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Clin Med III Exam 2 > Biliary Disease > Flashcards

Biliary Disease Flashcards

1
Q

What is bile made of

A

Water, bile salts, lecithin/traces of phospholipids, bilirubin & cholesterol

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2
Q

Function of bile

A

digest/absorb fat

vehicle for excretion of bilirubin, excess cholesterol and metabolic byproducts

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3
Q

cholelithiasis

A

stones in GB

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4
Q

Cholecystitis

A

inflammation of GB

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5
Q

Choledocholithiasis

A

stones in CBD

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6
Q

Cholangitis

A

inflammation of the bile ducts

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7
Q

Cholestasis

A

disruption of bile flow

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8
Q

Risk factors for cholelithiasis

A 
(female, fluffy, forty, fertile)
females
40 YO
obesity
pregnancy
estrogen (OCP, HRT)

rapid weight loss
familiy hx/genetics
ethnicity (native am)
DM

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9
Q

Types of gallbladder stones

A

cholesterol (80%)

Pigment (20%) - black vs. brown

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10
Q

Presentation of cholelithiasis

A

most asymptomatic

uncomplicated disease (biliary colic) - in the absence of gallstone-related complications

Complicated gallstone disease: gallstone-related complications

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11
Q

Gall stone related complications

A

acute cholcystitis
Choledocholithiasis w/ or w/out acute cholangitis
Gallstone pancreatitis

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12
Q

Test of choice for cholelithiasis

A

US

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13
Q

Additional dx for cholelithiasis

A 
US - test of choice
Abdominal plain film (rare finding)
CT abdomen (less sensitive than US)
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14
Q

Tx fo asymptomatic (incidental) gallstones

A

no tx
refer for cholecystectomy if symptoms develop

Exceptions (Treat):

  • increased risk of gallbladder CA
  • hemolytic disorders
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15
Q

When to treat asymptomatic gallstones

A 
increased risk of gallbladder CA
hemolytic disorders (Black stones)
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16
Q

Etiology of pain with biliary colic (non-inflammatory)

A

gallbladder contracts, stone forces against outlet –> increased intra-gallbladder pressure –> increase in pressure results in pain –> as gallbladder relaxes, obstruction is relieved (pain subsides)

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17
Q

Biliary colic sx

A
  • Intense RUQ (or epigastric) pain that may radiate to the R shoulder blade
  • Constant and steady (not colicky)
  • Pain lasting at lease 30 min, plateauing within 1 hour • Usually lasting < 5-6 hours
  • Postprandial pain, commonly after eating fatty or greasy foods
  • Assoc. nausea, vomiting, diaphoresis
  • Not exacerbated by movement
  • Not relieved by squatting, bowel movements, or flatus
  • Nocturnal pain—awakening patient is common
  • Recurrence is variable (not daily)
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18
Q

PE for biliary colic

A 
VSS
NAD
no jaundice
Anicteric
Ab exam: possible RUQ/epigastric tenderness, no peritoneal signs, NEGATIVE MURPHY'S SIGN
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19
Q

Dx for biliary colic

A

All normal: CBC, LFT, Amylase/lipase

US - show gallstones or sludge

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20
Q

Tx for symptomatic uncomplicated biliary colic

A

cholecystectomy

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21
Q

What is functional gallbladder disorder

A

Characterized by biliary-type pain in the absence of gallstones, sludge, microlithiasis, or microcrystal disease

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22
Q

Cause of functional gallbladder disorder pain

A

gall bladder dysmotility

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23
Q

Dx of functional gallbladder disorder

A 
Normal labs (CBC, LFT, amylase/lipase)
normal imagine/EGD

diagnosis of exclusion

Order HIDA (CCK-stimulated cholescintigraphy) after your r/o everything else: EF <35-40% support diagnosis

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24
Q

EF in functional gallbladder disorder

A

<35-40%

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25
Q

Rome IV criteria for functional gallbladder disorder

A

biliary pain
absence of gallstones/other patholgy

Supportive:

  • Low EF
  • Normal LFT, bilirubin, amylase/lipase
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26
Q

Tx of functional gallbladder disorder

A

educate/reassure
refer

Cholecystectomy recommended w/ biliary type pain and EF <40%

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27
Q

Types of complicated gallstone disease

A
  • Acute (calculous) cholecystitis
  • Choledocholithiasis
  • Acute cholangitis
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28
Q

What is acute (calculous) cholecystitis

A

acute inflammation of gall bladder due to complication of those w/ gallstones (cystic duct obstruction and gallbladder inflammation)

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29
Q

Presentation of acute cholecystitis

A

biliary pain that progressively worsens (most have had past episodes of biliary pain)
Prolong >4-6 hours, stead, RUQ/epigastric pain
Radiate to right shoulder or back
FEVER, N/V, anorexia
hx of fatty food ingestion

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30
Q

PE for cholecystitis

A 
VS: fever, tachycardic
Gen: ill appearing, may be lying still
NO JAUNDICE
Abd exam: RUQ tenderness, +/- guarding
POSITIVE MURPHY'S SIGN
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31
Q

labs for acute cholecystitis

A

Leukocytosis w/ left shift!!!
mild elevation of AST/ALT
Elevated bilirubin/ALP NOT COMMON (if present, should suspect cholangitis, choledocholithiasis)
Serum amylase = normal (unless pancreatitis)

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32
Q

Dx of acute cholecystitis

A

US - gallstones present, wall thickening (>4-5 mm) or edema, pericholecystic fluid, + sonographic murphy’s sign

HIDA - if diagnosis is uncertain; + = failure to visualize gallbladder in setting of cystic duct obstruction (doesn’t fill)

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33
Q

Complications of acute cholecystitis

A 
Gangrene (most common)
Perforation (often after gangrene)
Cholecystoenteric fistula
Gallstone ileus
Emphysematous cholecystitis, empyema, hydrops
Mirizzi syndrome
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34
Q

Tx of acute cholecystitis

A

Admit
NPO, IVF
IV pain control (ketoroloac, morphine, meperidine)
IV abx (empiric)

Cholecystectomy !!!!

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35
Q

Chronic cholecystitis

A

chronic inflammation of gallbladder due to gallstones or repeated acute/subacute cholecystitis

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36
Q

Sx of chronic cholecystitis

A

minimal
asymptomatic for years, may progress to symptomatic gallbladder disease or to acute cholecystitis or present w/ complications

no evidence that increases morbidity

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37
Q

Acalculous cholecystitis

A

Acute necroinflammatory disease of the gallbladder (in the absence of gallstones) – VERY SICK
high morbidity and mortality rates

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38
Q

Pathogenesis of acalculous cholecystitis

A
  • Gallbladder stasis and ischemia–>local inflammatory response in the gallbladder wall
  • Secondary bacterial infection is common; perforation in severe cases
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39
Q

Who gets acalculous cholecystitis

A

hospitalized and CRITICALLY ILL PATIENTS (trauma/burn, postpartum, ortho surgery)

40
Q

Sx of acalculous cholecystitis

A

similar to acute (calculous) cholecystitis OR clinical picture of sepsis-related cholestasis and jaundice (sepsis w/o a clear source)

41
Q

suspect acalculous cholecystitis

A

Critically ill patients with sepsis without a clear source or jaundice

42
Q

Workout for acalculous cholcystitis

A

US (CT, HIDA)

LFT, CBC, electrolytes, pancreatic enzymes, UA

43
Q

Tx for acalculous cholecystitis

A
  • Risk of gallbladder gangrene and perforation • Obtain blood cultures
  • Initiate antibiotics
  • Cholecystectomy vs. gallbladder drainage (if too ill)
44
Q

What is choledocholithiasis

A

gallstones in common bile duct (usually from gallstone in gallbladder); increases w/ age

45
Q

Presentation of choledocholithiasis

A

biliary type pain
prolonged than typical biliary colic
some are asymptomatic
JAUNDICE

