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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
Criteria to diagnose functional gallbladder disorder
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
26
How to exactly define biliary pain
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
27
Management for functional gallbladder disorder
Cholecystectomy recommended for those with typical biliary type pain and low GBEF (<40%)
28
What is acute calculous cholecystitis?
Acute inflammation of the GB -mostly complication of gallstone disease Occurs with cystic duct obstruction and gallbladder inflammation (must have both!!)
29
Presentation of acute calculous cholecystitis
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
30
What is seen on PE for acute calculous cholecystitis?
``` Fever and tachycardia Ill appearing, lying still No jaundice Anicteric Abd exam: RUQ tenderness, voluntary or involuntary guarding, + Murphy's sign ```
31
Labs seen with acute calculous cholecystitis
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
32
Preferred imaging for acute calculous cholecystitis
US (see gallstones, wall thickening >4-5 mm or edema, pericholecystic fluid, + sonographic Murphys sign)
33
HIDA for acute calculous cholecystitis
Use if uncertain of diagnose | + if failure to visualize GB in setting of cystic duct obstruction
34
Most common complication of acute calculous cholecystitis
Gangrene (older pts, DM, those delaying therapy-sepsis like pic)
35
Other complications of acute calculous cholecystitis
Perforation (often after developing gangrene) Cholecystoenteric fistula Gallstone ileus Emphysematous cholecystitis, empyema, hydrops Mirizzi syndrome
36
What is Mirizzi syndrome?
Stone in the cystic duct or Hartmann's pouch of the GB may compress common hepatic duct and cause jaundice!
37
Management of acute calculous cholecystitis
Admit, NPO, IVF IV pain (Ketorolac, Morphine, Meperidine) IV abx (empiric) Mainstay is cholecystectomy
38
What is chronic cholecystitis?
Chronic inflammation of the GB almost always associated with gallstones (repeated acute/subacute cholecystitis or prolonged medical irritation of GB wall)
39
Presentation of chronic cholecystitis
May have minimal sxs (asymptomatic for yrs and may progress to symptomatic GB disease of acute cholecystitis or just present with complications)
40
What is acalculous cholecystitis?
Acute necroinflammatory disease of GB in absence of gallstones (high morbidity and mortality)
41
Pathogenesis of acalculous cholecystitis
GB stasis and ischemia (local inflammatory response in GB wall) and secondary bacterial infection and maybe perf
42
When is acalculous cholecystitis common?
Hospitalized and critically ill pts (trauma, burn, postpartum, ortho surgery)
43
Presentation of acalculous cholecystitis
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
Management for acalculous cholecystitis
Must do quick to start abx (get cultures) | Cholecystectomy vs GB drainage
45
Labs for acalculous cholecystitis
US, CT, HIDA | LFTs, CBC, lytes, pancreatic enzymes, UA
46
What is choledocholithiasis?
Gallstones in common bile duct (increasing incidence with age) Can block flow of bile and cause jaundice!!!
47
History for choledocholithiasis
Usually with biliary type pain (more prolonged than with typical biliary colic) Can be asymptomatic tho Report jaundice
48
PE for choledocholithiasis
Vital signs WNL when uncomplicated RUQ or epigastric tenderness May be jaundiced Courvoisier signs (palpable gallbladder maybe)
49
Labs for choledocholithiasis
No leukocytosis Elevated LFTs (cholestasis) Normal amylase and lipase
50
Elevated liver tests in choledocholithiasis
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
Initial imaging for choledocholithiasis
US (cholelithiais, CBD stone and CBD dilation)--MRCP or endoscopic us if unsure
52
Why is MRCP used in choledocholithiasis?
Great to see biliary tree and pancreatic ducts | Can confirm dx of CBD stone
53
Management of choledocholithiasis
Remove CBD stone and treat complications if not gotten out in time ERCP is therapeutic and diagnositc Cholecystectomy if appropriate
54
Complications of choledocholithiasis
Acute cholangitis or acute pancreatitis
55
What is acute cholangitis?
Inflammation of biliary duct system
56
Cause of acute cholangitis
Bacterial infection in pt with biliary obstruction (choledolithiasis, benign biliary stricture, s/p ERCP, malignancy) Typically ascending from the duodenum
57
What must be remembered with acute cholangitis?
