Biliary Popcorn Flashcards
- Elevated bilirubin
- Elevated bilirubin direct
- Elevated bilirubin indirect
- ALT & AST are elevated
- Protime (PT) – ordered w/ INR
- Labs indicative of liver infection (hepatitis labs)
LFT elevation due to Inflammation / Hepatocellular Damage
- ↑Bilirubin elevated
- ↑Bilirubin Direct (conjugated)
- ↑Bilirubin Indirect (unconjugated)
- ↑Alkaline Phosphatase
- May see GGT
- ↓Urine Urobilinogen
LFT elevation due to Cholestasis (obstruction such as Choledocholithiasis)
- ↓Albumin LOW
- ↓Total Protein LOW
- ↑PT prolonged/HIGH (ordered w/ INR)
- ↑INR increased
LFT elevation due to Reduced Liver Function
Is urobilinogen normally in the urine?
YES
Is Bilirubin normally in the urine?
NO
Blood:
- ↑ bilirubin
- Normal ALP
- Normal ALT
Urine:
- Urobilinogen present +
- Bilirubin absent -
Pre-hepatic
Blood:
- ↑ bilirubin
- Normal or ↑ ALP
- ↑↑↑ ALT
Urine:
- Urobilinogen: Present (normal)
- Bilirubin: Present (abnormal)
Hepatic
Blood:
- ↑ bilirubin
- ↑↑↑ ALP
- Normal or ↑↑↑ ALP
Urine:
- Urobilinogen: absent - (abnormal)
- Bilirubin: present + (abnormal)
Post-hepatic
stones in the gallbladder
Cholelithiasis
inflammation of the GB
Cholecystitis
stones in the CBD
Choledocholithiasis
inflammation of the bile ducts
Cholangitis
disruption of bile flow…regardless of cause
Cholestasis
Which condition?
- Female, fluffy, forty, fertile
- Ethnicity: native americans, hispanics, caucasions
- Cholesterol stones are MC type!!!
- Initially order an US
Cholelithiasis
CCY (cholecystectomy) is recommended in which patient w/ cholelithiasis??
Symptomatic! (biliary colic)
Which condition?
- TEMPORARY obstruction (4-6 hrs)
- no inflammation
- “gallbladder attack” after fatty meal
- “symptomatic biliary disease”
- Dull RUQ pain
Biliary Colic
4 conditions where US is intitial test of choice?
Cholelithiasis
Biliary Colic
Acute Cholecystitis
Choledocholithiasis (RUQ US)
(BACC)
Which condition?
- Does not appear ill
- NO jaundice
- Negative murphy’s sign
Tx?
Biliary Colic
Tx: Prophylactic CCY
Which condition?
- Functional GB disorder
- Motility disorder of GB
- NO gallstones, so can do HIDA w/ CCK –> EF <35-40%
Tx?
Biliary Dyskinesia
- Tx: CCY if HIDA w/ low EF
- ***Do not give CCK if pt has gallstones****
Which condition?
- Sustained obstruction of cystic duct
- Acute inflammation of GB
- Prior hx of biliary colic
- SEVERE RUQ pain –> R shoulder/R flank
- PERSISTENT sxs (>6 hours)
- ↑ WBC w/ left shift
- Get US initially, HIDA to confirm
Tx?
Acute Cholecystitis
Tx:
- Admit, analgesics, IV abx (Piper Taco, Cef+Metro, Cipro+Metro)
- Early CCY
- Emergency CCY if severe complication (gangrene)
Which condition?
- Gangrene
- Cholecystoenteric fistula
- Ill appearing
- Palpable/Tender GB
- ++ Murphy’s sign
- Guarding/Rebound
- NO jaundice
Acute Cholecystitis
Tx for Acute Cholecystitis
ASA class 1 or 2
(healthy / low risk pt)
Early CCY (on initial hospitalization)
Tx for Acute Cholecystitis
ASA class 3, 4, 5
(High risk pt)
- Supportive
- Consult specialist for surgery clearance
- Failure of therapy–> percutaneous CCY tube for decompression
Which condition?
- Mechanical irritation from gallstones / repeated acute choleystitis
- Dx made upon reviewing histology s/p CCY
Chronic Cholecystitis
Which condition?
- Critically ill pts
- Stasis/ischemia
- Pt hospitalized / worse prognosis
- Jaundice / No gallstones
- Secondary infection of GB is COMMON! –> broad abx
Tx?
Acalculous Cholecystitis
Tx: Prompt tx w/ CCY or Cholecystostomy
Which condition?
- Blocks flow of bile –> jaundice
- Hx of biliary colic
- RUQ/Epi pain
- Clay stool / Cola urine
- Jaundice
- Pruritis
- RUQ US is intitial test
Tx?
Choledocholithiasis
Tx:
- Remove stone (ERCP is preferred therapy test)
- CCY
- Prophylactic abx (piper-taco, Cef+Metro, Cipro+Metro)
