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Foundations 5, Exam 5 GI > Biliary Diseases > Flashcards

Biliary Diseases Flashcards

1
Q

What are the primary functions of bile?

A

Digestion and absorption of fats (bile salts)

Vehicle for excretion of bilirubin, excess cholesterol and metabolic by-products

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2
Q

How bile made?

A

Secreted by liver, concentrated in GB

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3
Q

What is Choledocholithisasis

A

“The ducks”

stones in the CBD

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4
Q

What is Cholangitis

A

inflammation of bile ducts

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5
Q

What is Cholestasis

A

disruption of bile flow

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6
Q

What are Risk factors for Cholelithiasis?

A

The Four F’s (female, fluffy, forty, fertile)

Age over 40
Females more common (3:1)
Pregnancy
Obesity
Rapid Weight Loss
Estrogen (BCP’s)
Ethnicity (Native Americans, Hispanics, Caucasians)
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7
Q

MC type of type of cholelithiasis stones?

A

Cholesterol stones – most common (>80%)

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8
Q

What is the most common symptom of Cholelithiasis?

A

Asymptomatic (majority)

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9
Q

What is the initial test of choice for Cholelithiasis/ biliary disease?

Why is CT not prefereed

A

Ultrasound

CT is more expensive, has radiation, less sensative than U/S

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10
Q

How often does asymptomatic cholelithiasis turn into symtomatic disease?

What is not recommended

A

less than 1%

Cholecystectomy

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11
Q

Recommened treatement for Symptomatic Cholelithiasis

A

Cholecystectomy

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12
Q

What is Biliary Colic?

A

temporary obstruction of cystic duct

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13
Q

How is Biliary colic caused?

A

Usually caused by gallstone
Pressure rises progressively in gallbladder causing pain
As gallbladder relaxes obstruction is relieved
No associated inflammation

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14
Q

How does biliary colic initially present for patients?

A

Often initial presentation of symptomatic gallbladder disease (an “attack”)

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15
Q

What a typical history associated with biliary colic?

A

Dull constant RUQ pain w/ possible radiation to R shoulder blade

Symptoms are temporary
Do not last more than 4-6 hours

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16
Q

How does a patient with biliary colic present during abdominal exam?

Is Murphy’s sign positive?

A

Fairly benign with possible RUQ tenderness

No evidence of peritonitis (no rebound)

Murphy’s sign negative

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17
Q

Initially diagnostic test for Biliary colic?

What are findings that are seen?

A

Ultrasound

Gallstones and/or gallbladder sludge expected

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18
Q

What is the treatment for biliary colic?

A

Prophylactic Cholecystectomy recommended to prevent recurrent sx and complications

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19
Q

What is Biliary Dyskinesia

A

Also known as functional gallbladder disorder

Likely a motility disorder of gallbladder

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20
Q

What diagnostic test is used to look at biliary dyskinesia?

A

HIDA w/ cholecystikinin (CCK)

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21
Q

What kind of patient should be considered for biliary dyskinesia?

A

Has NO gallstones or sludge on US

Has normal labs (CBC, LFTs, amylase, lipase)

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22
Q

How does HIDA scan with CCK work?

A

Injection of 99m technetium-labeled derivative of (hepatic) iminodiacetic acid (HIDA)

Excreted in bile and taken up by gallbadder if cystic duct is patent

Normal gall bladder fills within 30 minutes

Radioactivity measured in gallbladder

CCK given to stimulate gallbladder to contract

Ejection fraction (EF) calculated

EF of < 35-40% = abnormal gallbladder motility

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23
Q

Who should you avoid giving CCK to?

What should be done instead to diagnose biliary dyskinesia?

A

Do not give CCK if pt has gallstones

Start with U/S

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24
Q

What is the preferred treatment for biliary dyskinesia

A

Cholecystectomy if they meet the criteria

Pt reporting typical biliary symptoms
HIDA w/ CCK EF < 35-40%
Reproduces symptoms…

