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Summer FDTN Exam 5 > Biliary disease > Flashcards

Biliary disease Flashcards

1
Q

What would happen if you didnt have a gallbladder

A

Release of digestive enzymes would not be timed as nicely, but eventually you can return to eating fatty foods

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2
Q

What is bile

A

Fluid secreted from liver (500ml/d) and stored in gallbladder
Made up of water, electrolytes, bile salts, phospholipids,

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3
Q

What is cholelithiasis

A

Stones in the gallbladder AKA gallstones

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4
Q

What is cholecystitis

A

Inflammation of the gallbladder

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5
Q

What is choledocolithiasis

A

Stones in the CBD

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6
Q

What is cholangitis

A

Inflammation of the bile ducts

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7
Q

What is Cholestasis

A

disruption of bile flow, regardless of cause

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8
Q

RF for cholelithiasis are

A 
Female 
Fluffy (obese) 
Forty (age >40) 
Fertile (pregnancy) 
Rapid weight loss 
Estrogens, BCP 
Ethnicity (native american, hispanic, caucasian)
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9
Q

What are the types of gallstones

A 
Cholesterol stones (MC) 
Pigment stones (calcium, bilirubin, proteins)
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10
Q

How can cholelithiasis present

A

ASx (MC)

Sx (biliary colic, or with complications)

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11
Q

What are complications of Cholelithiasis

A

Acute cholecystitis
Acute choledocolithiasis
Ascending cholangitis
Acute pancreatitis

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12
Q

How do you diagnose cholelithiasis

A

*US (initially)- can show gallstones, wall thickening, pericholecystic fluid
CT Abdomen- more expensive, more radiation, less Sn, but will show majority of stones
Abd XR has limited value in Dx gallstones

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13
Q

How do you manage asymptomatic cholelithiasis

A

If incidental finding and ASx, you should NOT do a CCY

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14
Q

How do you manage Symptomatic cholelithiasis

A

Cholecystectomy (CCY)

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15
Q

What is biliary colic

A

Temporary obstruction of cystic duct
MCC by gallstones which cause pressure in gallbladder to rise= pain
As gallbladder relaxes, obstruction is relieved
NO INFLAMMATION!!*****

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16
Q

How does biliary colic present

A

Dull, constant RUQ pain w/ possible radiation to R shoulder blade
MC after a fatty meal
Associated nausea, vomiting, and diaphoresis
Sx are TEMPORARY**, 4-6 hours max

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17
Q

What if they have biliary colic pain but it lasts >6 hours

A

This is acute cholangitis! Treat it more urgently

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18
Q

On PE for biliary colic you may find

A

They are NOT acutely ill
Vital signs are normal (no fever or tachy)
NO jaundice
NO scleral icterus
+/- RUQ ttp, but NO rebound, NEG murphy’s sign

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19
Q

What labs should you get to eval biliary colic

A

CBC
LFT
Amylase and lipase
(will all be normal)

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20
Q

How do you diagnose biliary colic

A

*US- expect to see gallstones or sludge, which is causing the temp obstruction

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21
Q

How do you manage biliary colic

A

Prophylactic CCY to prevent recurrent Sx and complications
MUST have r/o alternate diagnoses bc your workup is frequently normal. Gall stones could be present, but they may not be the root of the Sx

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22
Q

What is biliary dyskinesia

A

Functional gallbladder disorder;

No sludge, no stones, no inflammation. Gallbladder just doesn’t function correctly!

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23
Q

Consider biliary dyskinesia in a patient who

A

has NO gall stones or sludge on US

Has normal labs (CBC, LFT, Am, Lip)

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24
Q

How can you diagnose biliary dyskinesia

A

HIDA scan with CCK!
Inject HIDA, which should normally be excreted in bile and taken up by gallbladder w/in 30 min. Then measure radioactivity in gallbladder
Give CCK to stimulate gallbladder to contract and measure EF, but NOT if the pt has stones!
Abnormal gallbladder motility is EF <35-40%

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25
Q

How do you manage biliary dyskinesia

A

CCY if biliary dyskinesia and:
Biliary Sx
HIDA w/ CCK EF <35-40% that reproduces Sx
R/o PUD, gastritis, GERD cardiac ischemia

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26
Q

What is acute cholecystitis

A

Acute inflammation of the gallbladder due to sustained obstruction of cystic duct
MCC is cholesterol stones

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27
Q

What history findings point you to acute cholecystitis

A

Steady, severe RUQ pain +/- right shoulder radiation
Occurs s/p fatty meal
Associated nausea, vomiting, diaphoresis, fever
Sx persist >4-6 hours!
History of biliary colic

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28
Q

On PE for acute cholecystitis you may find

A 
Ill appearing 
fever, tachycardia 
NO jaundice 
NO scleral icterus 
RUQ ttp w/ palpablt, tender gallbladder 
\+/- rebound and guarding 
*Positive murphy's sign
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29
Q

What are complications of acute cholecystitis

A 
Gangrene, esp. if old, immunosuppressed, or delayed treatment 
Perforation 
Generalized peritonitis 
Cholecystoenteric fistula 
Gallstone ileus
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30
Q

What labs should you get for acute cholecystitis

A

CBC: elevated WBC w/ left shift**
LFT: normal, mils ALT/AST, alk phos, and bili elevation
UA: elevated urobilinogen
Pancreatic enzymes: mild elevation of amylase

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31
Q

If alk phos and bilirubin are significantly elevated when you suspect Acute cholecystitis, you must

A

rule out Cholangitis!

