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X Clin Med III Exam 2 > Biliary Disease > Flashcards

Biliary Disease Flashcards

1
Q

Function of bile

A

Digestion and absorption of fats

Vehicle for excretion of bilirubin, excess cholesterol and metabolic byproducts

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2
Q

Stones in the gallbladder

A

Cholelithiasis

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3
Q

Inflammation of the gallbladder

A

Cholecystitis

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4
Q

Stones in the common bile duct

A

Choledocholithiasis

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5
Q

Inflammation of the bile ducts

A

Cholangitis

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6
Q

Disruption of bile flow regardless of cause

A

Cholestasis

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7
Q

Risk factors for cholelithiasis

A

Four Fs (female, fluffy, forty, fertile)
Females, Age 40, Obese, Pregnant, Estrogen (OCTs, HRT)
Also rapid weight loss, family hx, ethnicity (Native Americans), diabetes

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8
Q

Types of stones

A

Cholesterol mostly

Can be pigment (black or brown)

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9
Q

Types of presentation of cholelithiasis

A

Asymptomatic incidental stones (MOST)
Uncomplicated disease (biliary colic and symptomatic in the absence of gallstone related complications)
Complicated gall stone disease with complications

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10
Q

Complications that can arise in complicated gallstone disease

A

Aute cholecystitis
Choledocholithiasis with or without acute cholangitis
Gallstone pancreatitis

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11
Q

Initial test of choice for cholelithiasis

A

Ultrasound (very sensitive to detect stones)

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12
Q

Other diagnostics for cholelithiasis

A 
Abd plain film (only positive in some pts)
CT abdomen (less sensitive)
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13
Q

Tx for asymptomatic gallstones

A

Mostly don’t need tx, manage expectantly

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14
Q

When to refer for cholecystectomy with asymptomatic gallstones

A 
Increased risk of gallbladder cancer
Hemolytic disorders (sickle cell, G6PD etc)
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15
Q

Why does biliary colic/uncomplicated gallstone disease occur?

A

Gall bladder contracts forcing stone against outlet or cystic duct opening–increased intra gall bladder pressure resulting in pain–when relaxes, obstruction is relieved and pain subsides
**no inflammation of the gall bladder!

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16
Q

Classic description of biliary type pain in biliary colic

A

Intense RUQ/epigastric pain that may radiate to R shoulder blade
Constant and steady
Pain lasting at least 30 min then plateaus (<5-6 hrs)
Postprandial pain (fatty or greasy foods)
N/v, diaphoresis
Not worse with movement
Not relieved with squatting, bowel movements or gas
Noctural pain waking pt

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17
Q

PE for biliary colic

A 
Often normal vitals (NO fever or tachycardia)
Not ill appearing
NO evidence of jaundice
Anicteric eyes
No peritoneal signs, - Murphys
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18
Q

Labs in biliary colic

A

Normal CBC, LFTS, amylase and lipase

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19
Q

Preferred diagnostic test for biliary colic

A

US (seeing gallstones or gallbladder sludge)

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20
Q

Management for uncomplicated gallstones/biliary colic

A

Cholecystectomy (prevents recurrence and complications)

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21
Q

What is functional gall bladder disorder/biliary dyskinesia?

A

Biliary type pain in ABSENCE of gallstones, sludge, microlithiasis or microcrystal disease
Results from gall bladder dysmotility

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22
Q

Labs in functional gall bladder disorder

A

Normal CBC, LFTS, amylase, lipase

Normal imaging and upper endoscopic exam

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23
Q

How to diagnose functional gall bladder disorder

A

Diagnosis of exclusion when have biliary type pain (make sure not PUD, functional dyspepsia or ischemia heart)
If no other causes, order CCK-stimulated cholescintigraphy (HIDA scan)

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24
Q

How HIDA scan is used in functional gallbladder disorder

A

CCK is given to stimulate GB to contract
Calculate GB ejection fraction
GBEF <35-40% is considered low and supports

