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Foundations III-GI > Biliary Dz > Flashcards

Biliary Dz Flashcards

1
Q

describe the composition of Bile and how much is secreted daily?

A

Water, electrolytes, bile salts, phospholipids, bilirubin & cholesterol

500mL daily

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2
Q

describe the function 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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3
Q

what is cholangitis?

A

inflammation of the bile ducts

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4
Q

Risk factors for cholelithiasis

A

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

Age over 40
Females MC (3:1)
Pregnancy
Obesity
Rapid Weight Loss
Estrogen (BCP’s)
Ethnicity (native americans hispanics)
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5
Q

what is the most common type of stones in cholelithiasis?

A

cholesterol stones (80%)

also pigment stones (calcium, bilirubin, proteins)

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6
Q

presentation of cholelithiasis

A

majority are asxs.

sxs: biliary colic and complications

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7
Q

complications of cholelithiasis

A

Acute Cholecystitis
Acute Choledocholithiasis
Ascending Cholangitis
Acute Pancreatitis

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8
Q

diagnosis of cholelithiasis

A

1 is Ultrasound – shows gallstones, wall thickening, pericholecystic fluid

also, CT

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9
Q

management of asxs. cholelithiasis

A

cholecystectomy NOT recommended

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10
Q

management for sxs. cholelithiasis

A

CCY (cholecystectomy) – prophylactive recommended to prevent recurrent sxs/complications

sxs = biliary colic, acute cholecystitis, choledocholithasis, ascending cholangitis

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11
Q

what is biliary colic?

A

temporary obstruction of cystic duct usu. d/t gallstone

pressure rises –> pain

gallbladder relaxes –> obstruction relieved

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12
Q

Presentation of biliary colic

A

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

assoc sxs: N/V, diaphoresis

sxs are temporary (no more than 4-6hrs)

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13
Q

PE findings for biliary colic

A 
don't appear acutely ill
normal VS
NO jaundice
sclera anicteric
\+/- RUQ TTP
no peritonitis
Murphy's sign neg
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14
Q

lab studies for biliary colic

A

CBC
LFTs
Amylase, Lipase

all labs NORMAL

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15
Q

diagnostic studies for biliary colic

A

Ultrasound – gallstones and/or gallbladder sludge

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16
Q

what is biliary dyskinesia?

A

aka functional gallbladder d/o

consider in pt’s w/ typical biliary colic:

  • NO gallstones or sludge
  • normal labs

consider HIDA w/ CCK

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17
Q

what if you suspect biliary dyskinesia but the pt has gallstones?

A

do NOT give CCK

start with US

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18
Q

what information does a HIDA Scan w/CCK tell you?

A

ejection fraction (EF)

normal gallbladder fills w/in 30mins

<35-40% = abnormal gallbladder motility

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19
Q

when is CCY recommended w/ suspected biliary dyskinesia

A
  • pt reports typical biliary sxs
  • HIDA w/ CCK EF <35-40% (reproduces sxs)
  • other dx r/o (PUD, gastritis, GERD, cardiac ischemia)
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20
Q

what is acute cholecystitis?

A

Acute inflammation of the gallbladder d/t sustained obstruction of cystic duct

MCC cholesterol stones

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21
Q

presentation of acute cholecystitis?

A

steady severe RUQ pain +/- radiation to R shoulder/flank

N/V, diaphoresis, Fv

sxs. persistant (longer than 4-6hrs)

prior h/o biliary colic

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22
Q

abnormal PE findings for acute cholecystitis?

A 
ill appearing
fever, tachycardia
RUQ TTP
\+/- guarding, rebound
\+ Murphy's sign
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23
Q

complications for acute cholecystitis?

A

gangrene, perforation, generalized peritonitis, cholecystoenteric fistula
gallstone ileus

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24
Q

Lab studies for acute choleystitis?

A

CBC - elevated WBC w/ L-shift

LFT’s usu. normal

UA - elevated urobilinogen

pancreatic enzymes: poss. mild elevated of amylase

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25
Q

diagnostic studies for acute cholecystitis?

A

1st study = U/S
- gallstones, wall thickening, pericholecystic fluid, positive sonograph Murphy’s sign

HIDA – used to confirm if ??

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26
Q

management for acute cholecystitis?

A 
hospital admission, 
analgesia (ketorolac, morphine, meperdine), 
NPO
IV fluids w/electrolytes
IV abx
early CCY (laparoscopic)
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27
Q

which abx can be used for acute cholecystitis?

