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GI Remediation > Biliary Disease > Flashcards

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

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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

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3
Q

AST:ALT elevation in EtOHers

A

2:1 or 3:1 in alcoholics

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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

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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

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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

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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

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8
Q

Normal range for bili

A

0-0.3

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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

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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

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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)

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12
Q

Isolated hyperbilirubinemia

A

Inc in bili but AST/ALT/Alk phos are totally normal.

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13
Q

Common causes of hepatocellular injury

A 
Viral hepatitis
EtOH
Drugs
Toxins
AI Hepatiis
Wilson
Ischemia (budd chiari)
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14
Q

Common causes of cholestatic dx

A 
Primary biliary sclerosis
PSC
Cholangiocarcinoma
Pancreatic Cancer
Choledocholithiasis
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15
Q

Common bile duct contents

A

Cystic duct and hepatic duct

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16
Q

Contents of bile

A

Bile
Phospholipids
Cholesterol

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17
Q

Bile function

A

Excretes cholesterol

Aids in digestion/absorption of fat

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18
Q

Cholestasis sx

A 
RUQ pain
colic (distention)
Jaundiced
Dark urine 
Weight loss
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19
Q

LFT lab values in cholestasis

A

Alk phos elev

AST/ALT elev

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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

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21
Q

Two types of gallstones (what’s more common)

A 
Cholesterol (80%)
Caclium bilirubimate (pigment)
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22
Q

What is biliary sludge

A

Mucuous like supersaturation of cholesterol or calcium. Probably a precursor to stones

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23
Q

4 RF for cholelithiasis!!! (FOUR F’S)

A

Think of mom!

```
Fat
Fertile
Forty
Fair
obesity, pregnancy,/OCP, age
~~~

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24
Q

Age and cholelithiasis

A

Forty is the magic number. Incidence if 4x higher after age 40

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25
Q

Cholelithiasis Clinical presentation

A

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)

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26
Q

Diagnosis imaging for cholelithiasis

A

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

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27
Q

Who gets gallstone tx?

A

Only the symptomatic

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28
Q

Three types of tx for symptomatic cholelithiasis

A

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

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29
Q

When does cholelithiasis become cholecystitis

A

When one of those stones is logded into the cystic duct. Cholestasis occurs!

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30
Q

Most common cause of acute cholecystitis

A

Gallstone obstruction. The pain will worsen. These patients will say they’ve had an “attack” like this that resolved completely

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31
Q

Sx of acute cholecystitis

A 
RUQ pain
Fever
Leukocytosis
N/V
Anorexia
RUQ pain
Murphys
Guarding Rebound
Courvoiseers sign
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32
Q

What is acalculus cholecystitis

A

It’s the same as acute cholecystitis, but it’s not caused by gallstones

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33
Q

Chronic cholecystitis?

A

From recurrent infection/mechanical irriattion by gallstones

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34
Q

Courvoisers sign?

A

Palpable gallbladder due to distention/dilation

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35
Q

Jaundice in cholecystitis?

A

25% of the time! You’re affecting the liver after all

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36
Q

Labs in acute cholecystitis

A

Elevated WBC
AST/ALT often elevated
Alk phos elevated
Elevated bili

Amylase may be high if pancreas gets ticked off

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37
Q

Imaging in cholecystitis

A 
RUQ US (88% sensitivity)
HIDA scan. 98% sensitive, watch the injected dye enter the cystic duct and not get into the gallbladder
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38
Q

PE sign for cholecystitis

A

MURPHYS

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39
Q

Management of cholecystitis

A 
NPO
IVF
Pain control (NOT MORPHINE)
IV Abx (3rd eph + flagyl)
Lap cholecystectomy
Not a surgical candidate? PerQ drainage
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40
Q

Why no morphine for cholecystitis?

A

Morphine can cause spasm of the sphincter of oddi. This is horribly painful

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41
Q

If you’ve had your gallbaldder taken out you can’t have choledocolithiasis right?

