitis
Most common in men aged 20-50 years *Often associated with ulcerative colitis* Progressive jaundice over time, pruritus, labs consistent with cholestasis Diagnosis on MRCP with classic cholangiographic findings 10-20% risk of cholangiocarcinoma
40
tx: Acute bacterial cholangitis component of Primary Sclerosing Cholangitis
Treated with antibiotics targeted towards gram negative pathogens (ciprofloxacin, 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems)
41
more Primary Sclerosing Cholangitis tx
Ursodeoxycholic acid can improve LFTs and decrease itching Possible balloon intervention of some of the sclerosed areas Possible stenting as a short term solution to relieve symptoms Long-term stenting may increase complications Liver transplantation for those with cirrhosis and clinical decompensation
42
Primary Sclerosing Cholangitis px
Average survival 9-17 years and up to 21 years in some studies Survival may be less with a dominant bile duct stricture Higher risk for colon cancer associated with longer survival Survival rates with liver transplantation are as high as 85% at 3 years