A

Single agent:
Piperacillin-tazobactam (Zosyn) IV
Ampicillin-Sulbactam (Unasyn) IV
Ticarcillin clavulanate (Timentin) IV

combo:

  • 3rd gen cephalosporin (ceftriaxone) + metronidazole
  • Cipro + metronidazole (flagyl)
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28
Q

which pt’s w/ acute cholecystitis need an emergent CCY?

A

If severe complication (gangrene, perforation, peritonitis etc)

Clinical deterioration despite supportive therapy

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29
Q

management for acute cholecystitis with ASA class I and II?

A

CCY recommended during initial hospitalization in healthy low risk pt’s

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30
Q

management for pts with acute cholecystitis ASA III, IV, V?

A

continue supprotive therapy

consult specialist for surg. clearance

med therapy fails –> consider percutaneous CCY tube for decompression

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31
Q

what is chronic cholecystitis?

A

chronic inflammation of gallbladder assoc w/ mechanical irritation

32
Q

what is acalculous cholecystitis?

A
  • common in critically ill pts
  • assoc. w/ stasis and ischemia
  • similar to acute cholecystitis but no gallstones & may have jaundice
33
Q

Tx for acalculous cholecystitis?

A

prompt tx!

CCY vs. cholecystostomy

34
Q

how can you check for secondary infection w/ acalculous cholecystitis?

A

check blood cultures, start broad spectrum abx

risk of gallbladder gangrene

35
Q

what is choledocholithiasis?

A

Stone in common bile duct (CBD)

will block bile flow and cause jaundice

36
Q

choledocholithiasis presentation?

A

p/w biliary type pain (RUQ or epig, N/V)

may be asxs.

jaundice: pruritis, tea colored urine, light colored stool

37
Q

uncomplicated choledocholithiasis abnormal PE findings?

A

jaundice
+/- RUQ TTP

if fever, jaundice, leukocytosis, and more prominent abd TTP –> think cholangitis

38
Q

Labs for choledocholithiasis?

A

CBC: no leukocytosis

LFTs (cholestasis): increased conjugated bilirubin, elevated alk phos

pancreatic enzymes: normal amylase, lipase

39
Q

imaging studies for choledocholithiasis?

A

confirm dx w/ imaging

RUQ U/S = initial test
- CBD stone, dilated CBD, gallstones in gallbladder

if uncertain –> consider MRCP (biliary and pancreatic ducts)

40
Q

management of choledocholithiasis?

A

Stone must be removed to prevent cholangitis and pancreatitis

Consider prophylactic Abx

ERCP –preferred therapeutic test

CCY to follow

41
Q

What is ascending cholangitis?

A

Infection of the biliary tract MCly the CBD

assoc. w/ biliary obstruction (CBD stone)

bacteria infects bile

pus under pressure –> surgical emergency

42
Q

ascending cholangitis?

A

RUQ/epigastric abd. pain, reports of jaundice, fever, h/o biliary colic or disease

43
Q

abnormal PE findings for ascending cholangitis?

A

acutely ill appearing, diaphoretic, fever, tachycardia, hypotension, jaundice, icterus, RUQ/epigastric TTP, guarding, mental status changes

44
Q

what is charcot’s triad?

A

dx’ing ascending cholangitis

fever/chills
RUQ pain
jaundice

45
Q

what is reynold’s pentad?

A

charcot’s ( fever, chills, RUQ pain, jaundice) + hypotension and mental status changes

46
Q

labs for ascending cholangitis?

A

CBC: marked leukocytosis

LFTs (cholestasis): incr conjugated bili and alk phos

pancreas enzymes: normal/mildly elevated

UA: elevated urobiinogen

47
Q

what imaging should you order in pts w/ ascending cholangitis dx in question

A

U/S

MRCP (CBD dilation and stone)

48
Q

general management of ascending cholangitis?

A

Admit to hospital
Consult GI (emergent)
NPO/IV fluids
broad-based abx for coverage of gram + and - bacteria

ERCP w/ sphincterotomy and stone extraction

follow w/CCY

49
Q

Abx for ascending cholangitis?

A

Ceftriaxone + Metronidazole

Cipro (good concentration in bile ducts) + Metronidazole

Piperacillin/Tazobactam

50
Q

what is imperative in management of ascending cholangitis?