A

No way! It can form spontaneously somehow.

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42
Q

When does cholelithiasis become choledocolithiasis

A

When a gallstone causes an obstruction in the COMMON bile duct. Be super careful, cystic duct is normal cholecystitis

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43
Q

Choledocolithiasis RF and epidemiology

A

Same as cholecystitis!! Literally same shit, just in the common bile duct instead of the cystic duct.

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44
Q

Complications of cholecystitis

A

Gangrene
Cholangitis
Hydrops (mucoid fluid in gallbladder post infectino)
Porceline gallbladder (inc risk of cancer)

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45
Q

Labs for choledocolithiasis

A

Very elevated ALT/AST dt the obstruction affecting the liver. Expect to see >1,000
Elevated Bili

Alk phos will rise slowly

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46
Q

ALT/AST >1,000?

A

Choledocolithiasis

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47
Q

Imaging for choledicolithiasis

A

RUQ US and CT will show dilated ducts.
MRCP (imaging biliary tree)
ERCP (actual scope)

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48
Q

ERCP vs MRCP

A

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!

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49
Q

What is cholangitis

A

Inflammation of the bile duct. COMPLICATION OF CHOLEDOCOLITHIASIS

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50
Q

What develops into cholangitis

A

Choledocolithiasis

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51
Q

What does charcots triad refer to?

A

Sx of cholangitis

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52
Q

What makes up charcots triad

A

Fever
Jaundice
Severe RUQ pain

53
Q

Other sx of cholangitis

A 
Charcots
Pruritis (bili)
Dark urine
Acholic stool
REYNOLDS PENTAD
54
Q

What is reynolds pentad

A

cholangitis

Charcots triad + HYPOTENSION AND AMS. THIS IS AN AMERGENCY

55
Q

Cholangitis tx

A

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
Q

Cholangitis tx post ERCP

A

Lap cholecystectomy to follow up

57
Q

What is primary sclerosing cholangitis

A

Chronic diffuse inflammation of the biliary system that leads to fibrosis and stricutures.

Wicked rare

58
Q

RF for PSC

A

UC (will not improve with colectomy)
CD- kinda
HLA-88, DR-3,DR-4
1st degree family member

59
Q

Clinical presentation of PSC

A 
Progressive obstructive jaundice
Fatigue
Pruritis
Anorexia
Indigestion
Malabsorption
60
Q

Labs for PSC

A

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
Q

Diagnosing PSC

A

ERCP/MRI.

Get a liver bx- “onion skinning” appearance

62
Q

PSC Liver biopsy results

A

“onion skinning”

63
Q

Scariest complication of PSC.

Prognosis?

A

Cholangiocarinoma in 20% of cases

Prognosis is 12-17 years

64
Q

Acute management of PSC

A

Acute bacterial? Cipro

65
Q

Chronic management of PSC

A

Balloon dilation/stenting- inc risk of complications

Stricture resection- may lead to longer survival and less cholangiocarcinoma!

US pt? Colectomy.

Liver transplant

66
Q

Have cirrhosis and PSC? What do you need?

A

Liver transplant

67
Q

Pancreas is an ____ organ

A

retroperitoneal!

68
Q

Function os the pancreas

A

Endocrine- insulin/glucagon/somatostatin

Exocrine- Digestion

69
Q

Function of the sphincter of oddi

A

Smooth muscle sphincter that sits on the pancreatic duct and common bile duct, prevents reflux

70
Q

Three types of pancreatitis

A

Acute (interstitial vs necrotizing pancreatitis) Recurrent (alcohol or cholelithiasis)
Chronic (from longstanding damage)

71
Q

Most common causes of acute pancreatitis.

Other causes?

A

Gallstone and chronic EtOH are the most common.

Other causes: 
Idiopathic
Post ERCP (5-10%)
HyperT
Rx
infections
Trauma
72
Q

What’s more common, interstitial or necrotic pancreatitis? What causes each of them?

