Biliary Disease

Question 1

What are RFs for cholelithiasis?

Answer 1

“Four F’s” = female, fluffy, forty, fertile

Pregnancy
Rapid wt loss
Ethnicity

Question 2

What is the MC type of stone seen in cholelithiasis?

Answer 2

Cholesterol!

Question 3

What is the clinical presentation of cholelithiasis?

Answer 3

Majority asx

Biliary colic

Question 4

What are complications of cholelithiasis?

Answer 4

Cholecystitis
Choledocholithiasis
Cholangitis
Pancreatitis

Question 5

What imaging is used for dx of cholelithiasis?

Answer 5

U/S = TOC!

Abd xray

CT abd

Question 6

How do you treat symptomatic cholelithiasis?

Answer 6

CCY

Question 7

Describe biliary colic

Answer 7

Temporary obstruction of cystic duct

Caused by gallstone usually

Increased pressure –> pain

Question 8

What is the clinical presentation of biliary colic?

Answer 8

Dull RUQ pain w/ radiation to R shoulder blade

N/V, diaphoresis

Sx are temporary! < 4-6hrs

Question 9

What can trigger biliary colic?

Answer 9

Fatty meal

Question 10

What labs are used in biliary colic?

Answer 10

CBC
LFTs
Amylase/lipase

ALL NORMAL!

Question 11

What imaging can you use to dx biliary colic?

Answer 11

U/S: TOC! Gallstones or sludge expected

Question 12

How do you treat biliary colic?

Answer 12

Prophylactic CCY

Question 13

When should you consider biliary dyskinesia (functional gallbladder disorder)?

Answer 13

In patient presenting w/ typical biliary colic, but have no gallstones or sludge

Question 14

What imaging should be considered in biliary dyskinesia?

Answer 14

HIDA w/ cholecystikinin (CCK)

*Don’t give CCK if gallstones present (start w/ U/S to r/o)

Question 15

How do you treat biliary dyskinesia?

Answer 15

CCY when criteria is met:

Biliary sx
HIDA w/ CCK EF < 35-40%
Other dx r/o

Question 16

What causes acute cholecystitis?

Answer 16

Sustained obstruction of the cystic duct

MC caused by cholesterol stones

Question 17

What is the clinical presentation of acute cholecystitis?

Answer 17

Severe RUQ pain +/- radiation to right shoulder/flank

N/V, diaphoresis, fever

Sx persistent! > 4-6hrs

Hx of biliary colic

Question 18

What does acute cholecystitis look like on PE?

Answer 18

Ill appearing
Fever, tachy
RUQ tenderness
+ Murphy’s sign

Question 19

What are complications of acute cholecystitis?

Answer 19

Gangrene (20%)
Perforation 
Peritonitis 
Fistula 
Gallstone

Question 20

What labs are used for the dx of acute cholecystitis?

Answer 20

Elevated WBC w/ left shift

+/- elevation of AST/ALT, alk phos, bilirubin

UA: elevated urobilinogen

+/- elevation of amylase

Question 21

What imaging is used to dx acute cholecystitis?

Answer 21

U/S: TOC! Presence of gallstones

HIDA: confirms dx

Question 22

How do you treat acute cholecystitis?

Answer 22

NPO, IVF, analgesia, IV abx

Early cholecystectomy

Question 23

What abx can be used for tx of acute cholecystitis?

Answer 23

Single agent:
Pipercillin tazobactam
Ampicillin sulbactam
Ticarcillin clavulanate

Combo:
Ceftriaxone + metronidazole
OR cipro + metronidazole

Question 24

What is chronic cholecystitis associated w/?

Answer 24

Mechanical irritation from gallstones or repeated episodes of acute cholecystitis

Question 25

What condition is common in critically ill patients & is associated w/ stasis & ischemia?

Answer 25

Acalculous cholecystitis

Question 26

How does acalculous cholecystitis present?

Answer 26

similar to acute cholecystitis except no gallstones present

Question 27

What imaging & labs are used for dx of acalculous cholecystitis?

Answer 27

U/S LFTs CBC

Question 28

How do you treat acalculous cholecystitis?

Answer 28

CCY vs cholecystostomy If secondary infection of gallbladder occurs --> abx

Question 29

What is the clinical presentation of choledocholithiasis?

Answer 29

Biliary pain (RUQ or epigastric, N/V) May be asx Jaundice: pruritis, tea urine, light colored stool Hx of biliary colic

Question 30

What does choledocholithiasis look like on PE?