*Alk phos and Bilirubin= obstruction!

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32
Q

How do you diagnose acute cholecystitis

A

*US- may see gallstones, thick wall, pericholecystic fluid, + sonographic murphy’s sign
HIDA scan: confirm Dx if the US was not definitive- will show failure of GB to fill

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33
Q

How do you manage acute cholecystitis

A

Admit
Analgesics (ketorolac, morphine, meperidine)
NPO
IVF, electrolytes
IV abx (cipro, flagyl
*Early CCY if healthy, low risk (ASA class I-II)- do it when they are not acutely inflammed

34
Q

What is criteria for emergent CCY

A

IF severe complication (gangrene, perforation, peritonitis)

Clinical deterioration despite supportive therpay

35
Q

What is the ASA classification system

A 
I: normal, healthy pt 
II: mild systemic dz 
III: severe systemic dz 
IV: severe systemic dz that is life threatening 
V: will not survive w/o surgery 
VI: brain dead, organ donor surgery
36
Q

How do you manage high risk acute cholecystitis patients

A

Supportive therapy
Consult specialist for risk vs benefir of CCY
If therapy fails, consider cholecystostomy tube to decompress

37
Q

What is chronic cholecystitis

A

Chronic inflammation of the gallbladder associated with mechanical irritation (gallstones) or repeat acute cholecystitis
Usually diagnosed s/p CCY when looking at histology

38
Q

What is acalculous cholecystitis

A

Similar to acute cholecystitis but no gallstones, and may have jaundice
Common in critically ill patients (associated stasis and ischemia)
Worse than calculous cholecystitis

39
Q

How do you diagnose acalculous cholecystitis

A

US
LFT
CBC

40
Q

PROMPT Tx of acalculous cholecystitis includes

A

CCY vs. Cholecystostomy (CCY best)

41
Q

Why do you want to be prompt about treating acalculous cholecystitis

A

bc secondary infection of the gallbladder is common;

Check blood cultures, start broad spectrum Abx, and prevent gallbladder gangrene!

42
Q

What is choledocolithiasis

A

Stone in the CBD that blocks bile flow and caused jaundice*

43
Q

History findings that indicate choledocolithiasis are

A 
RUQ or epigastric pain 
N/v
Sx similar to PUD 
Jaundice*, pruritis, tea colored urine, light colored stool 
(look for Hx of biliary colic)
44
Q

PE for UNcomplicated choledocolithiasis (no cholangitis) shows

A 
mild discomfort 
afebrile, no tachy, no hypotension 
Jaundice* 
Scleral icterus* 
\+/- RUQ ttp, no peritoneal signs
45
Q

What findings would make you suspect cholangitis with choledocolithiasis

A

Fever
Jaundice
Leukocytosis
Prominent RUQ ttp

46
Q

What labs should you get for uncomplicated choledocolithiasis

A

CBC (no leukocytosis)
LFT (if w/ cholestasis, high CONjugated bili and high Alk Phos)
Pancreatic enzymes (normal)

47
Q

What imaging can you get for choledocolithiasis

A 
RUQ US (first test)- may see CBD stone, dilated CBD, or stones in the GB 
If uncertain, can get an MRCP
48
Q

What does MRCP show

A

Biliary and pancreatic ducts

Confirms diagnosis of CBD stone

49
Q

How do you manage choledocolithiasis

A

Remove stone to prevent cholangitis or pancreatitis
+/- prophylactic Abx (cipro, flagyl)
ERCP as therapeutic test to remove stone, insert stent, and perform sphincterotomy
Then CCY

50
Q

When is it ok to perform an ERCP in choledocolithiasis

A

When you know you will have to treat

Because of how invasive it is, do not do it just for diagnostic purpose

51
Q

What is ascending cholangitis

A

Infection of the biliary tract, MC in CBD- like a pond of water just sitting
Associated with biliary obstruction
Bacteria infects bile (ascending infection from duodenum)
AKA: Pus under Pressure! so, this is an emergency!

