Biliary Tract Flashcards
Prolonged hospitalization with FASTING, TRAUMA, POST-OP, PPN/TPN can all cause this type of BILIARY DISEASE?
ACALCULOUS CHOLECYSTITIS
What occurred in a patient with CHOLECYSTITIS where AIR is noted in the biliary tree and they have not yet had an ERCP?
FISTULA
A patient with CHOLELITHIASIS feels better initially, but develops N/V and abdominal pain with inability to tolerate PO?
GALLSTONE ILEUS (stone stuck in small bowel, at IC valve or duodenum causing GOO)
For which patients with BILIARY DYSKINESIA would CHOLECYSTECTOMY be beneficial?
Those with SYMPTOMS
What is the recommended SURVEILLANCE for GALLBLADDER POLYPS <10 mm?
Imaging every 6 MONTHS for 1-2 YEARS to ensure no rapid growth then STOP
WHEN should CHOLECYSTECTOMY be performed for GALLBLADDER POLYPS?
When the POLYP >10 mm or ANY SIZE in PSC
This condition is associated with GALLSTONES, FEMALES, ANOMALOUS pancreaticobiliary ducts, PSC, chronic SAMLMONELLA typhi, IBD and galbladder POLYPS?
GALLBLADDER CANCER (very poor prognosis)
JAUNDICE, RUQ PAIN, FEVER?
CHOLANGITIS
This BILIARY CONDITION is more COMMON in patients post LIVER TRANSPLANT, AIDS and HYPERlipidemia?
Sphincter of Oddi Dysfunction (SOD)
Which SOD type is associated with AST/ALT elevation of >1.1 AND CBD >10 mm, AND BILIARY COLIC?
SOD Type I (treat with ERCP/sphincterotomy)
Which SOD type is associated with AST/ALT elevation OR CBD >10 mm, AND BILIARY COLIC?
SOD Type II (treat with ERCP/sphincterotomy)
Which SOD type is associated with BILIARY COLIC but WITHOUT AST/ALT elevation OR CBD DILATION?
SOD Type III (no longer considered) - NO ERCP (no different than placebo)
Does diagnosis of SOD and treatment depend on Sphincter of Oddi Manometry (SOM)?
NO (empiric sphincterotomy)
Choledochal Cyst associated with congenital HEPATIC FIBROSIS and RENAL disease with RECURRENT CHOLANGITIS and INTRA-HEPATIC CALCULI?
CAROLI’s DISEASE
What is the TREATMENT for CHOLEDOCHAL CYSTS?
SURGERY (to prevent cancer - cholangiocarcinoma)
In which POPULATION are CHOLEDOCHAL CYSTS most COMMON?
JAPANESE
Which condition is associated with BLACK gallstones?
CHRONIC HEMOLYSIS such as seen in PROSTHATIC AORTIC VALVE REPLACEMENT, LVAD, Cirrhosis, PSC
Rapid Weight Loss, Parity, Obesity, and Estrogen Replacement Therapy are all associated with what type of GALLSTONES?
CHOLESTEROL stones
How do you treat a patient who presents with BILIARY COLIC and is only found to have BILIARY SLUDGE?
CHOLECYSTECTOMY (same as stones)
What BILIARY DISEASE is PSC associated with?
CHOLANGIOCARCINOMA
What type of GALLBLADDER POLYPS are associated with CHOLANGIOCARCINOMA?
POLYPS >10 mm (cholesterol and adenomyomatosis)
Which CHOLEDOCHAL CYST TYPE does NOT need SURGERY and can be treated with ERCP ans SPHINCTEROTOMY alone?
Type III
What type of SURGERY is required for CHOLEDOCHAL CYSTS?
ROUX-en-Y HEPATICOJEJUNOSTOMY
In a patient WITHOUT CLEAR GB SYMPTOMS, even if they have MILD elevation of LIPASE or anti-gliuadin Ab positivity or reduced GB EF, what is their most LIKELY diagnosis?
FUNCTIONAL DYSPEPSIA (treat with anti-spasmotic or TCA)
In a patient with SOD symptoms (such as Type II) if elevated LFTs, these have to be elevated without NAFLD due to obesity, etc. and the most likely diagnosis of persistent GB symptoms, EVEN AFTER CHOLECYSTECTOMY is likely what?
FUNCTIONAL DYSPEPSIA (further imaging with CT, EUS or MRI) prior to ERCP/sphincterotomy
What are the COMMON 2 CONTRAINDICATIONS to LAPAROSCOPIC CHOLECYSTECTOMY?
ADHESIONS from prior surgeries, COAGULOPATHIES
Can GALLBLADDER DYSKINESIA cause symptoms?
More than likely NO (it’s usually functional dyspepsia)
Pt with CONVICING GB SYMPTOMS and NEGATIVE GB US, what do you do next BEFORE CHOLECYSTECTOMY?
CCK-HIDA scan (low EF)
Pt presents with RUQ abdominal pain, T.Bili >4, CBD >6 mm or >8 mm post-cholecystectomy, ASCENDING CHOLANGITIS or CBD STONE on US what’s the NEXT STEP?
ERCP
How LONG should you WAIT to perform an ERCP in a patient with BILIARY PANCREATITIS if they have NO CHOLANGITIS or continued PD obstruction?
48 HOURS (let pancreatitis subside as ERCP can cause pancreatitis)
What COLOR are CBD stones that formed POST-CHOLECYSTECTOMY (usually >2 years after)?
