Biliary Disease Flashcards
1
Q
ALT (alanine aminotransferase)
Where is it found?
WHen is it released?
Normal levels?
A
1) Found primarily in hepatocytes
2) Released when cells are hurt or destroyed
3) Normal is 5-55
2
Q
AST (aspartate aminotransferase)
1) Where is it found
2) Liver specific?
3) Relationship to ALT
4) Normal range
A
1) Found in a lot of places! liver, heart, muscle, intestine, pancreas
2) Really not specific for liver disease
3) Follows ALT (reverse alphabetic(
4) Normal range 8-48
3
Q
AST:ALT elevation in EtOHers
A
2:1 or 3:1 in alcoholics
4
Q
Alkaline phosphatase
1) Where is it found
2) When do we expect it to rise
3) Specificity compared to GCT
4) Normal range
A
1) Found in liver, ESPECIALLY biliary tract. But also bones, intestines and placenta.
2) Expect it to rise with biliary obstruction or infiltrative diseases like stones or tumors
3) Less specific (bones and placenta and all)
4) Normal is 4.5-11
5
Q
GGT (gamma glutamyl transpeptidase)
1) What is it?
2) Liver specific?
3) Relationship to Alk phos
4) EtOH abuse?
A
1) Enzyme fouund in many organs, with highest conc in liver.
2) Hella specific. It’s often the first enzyme to be elevated w/ liver damage
3) Elevated alk phos? Can check to see if its dt liver by seeing if GGT is also elevated. R/O bone.
4) Elevated in 75% of EtOHers
6
Q
LDH- Lactate dehydrogenase
1) What is it
A
It’s a cytoplasmic enzyme. We’ve seen this before, generic lab that just shows tissue damage
7
Q
What situations is bilirubin elevated?
A
Jaundice
Liver/bile duct disease
Anything that breaks down RBC
Anything that affects production/elimination of bili
8
Q
Normal range for bili
A
0-0.3
9
Q
Two forms of bilirubin
A
1) Unconjugated. This is what we’re measuring
2) Conjugated. it’s always attached to things, this should never be present in the blood
10
Q
Liver (hepatocellular) dx pattern of liver enzymes
A
This is intrahepatic injury
Inc AST/ALT dt to hepatocyte damage. Not so much alk phos (not biliary)
Bili may or may not be elevated
11
Q
Cholestasis pattern of liver enzymes
A
Elevated Alk Phos.
Not so much AST/ALT since it’s biliary.
Bili may/may not.
Can be extrahepatic (obstruction)
Can be intrahepatic (Primary biliary cholangitis)
12
Q
Isolated hyperbilirubinemia
A
Inc in bili but AST/ALT/Alk phos are totally normal.
13
Q
Common causes of hepatocellular injury
A
Viral hepatitis EtOH Drugs Toxins AI Hepatiis Wilson Ischemia (budd chiari)
14
Q
Common causes of cholestatic dx
A
Primary biliary sclerosis PSC Cholangiocarcinoma Pancreatic Cancer Choledocholithiasis
15
Q
Common bile duct contents
A
Cystic duct and hepatic duct
16
Q
Contents of bile
A
Bile
Phospholipids
Cholesterol
17
Q
Bile function
A
Excretes cholesterol
Aids in digestion/absorption of fat
18
Q
Cholestasis sx
A
RUQ pain colic (distention) Jaundiced Dark urine Weight loss
19
Q
LFT lab values in cholestasis
A
Alk phos elev
AST/ALT elev
20
Q
Cholestasis def
A
blockage of common bile duct. Until you check w/ US/CT/MRI you have no idea what’s blocking it
21
Q
Two types of gallstones (what’s more common)
A
Cholesterol (80%) Caclium bilirubimate (pigment)
22
Q
What is biliary sludge
A
Mucuous like supersaturation of cholesterol or calcium. Probably a precursor to stones
23
Q
4 RF for cholelithiasis!!! (FOUR F’S)
A
Think of mom!
