Biliary Diseases

Question 1

Gilbert and Crigler-Najjar syndromes result in what defects in bilirubin metabolism?

Answer 1

**UNCONJUGATED (=infantile jaundice)

Question 2

Rotor Syndrome, Dubin-Johnson Syndrome is characterized by what?

Answer 2

**CONJUGATED or mixed hyperbilirubinemia

Question 3

Bilirubin at what level is jaundice clinically visible?

Answer 3

3-4mg/dl

Question 4

Choledocholithiasis - define.

Answer 4

Obstruction of bile ducts due to gallstones (i.e. cholesterol or pigmented). Cause inflammation and infection.

Question 5

What labs suggest obstruction of bile ducts/choledocholithiasis?

Answer 5

Abnormal alkaline phosphatase and elevated aminotransferases.

Question 6

Obstruction of bile ducts due to what types of extrinsic compression?

Answer 6

Neoplasms such as pancreatic carcinoma, pancreatitis, vascular enlargement such as aneurysm.

Question 7

What type of gallstones form in bile ducts due to bacterial infection? What ethnicity associated with this?

What type are thought of as forming in the gallbladder?

Answer 7

Brown pigment. 30-90% of gallstones in Asians. Form in the cystic duct.

Black = hemolytic anemia

Cholesterol stones thought to form IN the GB and then going on to obstruct the cystic duct

Question 8

What results when a stone becomes lodged at gallbladder-cystic duct junction?

Answer 8

Acute Calculous Cholecystitis, –>aka Biliary Colic. - the most common complication of gallstone disease. (pain in RUQ, pain in epigastrium, etc. - REMITTING pain with NORMAL lab tests)

Question 9

Is Acute Calculous Cholecystitis primarily infectious or inflammatory?

Answer 9

inflammatory. ~50% have secondary E. coli.

Question 10

Pain in RUQ the radiates to back and right scapula.

Answer 10

Acute Calculous Cholecystitis

Question 11

What is Acute Calculous Cholecystitis called when it occurs 1-5hrs after a fatty meal?

Answer 11

Biliary colic.

Question 12

**UNREMITTING and may last several days, N/V/anorexia/fever with ABNORMAL lab values.

Answer 12

Acute Calculous Cholecystitis

Question 13

Murphy sign - what shows positive?

Answer 13

Acute Cholecystitis if inspiratory arrest (due to pain) during deep palpation of RUQ

Question 14

If pain in RUQ the radiates to back and right scapula and there is a palpable RUQ mass - what is this mass?

Answer 14

In 1/3 of patients they have omentum that has migrated to the area in response to inflammation.

Question 15

Significant jaundice suggests what 3 possible things? If fever present, what is most likely?

Answer 15

Common bile duct stone, cholangitis, or obstruction of common hepatic duct. **Fever=most likely ascending cholangitis (bacterial infection)

Question 16

Name the 5 possible types of diagnostic imaging for gallstones. Which is the procedure of choice?

Answer 16

1. Transabdominal ultrasound - #1 procedure of choice
2. Ultrasound - acoustic shadowing seen behind the stone
3. Cholenscintigraphy - noninvasive evaluation
4. Abdominal CT
5. MRI

Question 17

Difference between primary and secondary bile duct stones

Answer 17

Primary develop within the bile ducts.

Secondary: 1) develop in the GB and then filter 2) into the bile duct.

Question 18

Significance of Charcot’s triad:

Answer 18

Epigastric or RUQ pain, FEVER (differs from acute biliary colic), jaundice = cholangitis, dt bile duct stones

Question 19

Gilbert syndrome

Answer 19

Most prevalent in whites -

• Plasma bilirubin levels less than 3m/dl, but INCREASE 2-3x’s with fasting and intercurrent illness (so see jaundice)

Question 20

Gallstone risk factors!

Answer 20

• Females (dt estrogen and progesterone)
• Fertile (during pregnancy)
• ORAL CONTRACEPTIVE (Estrogen)
• (Fat) Weight loss, low calorie DIET
• Northern Europeans, PIMA Indian, Mexican-Americans