A

relief of biliary obstruction

51
Q

describe ERCP use in ascending cholangitis?

A

Sphincterotomy

CBD stone extraction

Relief of obstruction

+/- stent placement

52
Q

difference in presentation in btwn biliary colic and acute cholecystitis?

A

biliary colic: temporary RUQ, pain episodes, No fever, no leukocytosis, No jaundice

acute cholecystitis: persistent RUQ pain, fever, leukocytosis, no jaundice

53
Q

difference between choledocholithiasis and ascending cholangitis presentation?

A

Choledocholithiasis: RUQ/epigastric pain, jaundice, no fever, no leukocytosis

ascending cholangitis: RUQ/epigastric pain, jaundice, fever, leukocytosis

54
Q

what labs do you want to order for eval of biliary dz?

A

CBC w/differential – r/o infxn
Amylase/lipase – r/o pancreatitis (mild “bump” w/acute biliary dz)

LFTS

    • ↑ Alk Phos/Conjugated Bilirubin = Cholestasis
    • AST/ALT may have transient elevations
55
Q

when do you order U/s?

A

TOC for eval of biliary dz

shows gallstones, wall thickening, pericholecystic fluid, ductal dilation, CBD stones

56
Q

when is MRCP helpful?

A

for diagnosing stones/obstruction in the CBD when US non-diagnostic

57
Q

when do you order a HIDA scan?

A

confirm dx of cystic duct obstruction in cholecystitis

can use CCK to measure EF for biliary dyskinesia

58
Q

when do you order ERCP?

A

to relieve CBD obstruction

choledocholithiasis/cholangitis

59
Q

what is primary biliary cirrhosis (PBC)

A

Autoimmune destruction of small intrahepatic bile ducts –> cholestasis

leads to cirrhosis and liver failure

primarily females 35-60y/o

60
Q

presenation of PBC?

A

fatigue, pruritis (before jaundice)

also arthritis, RUQ pain, skin hyperpigmentation, xanthomas, hepatomegaly, CREST sx

61
Q

Labs for PBC?

A

LFTs (cholestatic pattern): elevated alk phos and GGT

anti-mitochondrial antibody (AMA) = hallmark

ANA, IgM, hyperlipidemia

62
Q

diagnosis for PBC?

A

Liver Bx- confirms diagnosis and stage of disease

63
Q

management of PBC?

A

Urso

Monitor bone density (DEXA)
d/t increased risk of osteoporosis

64
Q

what are s/s of primary sclerosing cholangitis (PSC)?

A

Asxs, fatigue, pruritis (after jaundice)

also, jaundice, steatorrhea, osteoporosis

65
Q

what is PSC?

A

Inflammation/fibrosis of medium & larger intra/extra hepatic ducts

Progresses to cirrhosis

66
Q

complications of PSC?

A 
Biliary stricture
Cholangitis
Cholangiocarcinoma
Gallbladder cancer
Colon cancer (if IBD present)
67
Q

Dx for PSC?

A

Abnormal LFTs

P-ANCA, ASMA, ANA, IgM

68
Q

imaging for PSC?

A

ERCP-diagnostic and therapeutic

MRCP (diagnostic) –Multifocal stricturing with intrahepatic/ extrahepatic ductal dilation

liver bx = usu. nondiagnostic

69
Q

management of PSC

A

Monitor bone density
Manage biliary strictures with ERCP
Monitor for complications (cholangiocarcinoma, cholangitis, etc)
Liver transplant with advanced disease

70
Q

what is Gilbert’s syndrome?

A

Deficiency in enzyme for glucuronidation of bilirubin in liver (conjugation)

Suspect in pt with unconjugated hyperbilirubinemia in absence of hemolysis

71
Q

Biliary neoplasms risk factors?

A

Cholelithiasis
Gallbladder polyps >1cm
Salmonella infection

72
Q

presentation for gallbladder CA

A

can be clinically indistinguishable from cholelithiasis

May have Sx suggestive of malignancy

73
Q

presentation for cholangiocarcinoma

A

jaundice, vague upper abd pain, anorexia, weight loss, pruritis

74
Q

labs for cholangiocarcinoma

A 
show cholestasis (obstructive pattern)
Elevated conjugated bilirubin and alk phos

↑ CA 19-9

75
Q

presentation for amupllary cancer?

A

obstructive jaundice (most common), occult GIB with microcytic anemia, abdominal pain

Foundations III-GI (8 decks)

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