Biliary disease Flashcards
1
Q
Hepatocellular pattern
A
Transaminase (AST and/or ALT)
2
Q
usually when you have an elevation of ALT or AST you also have an elevation of ______ as well
A
bilirubin
3
Q
MC Type of pattern you’ll see
A
transaminase dominant
4
Q
upper limit of normal AST ALT
A
40Normally b/w 15 and 20
5
Q
fatty infiltration into liver that results in mild elevation of transaminases
A
fatty liver disease other liver function tests should be normal
6
Q
chronic hep b and C you see
A
asymptomatic pt screen with ALT transaminase level and look for elevation
7
Q
medications that can elevate transaminases
A
(Tylenol, Rifampin, INH, Antifungals, Methotrexate, NSAIDS), Herbal drugs, occupational toxinsusually anything that utilizes the CYP450 system
8
Q
uncommon etiologies for pts with transaminase predominant panel
A
Hemochromatosis (iron OVER) Autoimmune Hepatitis Alpha-1-AT deficiency Wilson’s Disease (COPPER)Unknown causes
9
Q
Autoimmune Hepatitis can be diagnosed with
A
circulating autoantibodies and high serum globulin
10
Q
” Alpha-1-AT deficiency is seen in what population
A
deficiency (rare; neonatal hepatitis)
11
Q
” Wilson’s Disease is due to
A
rare; copper accumulation due to abnormal biliary copper transport
12
Q
AST predominant ratio
A
ETOH-related hepatitis, cirrhosis due to viral hepatitis, Wilson dz
13
Q
ALT predominant
A
usually all other casues of liver dz (not alcohol) drug-induced liver, chronic viral hepatitis (B&C), occupational, toxin related hepatocellular damage, autoimmune hepatitis, Wilson’s, Hemochromatosis, Alpha-1-AT deficiency, congestive hepatopathy, Malignant infiltration of the liver
14
Q
you want to confirm the elevation of transaminases for at least how long
A
> 3mo
15
Q
AST>ALT
A
- AST>ALT consistent w/ ETOH (rarely >300)
16
Q
ALT>AST consistent
A
consistent w/ viral (values often >500 greater than hepititis
17
Q
correlative factors with elevated transaminases
A
Correct reversible factors: obesity, ETOH, drugs, thyroid, celiac dz
18
Q
mild elevation recommendations
A
abstain from alcohol and medication recheck in 2 months
19
Q
what to do if you suspect if suspect fatty liver, splenomegaly, or tumor/mass
A
ULS- can see fatty infiltration right upper quadrant also done with biliary tract dz
20
Q
what to do if it looks like they have hep c
A
Hepatitis panel (A, B, C)
21
Q
elevated hematocrit or signs and symptoms of hemachromatosis
A
Ferritin, Fe/TIBC
22
Q
what to do if you suspect Wilsons
A
Copper & ceruloplasmin in young patients
23
Q
when would you do a liver biopsy
A
if no other source can be ascertained
24
Q
primarily alk phos is made
A
in liver and bones
25
if you don't have any signs or symptoms of biliary tract disease and you have a high alk phos
might be coming from somewhere else need to evaluate alk pho iso enzyme Based on alk phos isoenzyme, it will tell you the origin of Alk Phos-liver or bone GGT will be coming from the liver
26
common etiologies of elevated Alk Phos
Metastatic or biliary CaPBC (primary biliary cirrhosis)Fatty liver (mild elevation of Alk Phos and mild elevation of transaminases) Biliary stones
27
Pt's w/ bone cancer will show elevation in
2. Pt's w/ bone cancer will show elevation in Alk Phos
28
ULN for alk phos
Upper limit normal is 150
29
what population do you normally see an elevated alk phos
kids can be around 400also pregnant women
30
GGT increased will tel you the elevated alk phos will
. So if you have elevated Alk Phos and an elevated GGT then you know the problem is in the liver
31
elevated alk phos and GGT increased what do you do
RUQ ULS
32
what are you looking for with a ULS if you know alk phos elevation is coming from the liver
dilated biliary ducts
33
why would you see an isolated elevation in bilirubin
Gilbert's syndromemild elevation of just bilirubin 2 or 2.5 (normal 1 )hereditary un-conjugated bilirubin that is relatively common
34
acute pancreatitis
inflammatory condition that causes inflammation of the pancreas usually due to choledocholitahiasisETOH abuse
35
alcohol pt with abd pain
pancreatitis!