46
Q

PE for choledocholithiasis

A

VS: WNL
RUQ/epigastric tenderness
Jaundiced
Courvoisier sign (palpable gallbladder)

47
Q

Labs for choledocholithiasis

A

CBC- no leukocytosis
Elevated liver test (cholestasis) - elevated ALT/AST (early in course); later, liver test elevated in cholestatic pattern (increased bilirubin, ALP and GGT; exceeding elevations of ALT and AST)

Normal amylase and lipase

48
Q

Imaging for choledocholithiasis

A

US - cholelithiasis, CBD stone, CBD dilation (>6mm)

MRCP/EUS if unsure

49
Q

Tx for choledocholithiasis

A 
remove CBD stone
Treat complications (acute cholangitis, acute pancreatitis)

ERCP: therapeutic and diagnostic

Cholecystecotomy to follow (if appropriate: low vs. high risk)

50
Q

Acute cholangitis

A

inflammation of biliary duct system caused by bacterial infection in person w/ biliary obstruction (choledocholithiasis, benign biliary stricture, s/p ERCP, malignancy)

51
Q

main cause of acute cholagitis

A

choledocholithiasis

52
Q

Bacterial origin in cholangitis

A

ASCEND from duodenum

53
Q

Symptoms of acute cholangitis

A

Charcot’s Triad: fever, abdominal pain, jaundice

Reynolds Pentad: above + AMS and hypotension (significant morbidity and mortality)

54
Q

Labs for acute cholangitis

A

Leukocytosis w/ left shift
Elevated CRP/ESR

Liver tests: evidence of cholestasis

  • inc. bilirubin, ALP, GGT
  • may see inc. AST/ALT

amylase/lipase increased in pancreatitis
some have positive blood culture

55
Q

Imaging in acute cholangitis

A

US (CT, MRCP, EUS)

- CBD dilation, stone

56
Q

Tx for acute cholangitis

A

admit
monitor/tx for sepsis (empiric abx)
Emergent consult w/ GI and surgery - establishing biliary drainage (typically w/ ERCP)

57
Q

Biliary drainage

A

relief of biliary obstruction imperative;
Done w/ ERCP w/ sphincterotomy and stone extraction (and/or stent insertion)

F/u w/ cholecystectomy (if appropriate)

58
Q

Primary biliary cholangitis (PBC): what is it?

A

mainly in women 30-64 YO; AUTOIMMUNE destruction of intrahepatic bile ducts which causes cholestasis – may result in cirrhosis and liver failure

59
Q

presentation of PBC

A 
may be asymptomatic
fatigue, pruritis
jaundice
RUQ discomfort
skin hyperpigmentation
xanthelasmas
hepatomegaly
60
Q

PBC associated w/

A

other autoimmune conditions (sjogren, thyroid disease)

61
Q

Labs for PBC

A

Liver tests: cholestatic pattern (elevated ALP, GGT, 5-NT), +/- ALT/AST, increase bilirubin (later in disease)

Antimitochondrial antibodies (AMA) - serologica hallmark of PBC

ANA (70%)
HLD - strikingly elevated

62
Q

Antibodies for PBC

A

AMA, ANA

63
Q

Complications of PBC

A 
• Cirrhosis
• Hepatocellular carcinoma
• Malabsorption (and steatorrhea) 
- Fat-soluble vitamin deficiencies
• Metabolic bone disease
- Including osteopenia and osteoporosis
64
Q

Dx of PBC

A

• No extrahepatic biliary obstruction
• No comorbidity affecting the liver
• At least 2 of the following are present:
- Elevated Alk. Phos (1.5 times the upper normal limit)
- + AMA
- Histologic evidence of PBC (liver bx, if needed)

65
Q

Tx for PBC

A

refer to GI (meds and tx of complications)

66
Q

Primary sclerosing cholangitis (PSC): what is it?

