biliary diseases and pancreatitis Flashcards
how do bile acids precipitate?
- abnormal ratios of cholesterol, bile acids and lechtitin
- normally combine to form mixed micelles
cholestasis defintion
- bile does not move from gallbladder to duodenum
cholelithiasis definition
- formation of gallstones
choledocholithiasis definition
- gallstone blockage in CBD
biliary colic definition
- pain d/t blockage of cystic duct, usually gallstone
acute cholecystitis definition
- painful inflammation of gallbladder
- usually d/t build up of bile when stone blocks cystic duct
cholangitis definition
- bacterial infection on top of obstruction of biliary tree
common causes of cholestasis
- bile duct stone*
- procedural sequelae- ERCP
- liver diseases
- stricture of bile duct
- sclerosing cholangitis
management of cholestasis
- US to check of stone or obstruction
- ERCP for stone removal
- HIDA to check for gallbladder function
what type of stone are the majority of gallstones
- cholesterol
- cholesterol + bilirubin + ca salts
cholelithiasis risk factors
- four f’s: fat, female, fertile, forty
- hypercholesterolemia
- obesity, metabolic syndrome, DM
- bariatric surgery, rapid weight loss
- pregnancy, OCPs
- crohns
clinical presentation of cholelithiasis
- often asymptomatic
- severe, intermittent RUQ pain, usually post-prandial
- pain radiates to R shoulder or back
- n/v
- onset of sx at night > day
best imaging to dx cholelithiasis
- US
- in an obese pt may need to try CT or HIDA
treatment for cholelithiasis
- ERCP*- diagnostic and therapeutic
- life style modifications
- cholecystectomy
- dissolve stones with medications- 50% success rate and very expensive
- lithotripsy- uncommon
cholecystitis causes
- mechanical- distension
- chemical- lysolecithin
- bacteria*- e coli, klebsiella, strep, clostridium
causes of acalculous cholecystitis
- trauma, burns
- ortho/ non-biliary post op pts
- prolonged labor
- parenteral nutrition
- torsion, neoplasm
- DM
- atypical infections
triad of sx for cholecystitis
- RUQ pain (severe)
- fever
- increased WBC
sx of cholecystitis
- triad: RUQ pain, fever, WBC
- pain may radiate to r shoulder
- guarding/ rebound tenderness
- murphy’s sign- less sensitive in elderly
- fever/ chills, n/v- increased bili, alk phos, AST/ALT
- pain similar to MI in female
imaging for cholecystitis
- US to find stones, may see inflammation
- *pain meds before US
- HIDA, CT not as good
choledocholithiasis clinical presentation
- RUQ pain
- jaundice
- clay colored stool
- murphy’s sign
lab findings for choledocholithiasis
- increased AST/ALT
- increased direct bili
- increased alk phos
- increased amylase if pancreatic involvement
imaging for choledocholithiasis
- RUQ US*
- ECRP*
- CT
management for choledocholithiasis
- ERCP to decompress/ remove stones
- allow pt to stabilize for 72 hours before lap chole
charcot’s triad
- for cholangitis
- severe RUQ pain
- fever
- jaundice
- requires immediate intervention to avoid shock
reynolds pentad
- for cholangitis
- Severe RUQ pain
- fever
- jaundice
- hypotension
- acute mental status change
- medical emergency
sx of cholangitis
- chacot’s triad
- reynolds pentad
- pruritis
- dark urine
- clay colored stool (acholic)
imaging for cholangitis
- US
- ERCP
management of cholangitis
- requires admission
- ERCP for stone removal
- elective lap chole later
- IV abx: amp + gent or cipro +/- flagyl
- may need ICU admission
primary sclerosing cholangitis
- inflammation, scarring and stricture of bile ducts from chronic biliary disease
- usually dx in 30-50s
- increased risk of cholangiocancer
- assoc with IBD
management for primary sclerosing cholangitis
- balloon dilation
- eventual liver transplant
- prognosis is 12-17 years without transplant
si/sx of primary sclerosing cholangitis
- pain
- F/C, night sweats
- progressive obstructive jaundice, pruritis
- fatigue, anorexia, indigestion
- hepatomegaly
general causes of pancreatitis
- compression/ obstruction of ampulla of vater
- reflux of bile and contents into duodenum and pancreatic duct
subtypes of acute pancreatitis
- acute interstitial- inflammation/ edema of pancreas and peripancreatic tissues, stone, EtOH
- acute necrotic- autodigestion due to release of trypsinogen -> trypsin
- hemorrhagic
chronic pancreatitis
- due to longstanding damage of pancreas
- pancreas stops functioning properly
what are the lab markers for pancreatic issues
- amylase- short half life (24 hours)