36
Pancreatic enzymes released into circulation causes
a. Hypotensionb. ARDSc. Disturbance of coagulation cascaded. Hypocalcemiago into shock
37
predominant symptom of acute and chronic pancreatitis
PAINepigastric sharpstabbing through and through doesn't wrap around (biliary tract) BORING --> hot poker
38
pancreatitis is exacerbated by
Eating (PUD better w/eating)ETOH vomittingturns out enzymes for digestion and hurts
39
physical exam findings with pancreatitis
" Abdominal rigidity" Voluntary guarding" Fever" Tachycardia" Shock
40
pancreatitis dx test
" Abdominal pain film" CT abdomen is BEST
41
common lab finding specific to pancreatitis
increase amylase & lipase
42
other than increase in amylase what other labs diagnostics do we see
Hypocalcemia from release of pancreatic enzymesLeukocytosis - elevation of WBC b/c inflammation present BUN (b/c dehydration since they stopped eating or ARF)Hyperglycemia b/c pancreas not working LFTs (biliary obstruction pattern - Alk phos elevated)
43
biliary obstruction pattern
predominantly alk phos
44
Outcome of pancreatitis is influenced by -
a. Etiology: alcoholic doesn't do as well b. Co-morbidity: if they have hepatitis or HF not looking goodc. # of previous attacks: in chronic pt who continues to drink alcohol d. Severity of disease
45
complications of pancreatitis
1. Prolonged hospitalization2. Shock3. Hypoxia - pleural effusions, respiratory distress4. GI bleeding - pretty common5. 25% develop pseudocysts - need sx6. Pancreatic abscess - need sx
46
Chronic Pancreatitis why do we see only slightly elevated amylases
not a lot of pancrease function leftcan get just a mildly elevated amylaseneed to go back to the history and see how much they are drinking and if they have ever had this before
47
clincal findings in chronic pancreatitis
Similar presentation to acute ETOH pt's may develop pancreatic insufficiency30% have steatorrhea due to chronic calcific pancreatitis and malabsorption (floaty, oily, greasy stools)GI bleeding and pancreatic hemorrhage common
48
Malabsorption seen with chronic pancreatitis
emaciation, peripheral edema, multiple low total protein--> edema bloated asceitis type belly
49
why would we see DM with chronic pancreatitis
Diabetes from endocrine insufficiency
50
jaundice with pancreatitis suggests
Jaundice suggests common bile obstruction
51
prognosis of chornic pancreatitis
Chronic pancreatitis as a primary cause of death is rareUsually a consequence of associated complications -
52
management of chronic pancreatitis
a. ETOH abstinence!b. Smaller, more frequent meals to reduce post prandial pancreatic secretionsc. Analgesicsd. Pancreatic enzymes w/ meals to reduce exogenous enzymes releasee. Restriction of dietary fat intake
53
complications of chronic pancreatitis
GI bleedBiliary tract infectionLiver failureMalabsorptionElectrolyte abnormalities
54
what are cholesterol stones made of
80-90% cholesterol 10% pigmented bilirubin
55
pigmented bilirubin stones are more common in
alcohol only 10-20%
56
which percent of the population has gallstoneswhich % is symptomatic
10% of US population has gallstones50% of these will be symptomatic
57
Cholelithiasis is most common with
4 F's = Fat, Forty, Female, Fertile
58
CM of biliary colic
" RUQ to mid-epigastric painColicy pain --> intermittent"Sharp, maybe severeRadiates to back/R shoulder. wraps around Classically follows ingestion of fatty meal (1-2 hrs after meal)
59
PE with cholelithiasis
RUQ tenderness(-)Murphy's signinspiration cessation and pain
60
Dx
Based on hx, PE, normal labs, abdominal USPolyp doesn't have an acoustic shadow but a stone does on US
61
labs with biliary colic
amylase/lipase (pancreatitis)CBC-infection or inflammationcholecystitis you see elevation cholelitahisis you should have normal cbc and normal liver testmaybeee elevation of alk phos
62
dx for cholelithiasis
RUQ abd ULS
63
management of biliary colic
need to have gallbladder out cholecystectomy NON surgical:
64
non surgical mngmt of cholelithiasis
3. Non-surgical tx; 50% recurrence ratea.Oral bile salts slowly dissolves stonesb.Lithotripsyc.ERCP --> scope down to the gallbladder; if small enough and one stone, then can grab it and take it outi. Not commonly done anymore
65
Prognosis for cholelithiasis
1. Prognosis unrelated to severity of symptoms2. Complications increase with length of time symptoms are present3. Morbidity in pts who don't have cholecystectomy4. If they don't elect for sx then tell them to watch out for severe RUQ pain that doesn't go away
66
Morbidity in cholelithiasis pts who don't have cholecystectomy
a. Acute cholecystitisb. Cholangitis with liver abscessc. Necrotizing pancreatitisd. Gallstone ileus with SBOe. Gallbladder CA
67
CM of Acute Cholecystitis
" Severe, constant abd pain" Often epigastric, localizing to RUQ" Radiation to back, R shoulder" Exacerbation 1-2 hrs after meal" Fever
68
acute cholecystitis is usually caused by
inflammation of the gallbladder from obstructing stone
69
PE with acute cholecystitis
" Fever" RUQ tenderness" Involuntary guarding" (+) Murphy's sign
70
differentiating cholecystitis from cholelithiasis
SEVERE CONSTANT PAINN/V/F
71
acute cholangitis
ascending infection of the biliary tract results from acute cholecystitis
72
iii. Charcot's Triad
acute cholangitis " RUQ pain" Shaking chills & Fever" Jaundicesurgical emergency gall bladder out RIGHT NOW
73
Acute Cholecystitis lab
" Leukocytosis" Elevated Amylase, mild" Elevated ALT/AST, mild" Total bilirubin and Alk Phos typically not elevated" Order US
74
Acute Cholangitis labs
Leukocytosis w/ left shift (immature cell indicative of bacterial infection)Elevated Alk Phos, Total (direct) bili, GGTVariable elevations in ALT, AST
75
leukocytosis left shift is indicative of
bacterial infection
76
diagnostic test of cholecystitis
US of RUQ w/ acute cholecystitis --> marked thickening of gallbladder wall w/ fluid surrounding the distended gallbladder
77
mangmt of cholecystitis
1. Admission2. IV empiric abx for gram negatives 3. Pain management4. NPO, NG tube5. cholecystectomy
78
NPO, NG tube used for cholecystitis because
Want the gallbladder to rest since gallbladder most active when we are eating (it squirts a bunch of enzymes to digest the food)
79
Cholecystectomy definitive treatment because....