BROWN pigment
Which post-op bile duct leaks require IR drainage?
Those >3 cm
A patient presents ~2-10 DAYS post CHOLECYSTECTOMY with FEVER, ABDOMINAL PAIN and possible ASCITES usually have what?
Post-OP BILE DUCT LEAK
What is the TREATMENT for a post-OP COMMON HEPATIC DUCT (CHD) LEAK?
SURGICAL HEPATICOJEJUNOSTOMY
What is the TREATMENT of a post-OP Bile Duct Leak?
ERCP with 10 F stent (sphincterotomy is NOT needed) - remove after 4 WEEKS
Occlusive INJURY to this DUCT can occur during CHOLECYSTECTOMY resulting in SEGMENTAL cholestasis due to infection and INTRA-HEPATIC STONE disease, ATROPHY of the liver LOBE and CHOLANGITIS?
RIGHT HEPATIC DUCT (RHD)
2 YEARS post CHOLECYSTECTOMY, patient presents with elevated LFTs, biliary PAIN, JAUNDICE and DILATED INTRAHEPATIC DUCTS on imaging?
Post-OP OCCLUSIVE INJURY to CHD or CBD
Up to what LENTGH are BILIARY STRICTURES likely to respond to ERCP with stent placement?
1 CM
What is the TREATMENT for REFRACTORY BILIARY STRICTURES?
Biliary BYPASS surgery (alternative to hepaticojejunostomy)
What are SOD patients at RISK for if undergoing ERCP and how should they be treated?
PANCREATITIS - prophylactic PD stent placement, rectal INDOMETHACIN and IVFs
Metastatic COLON, GASTRIC, PANCREATIC, BREAST and MELANOMA can all cause BILIARY obstruction HOW?
HILAR LYMPHADENOPATHY
What TYPE of biliary STENT should be placed for a patient with INOPERABLE PANCREATIC CANCER?
BARE METAL STENT (fully covered stents can migrate, partially covered stents still occlude)
What should be done to determine TREATMENT of a HILAR MALIGNNCY prior to ERCP?
MRCP to determine which side (L or R) would benefit more from STENTING
What is BEST used to diagnosed IDIOPATHIC ACUTE PANCREATITIS (sludge, strictures, divisum, ampullary neoplasm, IPMN)?
EUS (or secrectin-MRCP)
What is the MODALITY of choice for diagnosis of CHRONIC PANCREATITIS?
EUS (Rosemont Criteria 9)
What should be EXCLUDED PRIOR to attempting EUS-guided Cystgastrostomy of a pancreatic PSEUDOCYST?
The presence of an ANEURYSM or PSEUDOANEURYSM
What is the RISK of POST-ERCP PANCREATITIS?
3-10% (up to 25% in high-risk patients)
Prior POST-ERCP pancreatitis, SOD, FEMALE, normal BILIRUBIN, previous ACUTE RECURRENT PANCREATITIS and NO CHRONIC PANCREATITIS are all RISK factors for what?
POST-ERCP PANCREATITIS
What should be MODIFIED when performing an ERCP for choledocholithiasis in a patient with CIRRHOSIS?
Balloon dilation of papilla rather than sphincterotomy to minimize risk of post-OP bleed
How are INTRAPERITONEAL perforations during ERCP or endoscopy treated (severe PAIN, GUARDING, FEVER, LEUKOCYTOSIS)?
SURGERY
How are RETROPERITONEAL perforations during ERCP treated?
NGT SUCTION, ANTIBIOTICS, OBSERVATIONS (only 10-20% require surgery)
WHEN are PHROPHYLACTIC antibiotics RECOMMENDED in the PERI-ERCP time?
Whenever there is a SUSPICION of OBSTRUCTION of a POORLY-DRAINING space (contiue for 5-7 days post ERCP if drainage is still poor such as in PSC, malignancy)
What is a SUPERIOR modlaity for staging ESOPHAGEAL MALIGNANCIES and lesions?
EUS
When should a GIST be removed surgically?
When it is >2 cm, IRREGULAR contour, is ULCERATED or BLEEDING
When performing an EUS, when is PROPHYLACTIC ANTIBIOTIC use recommended and why?
When performing FNA of CYSTS, to prevent ABSCESS formation (for peri-rectal spaces, continue for 48 hours post)
WHEN are B/L PTC DRAINS required with eventual HEPATICOJEJUNOSTOMY to fix a BILE LEAK?
When there has been a COMPLETE DISRUPTION of the Common Hepatic Duct (CHD)
Abdominal PAIN same as PRIOR to cholecystectomy, ELEVATED LFTs, DILATED CBD?
SOD-I (treat with ERCP/SPHINCTEROTOMY)
If on MANOMETRY, a patient is PROVEN to have ELEVATED ampullary pressure and thus SOD, especially in a patient with ACUTE RECURRENT IDIOPATHIC PANCREATITIS, what is the PERCENTAGE of clinical improvement post ERCP/SPHINCTEROTOMY?
50%
Which patients have the HIGHEST post-ERCP risk of BLEEDING?
Those that MUST resume ANTICOAGULATION within 3 days post-ERCP (valve replacements)
What can be ADDED to ERCP BRUSH CYTOLOGY to improve diagnostic yield by 20% when “ATYPICAL” cells are noted but no diagnosis of malignancy exists?
FISH analysis (Fluorescence In-Situ Hybridization)