```
Fat
Fertile
Forty
Fair
obesity, pregnancy,/OCP, age
~~~
24
Q
Age and cholelithiasis
A
Forty is the magic number. Incidence if 4x higher after age 40
25
Cholelithiasis Clinical presentation
RUQ pain radiating to scapula---can also be epigastric
Sudden onset
N/V w/ pain
Pain is post prandial-fatty meal
Night/day
CBC/LFT is normal until something scary is going on (cholestasis)
26
Diagnosis imaging for cholelithiasis
US- very sensitive for small stones
Plain films- suck. Only really useful for pigment stones dt calcium concentration.
HIDA scan- inject a tracer to watch the gallbladder empty. Determines if there's a cystic duct obstruction
27
Who gets gallstone tx?
Only the symptomatic
28
Three types of tx for symptomatic cholelithiasis
1) Laparascopic cholecystectomy. Outpatient. MOST COMMON
2) Lithotripsy in combo with the bile salt tx. less commonly done anymore
3) Chenodeoxycholic and ursodeoxycholic acid. Bile salts, takes 2 years. And they recur
29
When does cholelithiasis become cholecystitis
When one of those stones is logded into the cystic duct. Cholestasis occurs!
30
Most common cause of acute cholecystitis
Gallstone obstruction. The pain will worsen. These patients will say they've had an "attack" like this that resolved completely
31
Sx of acute cholecystitis
```
RUQ pain
Fever
Leukocytosis
N/V
Anorexia
RUQ pain
Murphys
Guarding Rebound
Courvoiseers sign
```
32
What is acalculus cholecystitis
It's the same as acute cholecystitis, but it's not caused by gallstones
33
Chronic cholecystitis?
From recurrent infection/mechanical irriattion by gallstones
34
Courvoisers sign?
Palpable gallbladder due to distention/dilation
35
Jaundice in cholecystitis?
25% of the time! You're affecting the liver after all
36
Labs in acute cholecystitis
Elevated WBC
AST/ALT often elevated
Alk phos elevated
Elevated bili
Amylase may be high if pancreas gets ticked off
37
Imaging in cholecystitis
```
RUQ US (88% sensitivity)
HIDA scan. 98% sensitive, watch the injected dye enter the cystic duct and not get into the gallbladder
```
38
PE sign for cholecystitis
MURPHYS
39
Management of cholecystitis
```
NPO
IVF
Pain control (NOT MORPHINE)
IV Abx (3rd eph + flagyl)
Lap cholecystectomy
Not a surgical candidate? PerQ drainage
```
40
Why no morphine for cholecystitis?
Morphine can cause spasm of the sphincter of oddi. This is horribly painful
41
If you've had your gallbaldder taken out you can't have choledocolithiasis right?
No way! It can form spontaneously somehow.
42
When does cholelithiasis become choledocolithiasis
When a gallstone causes an obstruction in the COMMON bile duct. Be super careful, cystic duct is normal cholecystitis
43
Choledocolithiasis RF and epidemiology
Same as cholecystitis!! Literally same shit, just in the common bile duct instead of the cystic duct.
44
Complications of cholecystitis
Gangrene
Cholangitis
Hydrops (mucoid fluid in gallbladder post infectino)
Porceline gallbladder (inc risk of cancer)
45
Labs for choledocolithiasis
Very elevated ALT/AST dt the obstruction affecting the liver. Expect to see >1,000
Elevated Bili
Alk phos will rise slowly
46
ALT/AST >1,000?
Choledocolithiasis
47
Imaging for choledicolithiasis
RUQ US and CT will show dilated ducts.
MRCP (imaging biliary tree)
ERCP (actual scope)
48
ERCP vs MRCP
MRCP is diagnostic but ERCP is rad as heck because it can be therapeutic too, can just go right in and confirm + fix w/ stent placement!