A

Interstitial is more common! It’s caused by acute inflammation of the pancreas.

Necrotizing is inflammation from cell death due to pancreatic ischemia

73
Q

Complications of acute pancreatitis

A

Multisystem organ failure (Prerenal azotemia and ARDS)

Ileus

Pancreatic necrosis- 17% mortality. May need perQ aspiration/abx/debridement

74
Q

Symptoms of acute pancreatitis

A

Mild epigastric pain (BE SCARED OF EPIGASTRIC) that radiates to the back-remember retroperitoneal?

N/V
Anorexia
Epigastric tenderness
Jaundice

75
Q

Signs of severe acute pancreatitis

A 
Tachypnea (alkalotic)
Hypoxemia
Hypotension
Cullens sign
Grey turner sign
76
Q

Grey turner sign

A

Sign of severe acute pancreatitis. Ecchymosis on the flanks from necrotizing pancreatitis w/ hemorrhage

77
Q

Cullen sign

A

Periumbilical ecchymosis

78
Q

Normal amylase and lipase

A

Normal amylase is 23-85

Normal lipase is 0-160

79
Q

Amylase and lipase in acute pancreatitis

A

3x ULN.

Amylase: ~240
Lipase: ~500

80
Q

Fasting TG in acute pancreatitis

A

If hyperTG is the cause, it can be >1,000. Jesus. Normal is 150

81
Q

Imaging we want in acute pancreatitis

A

Abdominal US
CT Abdomen w/ IV Contrast (IF DETERIORATING, NOT INITIAL)
MRI

82
Q

Problem with amylase lvl in acute pancreatitis

A

Short half life, will drop in 24 hours later. Specific

83
Q

Lipase level and acute pancreatitis

A

No correlation between severity of lipase and of pancreatitis

84
Q

Role of CT w/ contrast in acute pancreatitis

A

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
Q

Pancreatitis diagnosis criteria

A

> 2 of following

1) Characteristic epigastric abd pain +/- radiation to back
2) Lipase/Amylase >3xULN
3) CT confirmation of pancreatitis

86
Q

Management of acute pancreatitis

A

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
Q

RANSON criteria

A

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
Q

APACHE II score

A

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
Q

SIRS score (systemic inflammatory response syndrome)

A

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
Q

BISAP

A

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
Q

Atlanta classification for mild acute panreatitis

A

No local complications/organ failure.

Self limited, 3-7 day course

92
Q

Atlanta class for moderate/severe acute pancreatitis

A

Transient (<48hr) organ failure
Local systemic complications
May have local complications like a pseudocyst

93
Q

Atlanta class for severe acute pancreatitis

A

Persistent organ failure >48hours

This gets a CT scan to assess for necrosis

94
Q

Chronic pancreatitis definition

A

Irreversible damage to the pancreas. Whereas acute is irreversible.

Has histologic abnormalities including chronic inflammation/fibrosis/atrophy

95
Q

Chronic pancreatitis etiology

A

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
Q

Chronic pancreatitis complications

A 
Opioid addiction
DM (retinopathy/neuropathy/nephropathy)
Gastroparesis
Malabsorption
Pancreatic carcinoma (esp w/ hereditary pancreatitis)
97
Q

Sx of chronic pancreatitis

A 
Abd pain
Anorexia
Maldigestion
Weight loss
N/V
Steatorrhea.
98
Q

Physical findings in chronic pancreatitis

A

Unimpressive. That’s why this is an easy one for addicts to fake :(

May have tenderness over pancreas during attacks.

99
Q

Lab marker for early/mild chronic pancreatitis

A

None!

Might see milld elevation amylase/lipase

Secretin test? Not sensitive or specific

100
Q

Role of secretin test in chronic pancreatitis

A

Only positive when >60% of the pancreatic exocrine function has been lost. Not sensitive or specific to the current attack

101
Q

Role of imaging in chronic pancreatitis

A

Done to establish the diagnosis, not done with each exacerbation.