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25
Q

Criteria to diagnose functional gallbladder disorder

A

Rome IV criteria REQUIRES
Biliary pain
Absence of gallstones of other structural pathology
Other criteria supportive but not required
Low ejection fraction on scintigraphy
Normal liver enzymes, conjugated bilirubin and amylase/lipase

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26
Q

How to exactly define biliary pain

A

Pain in epigastrium and or RUQ
Builds up to steady level and lasts at least 30 min
Occurs at variable intervals (not daily)
Is severe enough to interrupt daily activities or lead to an ED visit
Is not significantly (<20%) relieved by BMs, postural changes or acid suppression
Other things supportive:
Pain associated with n/v
Pain radiates to back and or right subscap region
Pain awakens pt from sleep

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27
Q

Management for functional gallbladder disorder

A

Cholecystectomy recommended for those with typical biliary type pain and low GBEF (<40%)

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28
Q

What is acute calculous cholecystitis?

A

Acute inflammation of the GB
-mostly complication of gallstone disease
Occurs with cystic duct obstruction and gallbladder inflammation (must have both!!)

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29
Q

Presentation of acute calculous cholecystitis

A

Begins as attack of biliary pain that progressively worsens (usually have had a previous experience)
Prolonged (>4-6 hrs) steady, severe RUQ or epigastric pain
May radiate to right shoulder or back
Fever, n/v, anorexia
Often hx of fatty food ingestion

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30
Q

What is seen on PE for acute calculous cholecystitis?

A 
Fever and tachycardia
Ill appearing, lying still
No jaundice
Anicteric
Abd exam: RUQ tenderness, voluntary or involuntary guarding, + Murphy's sign
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31
Q

Labs seen with acute calculous cholecystitis

A

Leukocytosis with a left shift
Mild elevation in serum AST/ALT
Elevated serum total bilirubin and alk phos NOT COMMON (think biliary obstruction)
Normal serum amylase

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32
Q

Preferred imaging for acute calculous cholecystitis

A

US (see gallstones, wall thickening >4-5 mm or edema, pericholecystic fluid, + sonographic Murphys sign)

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33
Q

HIDA for acute calculous cholecystitis

A

Use if uncertain of diagnose

+ if failure to visualize GB in setting of cystic duct obstruction

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34
Q

Most common complication of acute calculous cholecystitis

A

Gangrene (older pts, DM, those delaying therapy-sepsis like pic)

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35
Q

Other complications of acute calculous cholecystitis

A

Perforation (often after developing gangrene)
Cholecystoenteric fistula
Gallstone ileus
Emphysematous cholecystitis, empyema, hydrops
Mirizzi syndrome

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36
Q

What is Mirizzi syndrome?

A

Stone in the cystic duct or Hartmann’s pouch of the GB may compress common hepatic duct and cause jaundice!

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37
Q

Management of acute calculous cholecystitis

A

Admit, NPO, IVF
IV pain (Ketorolac, Morphine, Meperidine)
IV abx (empiric)
Mainstay is cholecystectomy

38
Q

What is chronic cholecystitis?

A

Chronic inflammation of the GB almost always associated with gallstones (repeated acute/subacute cholecystitis or prolonged medical irritation of GB wall)

39
Q

Presentation of chronic cholecystitis

A

May have minimal sxs (asymptomatic for yrs and may progress to symptomatic GB disease of acute cholecystitis or just present with complications)

40
Q

What is acalculous cholecystitis?

A

Acute necroinflammatory disease of GB in absence of gallstones (high morbidity and mortality)

41
Q

Pathogenesis of acalculous cholecystitis

A

GB stasis and ischemia (local inflammatory response in GB wall) and secondary bacterial infection and maybe perf

42
Q

When is acalculous cholecystitis common?