a. 30-40% will progress to gangrenous cholecystitis and perforation without surgery
80
vi. Treatment of acute cholecystitis vs acute cholangitis
1Don't need to know detailsCan wait a day or 2 depending on how busy the OR is, etcAscending cholangitis = they need emergency sx right now
81
Primary Sclerosing Cholangitis is usually associated with this dz and seen with abnormal liver function
Associated w/ inflammatory bowel disease
82
c. Primary Sclerosing Cholangitis
inflammation and fibrosis in the biliary tree need to screen for it because
83
complications of primary sclerosing cholangitis
Primary Biliary cholangitis (primary biliary cirrhosis)ii. Recurrent pyogenic cholangitisiii. Cholangiocarcinoma
84
Rare bile duct cancer, often associated with PSC, presenting with painless jaundice, right upper quadrant abdominal pain, and weight loss
Cholangiocarcinoma
85
Intrabiliary pigment stone formation, resulting in stricturing of the biliary tree and biliary obstruction with recurrent bouts of cholangitis, found almost exclusively in people who live or who have lived in Southeast Asia
Recurrent pyogenic cholangitis
86
Rare T-lymphocyte-mediated attack on small intralobular bile ducts; affects women (95%) age 30-65
Primary Biliary cholangitis (primary biliary cirrhosis)
87
An obese 37-year-old female is in the emergency room for right-sided abdominal pain and excessive flatulence. This episode has persisted for several hours. On physical exam you palpate her right upper quadrant while she takes a deep breath. The patient experiences pain and has a transient pause in inspiration. What is the most likely diagnosis?
acute cholecystitis+Murphy's sign makes acute cholecystitis most likely; biliary colic may present with similar symptoms but will not have +Murphy's sign
88
A 50-year-old woman presents to the clinic with a two-day history of right upper quadrant pain. She has a history of hypercholesterolemia and her examination is significant for a positive Murphy's sign. What is the preferred imaging modality?
abdominal ultrasound
89
A 72-year-old man presents with concerns of “looking yellow.” He is asymptomatic but admits to an unintentional 15 pound weight loss over the last two months. Physical examination reveals jaundice, mild epigastric tenderness, and palpable periumbilical nodules. Which of the following is the most likely diagnosis?
pancreatic cancer
90
A 43-year-old woman presents with episodic epigastric pain that frequently follows a fatty meal and can last anywhere from 15 minutes to approximately two hours. At times the pain radiates toward her right shoulder. She has associated nausea without vomiting. Which of the following is the most appropriate next step in managing this patient?
US of the abdomen
91
A 57 y/o male has routine lab work for a physical exam; he is generally healthy and asymptomatic. His fasting labs reveal an elevated Alk Phos; the remainder of his CMP is normal, as is his CBC. What is the next step in the evaluation of this abnormal result?
order serum GGT and alkaline phosphatase isoenzyme
92
A 63 y/o male c/o abdominal pain x 1 week with anorexia, no weight loss or vomiting, no jaundice. Labs reveal AST 250 (normal 10-40), ALT 150 (normal 10-40), Alk Phos 185 (normal 40-150); amylase and lipase are both mildly elevated. Which of these is the most likely etiology of these abnormal lab results?
alcohol use
93
normal alk phos
44-147
94
why would you see an increase in bilirubin and ALP in a pt with chronic pancreatitis
secondary to extra hepatic biliary obstruction
95
crampy sharpRUQ
cholecystitisusually follows fatty meal
96
charcot's triad
for acute cholagitisfever chills RUQ pain jaundice
97
reynold's triad
fever chills RUQ pain jaundice(carchot's )shock and altered mental status acute cholangitis