- lipase- more specific for pancreas but no correlation between severity of lipase and pancreatitis
risk factors for pancreatitis
- cholelithiasis/ choledocholithiasis*
- EtOH*
- trauma
- hyperTG/ hyper Ca
- certain meds or infections
- idiopathic- 20%
acute pancreatitis sx
- severe/ sudden onset mid epigastric pain
- pain eased by leaning forward
- pain may radiate to back
- f/n/v
- abdominal distention
- steatorrhea
- cullens or grey turner sight
imaging for dx of acute pancreatitis
- US- rule in/out biliary involvement
- CT- imaging of choice
- ERCP, caution- may exacerbate
complications of acute pancreatitis
- multisystem organ failure
- ileus
- pseudocyst (rare)
- pancreatic necrosis
management of acute pancreatitis
- admission, assess severity
- ID underlying cause
- analgeisa, antiemetics, serial labs and monitoring
- clear fluids -> low fat diet, possible parenteral nutrition
ways to assess severity of acute pancreatitis
- ranson score
- apache II score
- SIRS score
- BISAP
mild acute pancreatitis
- without local complications
- self limited in 3-7 days
mod acute pancreatitis
- transient organ failure < 48 hours
- local systemic complications minus organ failure
- +/- local complications
severe acute pancreatitis
- persistent organ failure > 48 hours
- CT scan recommended to assess for necrosis
chronic pancreatitis
- chronic inflammation, fibrosis, progressive destruction of exocrine and endocrine function
- irreversible
- pancreatic atrophy
what is the most common cause for chronic pancreatitis
- alcohol abuse
sx of chronic pancreatitis
- abdominal pain
- anorexia, maldigestion, weight loss
- n/v, steatorrhea
- tenderness over pancreas during attack
dx of chronic pancreatitis
- can be challenging
- no biomarker
- amylase and lipase +/- elevation
- LFTs +/- elevation
- glucose +/- elevation
- secretin abnormal when >60% of pancreatic exocrine function lost
imaging of choice for chronic pancreatitis
- CT for initial dx
treatment for chronic pancreatitis
- low fat diet, no alcohol
- steatorrhea may be treated with FDA approved pancreatic enzymes
- mgmt of pain may be challenging -> opioid addiction
- endoscopic tx: sphincterectomy, stenting, stone extraction
- whipple, total pancreatectomy, or autologous islet cell transplant
complications of chronic pancreatitis
- narcotic addiction
- DM/ impaired glucose tolerance
- gastroparesis
- malabsorption
- biliary stricture
- pancreatic carcinoma
diverticulosis
- sac like protrusion of colon
- mucosa and submucosa herniate through muscle layer
- usu incidentally dx on colonoscopy
diverticular bleed
- painless bleeding of diverticula
- BRBPR
diverticulitis
- inflammation of diverticulum
- simple vs complicated
- complicated= abscess, obstruction, perforation, fistula
where do most diverticula occur?
- sigmoid colon
risk factors for diverticulosis
- age
- constipation
- diet- high fat, red meat
- obesity
- genetics- CT disorders
- physical inactivity
sx of diverticulitis
- LLQ abdomina pain- constant
- n/v/f
- change in bowel habits- usu constipation
- tender palpable mass- due to stool build up
dx of diverticulitis
- CT with IV contrast *
- cbc with diff, bmp, urinalysis
medical management of diverticulitis
- cipro + flagyl**
- augmentin
- ertapenem or zosyn IV
- 2nd or 3rd gen ceph + flagyl
- analgesia and antiemetics
- NPO -> clear diet -> normal diet
surgical options for diverticulitis
- one stage procedure: colon resection with primary anastomosis
- two stage procedure: colonic resection and end stage colostomy, primary anastamosis with diverting ileostomy
follow up for diverticulitis
- colonoscopy 6 weeks after dx
- dietary modifications- high fiber/ long term fiber supplementation
- avoid seeds, nuts, corn possibly
what is the most common cause of overt lower GI bleed
- diverticular bleed
- usually spontaneously stop
- mostly due to right colonic diverticula
si/sx of diverticular bleed
- PAINLESS hematochezia, maroon colored stool
- bloating, cramping, urge to defecate
- if a lot of blood loss may be hemodynamically unstable
dx of diverticular bleed
- colonoscopy
- nuclear scintigraphy- tagged RBC scan
- angiography
management of diverticular bleeds
- IVFs, NS, blood transfusion PRN
- +/- NGT to r/o upper GI
- surgical intervention not commonly needed
surgical options for diverticular bleeds
- colonoscopy with epi or endoscopic tamponade
- angiography- infuse with vasoconstricting meds or embolization
- segemental colectomy last line