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25
What is the cause of Acute Cholecystitis?
Acute inflammation of the gallbladder due to sustained obstruction of cystic duct Most commonly caused by cholesterol stones
26
What are signs associated with Acute cholecystitis
Steady severe RUQ pain +/- radiation to right shoulder/flank Nausea, vomiting, diaphoresis, fever
27
How long do symptoms persist for acute cholecystitis
persistent: Often longer then 4-6 hours
28
What are physical exam signs seen with acute cholecystitis?
RUQ tenderness Palpable, tender gall bladder in 30-40% May also see guarding & rebound Positive Murphy’s sign
29
What is a complication of Acute cholecystitis?
Gangrene (up to 20% of cases) - Elderly, immunosuppressed, delayed treatment - Signs of sepsis
30
What CBC finding is common with acute cholecystitis?
Elevated WBC with left shift
31
What are other lab findings associated with acute cholecystitis?
LFTs: Usually normal Possible mild elevations in AST/ALT, alk phos, bilirubin If significant elevations in alk phos/bilirubin – must r/o cholangitis (due to CBD obstruction) UA – elevated urobilinogen Pancreatic Enzymes Possible mild elevation of amylase
32
What is the preferred diagnostic study done for acute cholecystitis
Ultrasound
33
What is management for Acute Cholecystitis?
``` Hospital admission for all patients Analgesia (Ketorolac, Morphine, Meperidine) NPO IV fluids w/ electrolyte correction IV Antibiotics Early cholecystectomy Majority are done laparoscopically ```
34
When should cholecystectomy be recommended for acute cholecystitis?
CCY typically recommended during initial hospitalization in healthy low risk patients ASA class I and II
35
Who is considered high risk patients with acute cholecystitis?
High Risk Patients (ASA III, IV, V) | Continue with supportive therapy
36
What should be done if medical therapy initially fails to treat acute cholescystitis?
percutaneous cholecystostomy tube for decompression
37
How is Chronic Cholecystitis?
Associated with mechanical irritation from gallstones or repeated episodes of acute cholecystitis
38
How does Acalculous Cholecystitis present? Who usually gets these How is this caused?
Presents similar to acute cholecystitis except: No gallstones present May have jaundice Seen in critically ill patient Associated with stasis and ischemia (no blood flow)
39
What is the treatment for Acalculous cholecystitis?
CCY vs. Cholecystostomy Mainly cystotomy if healthy enough
40
What is Choledocholithiasis. What do these cause?
Stone in common bile duct (CBD) Will block bile flow and cause jaundice
41
What is a positive history of choledocholithiasis?
Reports of jaundice Pruritis Tea colored urine Light colored stool*
42
cholodoco physical exam slide
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43
What are lab findings seen with choledocholithiasis?
CBC – no leukocytosis LFTs (cholestasis) - Increased conjugated bilirubin - Elevated alkaline phosphatase Pancreatic Enzymes Normal amylase and lipase
44
What imaging test is done for Cholodocolithiaisis? What are expected findings
Confirm Dx with imaging RUQ U/S – initial test of choice CBD stone Dilated CBD Gallstones in gallbladder
45
what imaging test can be used to search for CBD stones in the biliary and pancreatic ducts
MRCP
46
How is choledocholithiasis treated?
Remove stone to prevent complications Give prophylactic Abx (Ciprofloxacin and Flagil)
47
What is the preferred therapeutic test for choledocholithiasis?
ERCP –preferred therapeutic test
48
What is Ascending Cholangitis?
Infection of the biliary tract, | Most commonly associated with biliary obstruction (CBD stone)
49
What is the pathophysiology of Ascending cholangitis?
Bacteria infects bile (ascending infection from duodenum) “Pus under pressure” = surgical emergency
50
What is a history associated with Ascending cholangitis?
RUQ/epigastric abdominal pain Reports of jaundice Fever Hx of biliary colic or disease
51
What are physical exam findings seen with ascending cholangitis?
``` Gen: Acutely ill appearing, diaphoretic V/S: Fever, tachycardia, hypotension Skin: Jaundice Eyes: Icterus Abd: RUQ/epigastric tenderness, guarding Neuro: Mental status changes ```
52
What is the Charcot's triad associated with Ascending cholangitis?
Fever/chills RUQ pain Jaundice
53
Charcot’s Triad plus hypotension and mental status changes is what?
Reynold's Pentad
54
What are lab studies associated with ascending cholangitis?
CBC – marked leukocytosis Typically >20,000 LFTs – Cholestasis ↑ Conjugated Bili ↑ Alk Phos Pancreas enzymes- normal/mildly elevated UA- elevated urobilinogen
55
What are diagnostic imaging ordered for ascending cholangitis?
Ultrasound MRCP CBD dilation CBD Stone
56
How is ascending cholangitis managed?
ERCP w/ sphincterotomy and stone extraction Follow with CCY
57
Who is Primary Biliary Cirrhosis most common in?
Females 35-60
58
What is the pathophysioology of Biliary Cirrhosis?
Autoimmune destruction of small intrahepatic bile ducts – cause cholestasis
59
How does Primary Biliary Cirrhosis present?
FATIGUE AND PRURITIS (before jaundice) Arthritis RUQ pain Skin hyperpigmentation
60
What will LFT labs show with PBC?
LFTs (cholestatic pattern) Elevated alk phos (↑conjugated bilirubin later in disease) Elevated GGT
61
What is Hallmark lab finding with PBC
Anti-mitochondrial antibody- (AMA) (95%)* - hallmark
62
What diagnostic test helps confirm suspicion for PBC
Liver biopsy - helps also stage disease
63
How is PBC managed?
Urso (ursodiol) Monitor bone density (DEXA) Increased risk of osteoporosis
64
Who is Primary Sclerosing Cholangitis (PSC) most common in?
Men 75% have IBD mostly Ulcerative cholitis
65
What are signs and symptoms seen with PSC?
Asymptomatic, fatigue, pruritis (after jaundice), jaundice, steatorrhea, osteoporosis
66
What are lab values seen with PSC?
Abnormal LFTs (cholestatic pattern--> alk phos, conjugated bilirubin) P-ANCA, ASMA, ANA, IgM
67
What imaging test is ordered for PSC? What findings are seen?
ERCP-diagnostic and therapeutic Multifocal stricturing with intrahepatic/ extrahepatic ductal dilation
68
How do you treat PSC?
Monitor bone density Manage biliary strictures with ERCP Biliary ductal dilation or stenting Monitor for complications (cholangiocarcinoma, cholangitis, etc)
69
What is Gilberts syndrome?
Deficiency in enzyme for glucuronidation of bilirubin in liver (conjugation)
70
Who should Gilbert's syndrome be suspected in?
Suspect in pt with unconjugated hyperbilirubinemia in absence of hemolysis

Foundations 5, Exam 5 GI (6 decks)

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