Abdominal CT is the initial modality of choice.

102
Q

Chronic pancreatitis tx

A

Low fat diet
No EtOH
May use FDA approved pancreatic enzyme to decrease steatorrhea

Surgery (whipple/pancreatectomy/transplant/sphincterectomy)

103
Q

Diverticulosis

A

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
Q

Diverticulitis

A

When the diverticulum become inflammed. Can be simple or complicated

105
Q

Which section of the colon is most often affected by diverticulosis

A

Sigmoid 95%

106
Q

Divertucolosis symptomatic?

A

Not really. Only 20% of patients develop sx, and only 1% of those patients require surgery

107
Q

Rf for diverticulosis

A 
age
constipation
Diet high in fat and red meat
Obesity
Genetics (CT disorders)
Sedentary lifestyle
108
Q

How do we diagnose diverticulosis

A

C scope. Can be found incidentally on CT/MRI/BE

109
Q

Diverticulitis comes in two flavors, what are they?

What’s more common?

A

Simple vs complicated.

Simple is 75% of the cases.

110
Q

Ft of complicated diverticulitis

A

When we start seeing bowel obstruction, abscess, fistula and perforations. When it’s complicated we need to admit the patient

111
Q

Complications of recurrent diverticulitis

A

Chronic abd pain

Fibrosis w/ strictures. These can lead to ileus and bowel obstruction

112
Q

Symptoms of diverticulitis

A

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
Q

What does rebound pain indicate

A

Peritonitis. Something is in the peritoneum

114
Q

Radiographic studies for diverticulitis

A

Abdominal CT w/ IV contrast. +/- PO contrast

115
Q

What situations would we treat diverticulitis surgically?

A

Acute complicated.

When we have a free perforation (duh) or if there’s significant obstruction

116
Q

Abx for acute diverticulitis

A

Trying to cover Enterobacteriaciae and b frag.

Cipro/flagyl
Augmentin PO
The others are all hardcore and IV only

117
Q

Acute diverticulitis, who gets emergent surgery?

A

Free perforation

+/- bowel obstruction

118
Q

Acute diverticulitis, who gets urgent surgery?

A

Failure Rxtx
Lowkey obstruction
Abscess that failed draining

119
Q

Acute diverticulitis, who gets elective surgery?

A

Persistent pain
Fistula
IC pt w/ prior acute diverticulitis

120
Q

Two srgical options for diverticulitis

A

One stage Procedure

Two stage procedure (Hartmann’s, primary anastomosis w/ diverting ileostomy)

121
Q

FU For diverticulitis- new diagnosis

A

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
Q

Diet modifications for diverticulitis

A

High fiber!

The thing about seeds, corns and nuts isn’t proven to be efficacious

123
Q

Most common cause of overt (hematochezia/maroon) LGIB in adults.

A

Diverticular bleed! Just from the vasa recta being a little week.

124
Q

Sx of a diverticular bleed

A

Painless hematochezia
Painless marron stool
Bloating, cramping, urge to defecate
May be hemodynamically unstable.

BRBPR
BENIGN ABDOMEN

125
Q

Diagnostic imaging for diverticular bleed

A

Colonscopy!! Once stable, can diagnose and treat.

Can also do tagged RBC
or angiography

126
Q

When to consider NGT for a diverticular bleed

A

To r/o UGIB. Do this if the blood is dark and its difficult to differentiate melena

127
Q

Diverticular bleeds are dangerous right?

A

These are actually often self limited

128
Q

Diverticular bleed surgical options

A

C scope (MOST COMMON)
Angiograph
Segmental colectomy

129
Q

Indication for a segmental colectomy

A

Hemodynamically stable. This is an emergency.

Failed C scope and angio

GI Remediation (6 decks)

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