A

a sclerosing, inflammatory , and obliterative process involving the intrahepatic and/or extrahepatic biliary tree; chronic/progressive w/ unknown etiology

67
Q

PSC most common in

A

MEN! (40 YO)

68
Q

PBC most common in

A

women (30-64 YO)

69
Q

PSC associated w/

A

IBD (UC>UD)

70
Q

Complications of PSC

A

cholestasis

end-stage liver disease

71
Q

S/sx of PSC

A

asymptomatic
fatigue, pruritus
jaundice!
hepatomegaly

72
Q

Labs for PSC

A

liver test- cholestatic pattern
Increased IgM levels, +P-ANCA, autoantibodies (ANA, ASMA)
NEGATIVE AMA!!!

73
Q

Dx of PSC

A

Liver tests - especially in those w/ IBD
Cholangiography (MRCP or ERCP)
Liver bx (supports but rarely diagnostic)

74
Q

Complications of PSC

A
  • End-stage liver disease
  • Fat-soluble vitamin deficiencies
  • Metabolic bone disease
  • Cholangitis and cholelithiasis
  • Hepatobiliary cancer
  • Colon cancer
  • Patients with UC
75
Q

Tx for PSC

A

refer to GI (meds/treatment of complications)

76
Q

Gilbert’s

A

inherited; inability to conjugate bilirubin (deficiency of enzyme for glucoronidation of bilirubin);

Unconjugated hyperbilirubinemia in ABSENCE OF HEMOLYSIS (normal CBC, blood smear, reticulocyte), remainder of liver tests normal

77
Q

Presentation of Gilbert Syndrome

A 
• Typically present during adolescence
(post-puberty)
• More common in males
• Mild intermittent episodes of jaundice
• Otherwise, most are asymptomatic with normal physical exam findings
78
Q

Jaundice occurs when w/ Gilbert

A

dehydration
fasting
menstruation
stress

79
Q

Most common cancer in biliary tract

A

Gallbladder CA (uncommon, but hightly fatal); W>M

80
Q

Risk factors for gallbladder CA

A 
Gallstone disease
Porcelain gallbladder***
Gallbladder polyps ***
PSC
Chronic infection (salmonella, Helicobacter)
Obesity
81
Q

Presentation of gallbladder CA

A

asymptomatic
may mimic cholelithiasis or suggestive of malignancy (weight loss)
may see jaundice

82
Q

Etiology of cholangiocarcinoma (bile duct cancer)

A

Arise from epithelial cells of the bile ducts (intrahepatic, perihilar, or distal extrahepatic biliary tree); rare; M>F

83
Q

Cholangiocarcinoma associated w/

A

PSC

choledochal cysts

84
Q

Presentation of chlangiocarcionoma

A 
jaundice
pruritus
abd pain
anorexia
weight loss
palpable gallbaldder (courvoisier sign)
85
Q

Labs for cholangiocarcinoma

A

cholestasis pattern

Increased CA 19-9 (in those w/ PSC)

86
Q

Ampullary carcinoma

A

rare; arise w/i ampulla of vater (complex) - distal to the difurcation of distal CBD and pancreatic duct

87
Q

Ampullary carcinoma associated w/

A

Familial Adenomatous Polyposis (FAP)

Hereditary Non-Polyposis Colon Cancer (HNPCC)

88
Q

Presentation of ampullary carcinoma

A

jaundice
GI bleed w/ microcytic anemia
abdominal pain

89
Q

women, pruritus, + AMA

A

PBC

90
Q

men, IBD (UC), risk of cholangiocarcinoma

A

PSC

91
Q

men, post-puberty, elevated unconjugated hyperbilirubinemia

A

Gilbert Syndrome

92
Q

Initial test of choice in evaluation of biliary disease

A

US

93
Q

Helpful for diagnosing stones/obstruction in the CBD when US non-diagnostic

A

MRCP

94
Q

Uses CCK to measure EF for functional gallbladder disorder

A

HIDA

95
Q

Used to relieve CBD obstruction; Choledocholithiasis, Cholangitis

A

ERCP

Clin Med III Exam 2 (8 decks)

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