A

Hospitalized and critically ill pts (trauma, burn, postpartum, ortho surgery)

43
Q

Presentation of acalculous cholecystitis

A

May be similar to acute calculous or may have picture of sepsis related cholestasis and jaundice (so think with critically ill pt with sepsis without clear source or jaundice)

44
Q

Management for acalculous cholecystitis

A

Must do quick to start abx (get cultures)

Cholecystectomy vs GB drainage

45
Q

Labs for acalculous cholecystitis

A

US, CT, HIDA

LFTs, CBC, lytes, pancreatic enzymes, UA

46
Q

What is choledocholithiasis?

A

Gallstones in common bile duct (increasing incidence with age)
Can block flow of bile and cause jaundice!!!

47
Q

History for choledocholithiasis

A

Usually with biliary type pain (more prolonged than with typical biliary colic)
Can be asymptomatic tho
Report jaundice

48
Q

PE for choledocholithiasis

A

Vital signs WNL when uncomplicated
RUQ or epigastric tenderness
May be jaundiced
Courvoisier signs (palpable gallbladder maybe)

49
Q

Labs for choledocholithiasis

A

No leukocytosis
Elevated LFTs (cholestasis)
Normal amylase and lipase

50
Q

Elevated liver tests in choledocholithiasis

A

Elevated ALT and AST early on with biliary obstruction
Later on, elevated in cholestatic pattern (increase in serum bilirubin, alk phos, gamma-glutamyl transpeptidase that are higher than AST and ALT)

51
Q

Initial imaging for choledocholithiasis

A

US (cholelithiais, CBD stone and CBD dilation)–MRCP or endoscopic us if unsure

52
Q

Why is MRCP used in choledocholithiasis?

A

Great to see biliary tree and pancreatic ducts

Can confirm dx of CBD stone

53
Q

Management of choledocholithiasis

A

Remove CBD stone and treat complications if not gotten out in time
ERCP is therapeutic and diagnositc
Cholecystectomy if appropriate

54
Q

Complications of choledocholithiasis

A

Acute cholangitis or acute pancreatitis

55
Q

What is acute cholangitis?

A

Inflammation of biliary duct system

56
Q

Cause of acute cholangitis

A

Bacterial infection in pt with biliary obstruction (choledolithiasis, benign biliary stricture, s/p ERCP, malignancy)
Typically ascending from the duodenum

57
Q

What must be remembered with acute cholangitis?

A

“Pus under pressure” is surgical emergency so must do something immediately

58
Q

Manifestations of acute cholangitis

A

Charcots (fever, abd pain, jaundice)

Reynolds (Charcots and AMS and hypotension)

59
Q

Labs for acute cholangitis

A

Leukocytosis with a left shift
Elevated CRP or ESR
Liver tests show cholestasis (increased bilirubin, alk phos, GGT and maybe AST/ALT)
Can see increased amylase or lipase with associated pancreatitis
+blood cultures

60
Q

Imaging for acute cholangitis

A

U/s
CT
MRCP (or EUS) to see CBD dilation or stone

61
Q

Management for acute cholangitis

A

Admit and monitor for sepsis (empiric abx)

Consult GI and surgery immediately (ERCP to do biliary drainage)

62
Q

Biliary drainage with acute cholangitis

A

Must relieve the biliary obstruction!!
ERCP with sphincterotomy and stone extraction or stent insertion
Can follow with cholecystectomy if needed

63
Q

What does increased alk phos, bilirubin or GGT suggest?

A

Cholestasis (biliary obstruction-choledocho)

64
Q

Who do you see primary biliary cholangitis in?

A

Women 30-65

65
Q

What is primary biliary cholangitis?

A

Autoimmune destruction of intrahepatic bile ducts which causes cholestasis
May result in cirrhosis or liver failure

66
Q

Presentation of primary biliary cholangitis

A

Maybe asymptomatic

Fatigue, pruritus, jaundice, RUQ discomfort, skin hyperpigmentation, xanthelasmas, hepatomegaly

67
Q

What is primary biliary cholangitis associated with?