Answer 30

Jaundice, icterus | +/- RUQ tenderness

Question 31

If choledocholithiasis presents with fever, jaundice, leukocytosis, & more prominent tenderness, what should you think?

Answer 31

Cholangitis!

Question 32

What labs are used for dx of choledocholithiasis?

Answer 32

CBC LFTs: increased conjugated bilirubin & alk phos Amylase/lipase

Question 33

What imaging is used for the dx of choledocholithiasis?

Answer 33

RUQ U/S = TOC! CBD stone, dilated CBD, gallstones If dx uncertain --> MRCP

Question 34

How do you treat choledocholithiasis?

Answer 34

Removal of stones Prophylactic abx ERCP (preferred therapeutic test) Cholecystectomy to follow

Question 35

What is ascending cholangitis associated w/?

Answer 35

Biliary obstruction Bile infected w/ bacteria

Question 36

How does ascending cholangitis present?

Answer 36

RUQ/epigastric abd pain Jaundice Fever Hx of biliary colic

Question 37

What does ascending cholangitis look like on PE?

Answer 37

Ill appearing, diaphoretic Fever, tachy, hypotension Jaundice, icterus MSC

Question 38

What is the most acute presentation for ascending cholangitis? AKA Charcot's triad

Answer 38

Fever/chills RUQ pain Jaundice

Question 39

What is Reynold's Pentad?

Answer 39

Charcots triad + hypotension & MSC

Question 40

What labs are used for dx of ascending cholangitis?

Answer 40

CBC: leukocytosis LFTs: cholestasis (elevated conjugated bili & alk phos) +/- elevated pancreas enzymes UA: elevated urobilinogen Blood cultures

Question 41

What imaging is used for dx of ascending cholangitis?

Answer 41

U/S MRCP: CBD dilation & stone

Question 42

How do you treat ascending cholangitis?

Answer 42

NPO, IVF Abx for Gram+ & Gram- : Ceftrazone + metronidazole Cipro + metronidazole Piperacillin/tazobactam

Question 43

What procedures are used for ascending cholangitis?

Answer 43

Relief of biliary obstruction is imperative!! ERCP w/ sphincterotomy & stone extraction F/u w/ CCY

Question 44

What are characteristics of primary biliary cirrhosis?

Answer 44

Females 35-60yo Causes cholestasis

Question 45

What is the clinical presentation of PBC?

Answer 45

Fatigue | Pruritis (before jaundice)

Question 46

What labs are used for dx of PBC?

Answer 46

LFTs: elevated alk phos & GGT Anti-mitochondrial antibody (AMA) = hallmark!! ANA IgM HLD

Question 47

What confirms the dx & stages PBC?

Answer 47

Liver bx!

Question 48

How do you treat PBC?

Answer 48

Urso DEXA (increased risk of osteoporosis)

Question 49

How does primary sclerosing cholangitis (PSC) present?

Answer 49

Fatigue | Pruritis (after jaundice)

Question 50

What are complications of PSC?

Answer 50

``` Biliary stricture Cholangitis Cholangiocarcinoma Gallbladder CA Colon CA (if IBD present) ```

Question 51

What labs are used for dx of PSC?

Answer 51

LFTs ANCA, ASMA, ANA, IgM

Question 52

What imaging is used for dx of PSC?

Answer 52

ERCP (dx & therapeutic) MRCP: multifocal stricturing w/ intrahepatic/extrahepatic dutal dilation

Question 53

How do you treat PSC?

Answer 53

Monitor bone density Manage biliary strictures w/ ERCP Liver transplant if advanced

Question 54

What is Gilbert's syndrome?

Answer 54

Deficiency in enzyme for glucuronidation of bilirubin in liver

Question 55

When should you suspect Gilbert's syndrome?

Answer 55

Unconjugated hyperbilirubinemia in absence of hemolysis

Question 56

What are RFs for gallbladder CA?

Answer 56

Cholelithiasis Gallbladder polyps > 1cm Salmonella

Question 57

How does gallbladder CA present?

Answer 57

Can be indistinguishable from cholelithiasis May be asx

Question 58

How does cholangiocarcinoma (adenocarcinoma of the bile ducts) present?

Answer 58

Jaundice Upper abd pain Anorexia, wt loss Pruritis

Question 59

What labs are used to dx cholangiocarcinoma?

Answer 59

Labs show cholestasis (elevated conjugated bili & alk phos) Elevated CA 19-9

Question 60

How does ampullary cancer present?

Answer 60

Obstructive jaundice**MC Occult GIB w/ microcytic anemia Abd pain

Question 61

What is ampullary CA associated w?

Answer 61

FAP & HNPCC