49
What is cholangitis
Inflammation of the bile duct. COMPLICATION OF CHOLEDOCOLITHIASIS
50
What develops into cholangitis
Choledocolithiasis
51
What does charcots triad refer to?
Sx of cholangitis
52
What makes up charcots triad
Fever
Jaundice
Severe RUQ pain
53
Other sx of cholangitis
```
Charcots
Pruritis (bili)
Dark urine
Acholic stool
REYNOLDS PENTAD
```
54
What is reynolds pentad
cholangitis
Charcots triad + HYPOTENSION AND AMS. THIS IS AN AMERGENCY
55
Cholangitis tx
This is an emergency. May even be septic.
Endoscopic shincterotomy and stone extraction. AKA ERCP!!!!!!
Hang IV Abx as you're running into the OR (ampi + gent/cipro + flagyl)
56
Cholangitis tx post ERCP
Lap cholecystectomy to follow up
57
What is primary sclerosing cholangitis
Chronic diffuse inflammation of the biliary system that leads to fibrosis and stricutures.
Wicked rare
58
RF for PSC
UC (will not improve with colectomy)
CD- kinda
HLA-88, DR-3,DR-4
1st degree family member
59
Clinical presentation of PSC
```
Progressive obstructive jaundice
Fatigue
Pruritis
Anorexia
Indigestion
Malabsorption
```
60
Labs for PSC
Alk phos is the the only thing elevated. This is really only fibrosing the biliary tree.
Will also have a low serum albumin dt anorexi and malabsorption
61
Diagnosing PSC
ERCP/MRI.
Get a liver bx- "onion skinning" appearance
62
PSC Liver biopsy results
"onion skinning"
63
Scariest complication of PSC.
Prognosis?
Cholangiocarinoma in 20% of cases
Prognosis is 12-17 years
64
Acute management of PSC
Acute bacterial? Cipro
65
Chronic management of PSC
Balloon dilation/stenting- inc risk of complications
Stricture resection- may lead to longer survival and less cholangiocarcinoma!
US pt? Colectomy.
Liver transplant
66
Have cirrhosis and PSC? What do you need?
Liver transplant
67
Pancreas is an ____ organ
retroperitoneal!
68
Function os the pancreas
Endocrine- insulin/glucagon/somatostatin
| Exocrine- Digestion
69
Function of the sphincter of oddi
Smooth muscle sphincter that sits on the pancreatic duct and common bile duct, prevents reflux
70
Three types of pancreatitis
Acute (interstitial vs necrotizing pancreatitis) Recurrent (alcohol or cholelithiasis)
Chronic (from longstanding damage)
71
Most common causes of acute pancreatitis.
Other causes?
Gallstone and chronic EtOH are the most common.
```
Other causes:
Idiopathic
Post ERCP (5-10%)
HyperT
Rx
infections
Trauma
```
72
What's more common, interstitial or necrotic pancreatitis? What causes each of them?
Interstitial is more common! It's caused by acute inflammation of the pancreas.
Necrotizing is inflammation from cell death due to pancreatic ischemia
73
Complications of acute pancreatitis
Multisystem organ failure (Prerenal azotemia and ARDS)
Ileus
Pancreatic necrosis- 17% mortality. May need perQ aspiration/abx/debridement
74
Symptoms of acute pancreatitis
Mild epigastric pain (BE SCARED OF EPIGASTRIC) that radiates to the back-remember retroperitoneal?
N/V
Anorexia
Epigastric tenderness
Jaundice
75
Signs of severe acute pancreatitis
```
Tachypnea (alkalotic)
Hypoxemia
Hypotension
Cullens sign
Grey turner sign
```
76
Grey turner sign
Sign of severe acute pancreatitis. Ecchymosis on the flanks from necrotizing pancreatitis w/ hemorrhage
77
Cullen sign
Periumbilical ecchymosis
78
Normal amylase and lipase
Normal amylase is 23-85
| Normal lipase is 0-160
79
Amylase and lipase in acute pancreatitis
3x ULN.