A

Other autoimmune conditions (Sjogrens, thyroid)

68
Q

Labs in primary biliary cholangitis

A

Cholestatic patter of liver tests (elevated alk phos, GGT and maybe AST/ALT, increased bilirubin later on)
AMA (antimitochondrial!!!!)
ANA but not specific
Hyperlipidemia

69
Q

Complications of primary biliary cholangitis

A

Cirrhosis
Hepatocellular carcinoma
Malabsorption (and steatorrhea)
Metabolic bone disease

70
Q

How to diagnose primary biliary cholangitis

A

No extrahepatic biliary obstruction
No comorbidity affecting liver
Must have 2: elevated alk phos (1.5x), +AMA, histologic evidence of PBC

71
Q

Management of primary biliary cholangitis

A

Refer to GI for meds and complication tx

72
Q

What is primary sclerosing cholangitis?

A

Sclerosing, inflammatory and obliterative process involving intrahepatic and or extra hepatic biliary tree

73
Q

Who do we see primary sclerosing cholangitis in ?

A

Men (usually around 40)

74
Q

Close association of primary sclerosing cholangitis

A

IBD (mostly UC!!!!)

75
Q

Ultimate complications of primary sclerosing cholangitis

A

Cholestasis and end stage liver disease

76
Q

Presentation of primary sclerosing cholangitis

A

Asymptomatic, fatigue, pruritus, jaundice, hepatomegaly

77
Q

Labs for primary sclerosing cholangitis

A

Cholestatic pattern of liver tests
Increased IgM, + P-ANCA, autoantibodies (ANA,ASMA)
Negative AMA!!!

78
Q

How to diagnose primary sclerosing cholangitis

A

Abnormal liver tests especially with IBD
Cholangiography (MRCP or ERCP-multifocal stricturing and dilation of intrahepatic or extrahepatic bile ducts)
Liver bx

79
Q

Complications of primary sclerosing cholangitis

A 
End stage liver disease
Fat soluble vit deficiencies
Metabolic bone disease
Cholangitis and cholelithiasis
Hepatobiliary cancer
Colon cancer (pts with UC)
80
Q

Management of primary sclerosing cholangitis

A

Refer to GI for meds and complication tx

81
Q

What is Gilbert syndrome?

A

Inherited disorder of deficiency in enzyme for glucuronidation of bilirubin in liver
Have unconjugated hyperbilirubinemia in absence of hemolysis (normal CBC, blood smear and retic count)

82
Q

Presentation of Gilbert syndrome

A

Present during adolescence (post puberty)
Males
Mild intermittent episodes of jaundice!!!
Otherwise probably asymptomatic

83
Q

Risk factors for gall bladder cancer

A 
Gallstone disease
Gallbladder polyps
Porcelain GB
PSC
Chronic infection
Obese
84
Q

Presentation of GB cancer

A

May be asymptomaatic, mimic cholelithiais or malignancy or see jaundice

85
Q

What does cholangiocarcinoma arise from?

A

Epithelial cells of bile ducts (not GB or ampulla or vater)

86
Q

Association of cholangiocarcinoma

A

PSC and choledochal cysts (cystic dilatations of bile ducts)

87
Q

Presentation of cholangiocarcinoma

A

Jaundice, pruritus, abd pain, anorexia, weight loss, Courvoisier
Labs are cholestatic pattern
Increased CA 19-9 (Screen when have PSC)

88
Q

Where does ampullary carcinoma arise?

A

In ampulla of vater distal to bifurcation of distal CBD and pancreatic duct

89
Q

When is there and increased risk of ampullary carcinoma?

A

With familial adenomatous polyposis (FAP) and HNPCC

90
Q

Presentation of ampullary carcinoma

A

Obstructive jaundice most, can be occult GI bleed with microcytic anemia and abd pain

X Clin Med III Exam 2 (9 decks)

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