52
Q

What history findings point you to ascending cholangitis

A

RUQ epigastric pain
jaundice
fever
Hx of biliary colic or disease

53
Q

On ascending cholangitis PE you may find

A 
acutely ill appearing, diaphoretic 
fever, tachycardia, hypotension 
jaundice 
scleral icterus 
RUQ ttp, guarding 
AMS
54
Q

Acute presentation of ascending cholangitis is

A

**Charcot’s triad: Fever, RUQ pain, jaundice
**Reynolds pentad: Fever, RUQ pain, Jaundice, hypotension, mental status changes
Signs of peritonitis and sepsis

55
Q

What are some lab findings in acute cholangitis

A 
Leukocytosis (>20K) 
LFT: elevated Conjugated bili and alk phos** indicate cholestasis 
Pancreatic enzymes: nl-mild high 
UA: high urobilinogen 
Blood cultures may show sepsis
56
Q

How do you diagnose ascending cholangitis

A

US

MRCP (CBD stone and dilation)

57
Q

How do you manage ascending cholangitis

A 
Admit 
Consult GI 
NPO, IVF 
Broad spectrum Cipro+Flagyl 
MUST relieve obstruction 
ERCP w/ sphincterotomy and stone extraction 
Follow with CCY
58
Q

How does an ERCP treat ascending cholangitis

A

Sphincterectome
Stone extraction from CBD
Relieve obstruction
+/- stent

59
Q

If you suspect biliary disease, what diagnostics do you order to r/o others

A

CBC w/ diff: r/o infection
Amylase/lipase: r/o pancreatitis (mild bump with acute biliary dz)
LFT: high alk phos and conjugated bili= cholestasis 2/2 obstruction. ALT/AST with transient elevations
US
MRCP: helpful w/ dx stones/obstruction in CBD when US non-diagnostic

60
Q

Additional diagnostics in biliary disease are

A

HIDA scan to confirm cystic duct obstruction. Add CCK to measure EF for biliary dyskinesia
ERCP: relieve CBD obstruction

61
Q

What is primary biliary cirrhosis

A

Autoimmune destruction of small intrahepatic bile ducts causing cholestasis
Leads to cirrhosis and liver failure
MC in females 35-60

62
Q

How does primary biliary cirrhosis present

A

*Fatigue, pruritis before jaundice (2/2 bile getting into circulation)
Arthritis, RUQ pain, CREST Sx

63
Q

If a patient comes in with itching, what labs do you get

A

Conjugated bili
Alk Phos
ALT, AST
(pruritis is usually skin, but need to r/o bile in the circulation!)

64
Q

What labs should you get to eval primary biliary cirrhosis

A 
LFT (high alk phos, then high Con bili; high GGT) 
*Anti-mitochondrial antibody (AMA) 
ANA
IgM
HLD
65
Q

What is GGT

A

a very sensitive liver marker of inflammation

If alk phos is high and you don’t know whether it is from liver or bone, GGT helps tell you its liver!

66
Q

How do you diagnose primary biliary cirrhosis

A

Liver biopsy!

Confirm dx and stage dz

67
Q

How do you manage primary biliary cirrhosis

A

Urso (med to help w/ stasis)

DEXA to monitor bone density

68
Q

What is primary sclerosing cholangitis

A

Inflammation/fibrosis of medium and large intra/extra hepatic ducts
Progress to cirrhosis (survival is 10-12 yrs s/p dx)
MC in men

69
Q

Sx of primary sclerosing cholangitis are

A

*Fatigue, pruritis after jaundice, steatorrhea

70
Q

Complications of primary sclerosing cholangitis are

A 
Biliary stricture 
Cholangitis 
Cholangiocarcinoma 
Gallbladder cancer 
Colon cancer
71
Q

How do you diagnose primary sclerosing cholangitis

A

LFT have cholestatic pattern (high alk phos and conj bili)
*P-ANCA, ASMA, ANA, IgM
ERCP: Dx and therapeutic
MRCP: will see multifocal stricturing w/ intra/extra hepatic ductal dilation
Liver biopsy is usually non-diagnostic

72
Q

How do you manage primary sclerosing cholangitis

A

Monitor bone density
Manage biliary strictures with ERCP (dilate/stent)
Monitor for complications
Liver transplant with advanced disease

73
Q

What is Gilbert’s syndrome

A

Deficiency in enzyme to conjugate bilirubin in the liver
Leads to *Unconjugated hyperbilirubinemia withOUT hemolysis
They are totally ASx

74
Q

Labs for Gilbert’s syndrome show

A

High unconjugated bili

Normal CBC, blood smear, reticulocytes, all other LFT are normal

75
Q

RF for gallbladder cancer are

A

Cholelithiasis
Gallbladder polyps >1cm
Salmonella infection

76
Q

How does gallbladder cancer present

A

ASx or looks just like cholelithiasis

Sx can suggest malignancy (anorexia, wt loss)

77
Q

What is Cholangiocarcinoma

A

Adenocarcinoma of bile ducts, associated with PSC and choledochal cysts

78
Q

How does cholangiocarcinoma present

A 
*Jaundice 
upper abd pain 
anorexia 
weight loss 
pruritis
79
Q

Cholangiocarcinoma labs show

A

Cholestasis: high conj bili and alk phos

Elevated CA-19-9 (pancreatic cancer marker)

80
Q

What is ampullary cancer

A

Cancer of ampulla of vater, where CBD and pancreatic duct meet
Associated w/ familial adenomatous polyposis and HNPCC

81
Q

How does ampullary cancer present

A

*Obstructive jaundice
occult GIB w/ microcytic anemia
abdominal pain

Summer FDTN Exam 5 (12 decks)

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