"Pus under pressure" is surgical emergency so must do something immediately
58
Manifestations of acute cholangitis
Charcots (fever, abd pain, jaundice) | Reynolds (Charcots and AMS and hypotension)
59
Labs for acute cholangitis
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
Imaging for acute cholangitis
U/s CT MRCP (or EUS) to see CBD dilation or stone
61
Management for acute cholangitis
Admit and monitor for sepsis (empiric abx) | Consult GI and surgery immediately (ERCP to do biliary drainage)
62
Biliary drainage with acute cholangitis
Must relieve the biliary obstruction!! ERCP with sphincterotomy and stone extraction or stent insertion Can follow with cholecystectomy if needed
63
What does increased alk phos, bilirubin or GGT suggest?
Cholestasis (biliary obstruction-choledocho)
64
Who do you see primary biliary cholangitis in?
Women 30-65
65
What is primary biliary cholangitis?
Autoimmune destruction of intrahepatic bile ducts which causes cholestasis May result in cirrhosis or liver failure
66
Presentation of primary biliary cholangitis
Maybe asymptomatic | Fatigue, pruritus, jaundice, RUQ discomfort, skin hyperpigmentation, xanthelasmas, hepatomegaly
67
What is primary biliary cholangitis associated with?
Other autoimmune conditions (Sjogrens, thyroid)
68
Labs in primary biliary cholangitis
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
Complications of primary biliary cholangitis
Cirrhosis Hepatocellular carcinoma Malabsorption (and steatorrhea) Metabolic bone disease
70
How to diagnose primary biliary cholangitis
No extrahepatic biliary obstruction No comorbidity affecting liver Must have 2: elevated alk phos (1.5x), +AMA, histologic evidence of PBC
71
Management of primary biliary cholangitis
Refer to GI for meds and complication tx
72
What is primary sclerosing cholangitis?
Sclerosing, inflammatory and obliterative process involving intrahepatic and or extra hepatic biliary tree
73
Who do we see primary sclerosing cholangitis in ?
Men (usually around 40)
74
Close association of primary sclerosing cholangitis
IBD (mostly UC!!!!)
75
Ultimate complications of primary sclerosing cholangitis
Cholestasis and end stage liver disease
76
Presentation of primary sclerosing cholangitis
Asymptomatic, fatigue, pruritus, jaundice, hepatomegaly
77
Labs for primary sclerosing cholangitis
Cholestatic pattern of liver tests Increased IgM, + P-ANCA, autoantibodies (ANA,ASMA) Negative AMA!!!
78
How to diagnose primary sclerosing cholangitis
Abnormal liver tests especially with IBD Cholangiography (MRCP or ERCP-multifocal stricturing and dilation of intrahepatic or extrahepatic bile ducts) Liver bx
79
Complications of primary sclerosing cholangitis
``` End stage liver disease Fat soluble vit deficiencies Metabolic bone disease Cholangitis and cholelithiasis Hepatobiliary cancer Colon cancer (pts with UC) ```
80
Management of primary sclerosing cholangitis
Refer to GI for meds and complication tx
81
What is Gilbert syndrome?
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
Presentation of Gilbert syndrome
Present during adolescence (post puberty) Males Mild intermittent episodes of jaundice!!! Otherwise probably asymptomatic
83
Risk factors for gall bladder cancer
``` Gallstone disease Gallbladder polyps Porcelain GB PSC Chronic infection Obese ```
84
Presentation of GB cancer
May be asymptomaatic, mimic cholelithiais or malignancy or see jaundice
85
What does cholangiocarcinoma arise from?
Epithelial cells of bile ducts (not GB or ampulla or vater)
86
Association of cholangiocarcinoma
PSC and choledochal cysts (cystic dilatations of bile ducts)
87
Presentation of cholangiocarcinoma
Jaundice, pruritus, abd pain, anorexia, weight loss, Courvoisier Labs are cholestatic pattern Increased CA 19-9 (Screen when have PSC)
88
Where does ampullary carcinoma arise?
In ampulla of vater distal to bifurcation of distal CBD and pancreatic duct
89
When is there and increased risk of ampullary carcinoma?
With familial adenomatous polyposis (FAP) and HNPCC
90
Presentation of ampullary carcinoma
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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