Amylase: ~240
Lipase: ~500
80
Fasting TG in acute pancreatitis
If hyperTG is the cause, it can be >1,000. Jesus. Normal is 150
81
Imaging we want in acute pancreatitis
Abdominal US
CT Abdomen w/ IV Contrast (IF DETERIORATING, NOT INITIAL)
MRI
82
Problem with amylase lvl in acute pancreatitis
Short half life, will drop in 24 hours later. Specific
83
Lipase level and acute pancreatitis
No correlation between severity of lipase and of pancreatitis
84
Role of CT w/ contrast in acute pancreatitis
When patient is deteriorating. Not an initial scan.
The IV contrast can help us distinguish between inflammation and necrosis, may be able to see things like pseudocysts/CBD stones and masses
85
Pancreatitis diagnosis criteria
>2 of following
1) Characteristic epigastric abd pain +/- radiation to back
2) Lipase/Amylase >3xULN
3) CT confirmation of pancreatitis
86
Management of acute pancreatitis
Admit
Assess using scoring thing
NPO
IVF
IV analgesia/antiemetic
Repeat labs assessing BUN/Cr/HCT q8-12 hours
start introducing clear liquids a few days later
87
RANSON criteria
Acute pancreatitis predictor score
'ranson= RAndor= ED. Sees them at admission and maybe like two days later tops. ER so its severe, predicts MM"
Calculated on ADMiSSION and @ 48 hours
Estimates MM from pancreatitis
88
APACHE II score
Acute pancreatitis predictor score
APACHE= alpaca farmer. Need to see the patients/alpacas daily
Most widely studied.
PERFORMED DAILY
Good negative value, poor positive. It's a R/O score
Poor predictive value @ 24 hours.
89
SIRS score (systemic inflammatory response syndrome)
Acute pancreatitis predictor score
SIRS. Gotta sit at the bedside and have serious talk about how severe their pancreatitis is
EASILY DONE AT THE BEDSIDE
Can reliably predict severity of pancreatitis
90
BISAP
Acute pancreatitis predictor score
BISAP- Bedside, MM ASAP
BEDSIDE
ID's patients at high risk for MM during early course. Used a lot for admitting
91
Atlanta classification for mild acute panreatitis
No local complications/organ failure.
Self limited, 3-7 day course
92
Atlanta class for moderate/severe acute pancreatitis
Transient (<48hr) organ failure
Local systemic complications
May have local complications like a pseudocyst
93
Atlanta class for severe acute pancreatitis
Persistent organ failure >48hours
| This gets a CT scan to assess for necrosis
94
Chronic pancreatitis definition
Irreversible damage to the pancreas. Whereas acute is irreversible.
Has histologic abnormalities including chronic inflammation/fibrosis/atrophy
95
Chronic pancreatitis etiology
EtOH abuse!!!!!!
idiopathic
smoking
cystic fibrosis (kids)
Also autoimmune pancreatitis (ANA/RF/PSC/UC/RA)-- more mild symptoms w/ diffuse pancreas swelling. Almost mimics carcinoma)
96
Chronic pancreatitis complications
```
Opioid addiction
DM (retinopathy/neuropathy/nephropathy)
Gastroparesis
Malabsorption
Pancreatic carcinoma (esp w/ hereditary pancreatitis)
```
97
Sx of chronic pancreatitis
```
Abd pain
Anorexia
Maldigestion
Weight loss
N/V
Steatorrhea.
```
98
Physical findings in chronic pancreatitis
Unimpressive. That's why this is an easy one for addicts to fake :(
May have tenderness over pancreas during attacks.
99
Lab marker for early/mild chronic pancreatitis
None!
Might see milld elevation amylase/lipase
Secretin test? Not sensitive or specific
100
Role of secretin test in chronic pancreatitis
Only positive when >60% of the pancreatic exocrine function has been lost. Not sensitive or specific to the current attack
101
Role of imaging in chronic pancreatitis
Done to establish the diagnosis, not done with each exacerbation.
Abdominal CT is the initial modality of choice.
102
Chronic pancreatitis tx
Low fat diet
No EtOH
May use FDA approved pancreatic enzyme to decrease steatorrhea
Surgery (whipple/pancreatectomy/transplant/sphincterectomy)
103
Diverticulosis
Sac like protrusion, the mucosa and the submocsa herniate thru the muscle. Seen on cscope. Tend to bleed. Super super common, 70% of people >80 have these.
104
Diverticulitis
When the diverticulum become inflammed. Can be simple or complicated
105
Which section of the colon is most often affected by diverticulosis
Sigmoid 95%
106
Divertucolosis symptomatic?
Not really. Only 20% of patients develop sx, and only 1% of those patients require surgery
107
Rf for diverticulosis
```
age
constipation
Diet high in fat and red meat
Obesity
Genetics (CT disorders)
Sedentary lifestyle
```
108
How do we diagnose diverticulosis
C scope. Can be found incidentally on CT/MRI/BE
109
Diverticulitis comes in two flavors, what are they?
What's more common?
Simple vs complicated.
Simple is 75% of the cases.
110
Ft of complicated diverticulitis
When we start seeing bowel obstruction, abscess, fistula and perforations. When it's complicated we need to admit the patient
111
Complications of recurrent diverticulitis
Chronic abd pain
| Fibrosis w/ strictures. These can lead to ileus and bowel obstruction
112
Symptoms of diverticulitis
LLQ tender abdominal pain. It's constantly, over several days.
TENDER PALPABLE MASS, guarding/rigidity/REBOUND PAIN
N/V
Fever
Can see a change in bowel habits (constipation or diarrhea)
113
What does rebound pain indicate
Peritonitis. Something is in the peritoneum
114
Radiographic studies for diverticulitis
Abdominal CT w/ IV contrast. +/- PO contrast
115
What situations would we treat diverticulitis surgically?
Acute complicated.
| When we have a free perforation (duh) or if there's significant obstruction
116
Abx for acute diverticulitis
Trying to cover Enterobacteriaciae and b frag.
Cipro/flagyl
Augmentin PO
The others are all hardcore and IV only
117
Acute diverticulitis, who gets emergent surgery?
Free perforation
| +/- bowel obstruction
118
Acute diverticulitis, who gets urgent surgery?
Failure Rxtx
Lowkey obstruction
Abscess that failed draining
119
Acute diverticulitis, who gets elective surgery?
Persistent pain
Fistula
IC pt w/ prior acute diverticulitis
120
Two srgical options for diverticulitis
One stage Procedure
| Two stage procedure (Hartmann's, primary anastomosis w/ diverting ileostomy)
121
FU For diverticulitis- new diagnosis
Get a c scope to make the diagnosis approximately 6 weeks post infection to r/o colon cancer and assess the extent of the disease. Unless they had a colonoscopy in the last year
122
Diet modifications for diverticulitis
High fiber!
The thing about seeds, corns and nuts isn't proven to be efficacious
123
Most common cause of overt (hematochezia/maroon) LGIB in adults.
Diverticular bleed! Just from the vasa recta being a little week.
124
Sx of a diverticular bleed
Painless hematochezia
Painless marron stool
Bloating, cramping, urge to defecate
May be hemodynamically unstable.
BRBPR
BENIGN ABDOMEN
125
Diagnostic imaging for diverticular bleed
Colonscopy!! Once stable, can diagnose and treat.
Can also do tagged RBC
or angiography
126
When to consider NGT for a diverticular bleed
To r/o UGIB. Do this if the blood is dark and its difficult to differentiate melena
127
Diverticular bleeds are dangerous right?
These are actually often self limited
128
Diverticular bleed surgical options
C scope (MOST COMMON)
Angiograph
Segmental colectomy
129
Indication for a segmental colectomy
Hemodynamically stable. This is an emergency.
Failed C scope and angio
