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GI Boards November 20th 2024 > Biliary Tract Disease > Flashcards

Biliary Tract Disease Flashcards

1
Q

What causes BLACK PIGMENT gallstones?

A

HEMOLYSIS (prosthetic AVR, cirrhosis, sickle cell, spherocytosis)

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2
Q

TERMINAL ILEAL resection or disease (CHROHN’s), OCP’s ESTROGEN, OCTREOTIDE, VAGOTOMY can all cause what biliary disease?

A

CHOLESTEROL GALLSTONES

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3
Q

Why can BROWN PIGMENT (cholesterol) stones be found in patients with periamullary DIVERTICULA?

A

Biliary STASIS

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4
Q

What is RECOMMENDED in a patient with presumed BILIARY PANCREATITIS who likely PASSED their stone and has GB stones?

A

CHOLECYSTECTOMY - next available

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5
Q

T.Bili & Alk Phos WNL, CD obstruction, RUQ and EPIGASTRIC abd pain for hours to days?

A

Acute CHOLANGITIS

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6
Q

In a patient with gallstones and biliary colic, whom refuses the recommended LAP CHOLY, what is an alternative that is EFFECTIVE for SMALL STONES but stones RECUR 50% of the time?

A

URSO

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7
Q

On imaging, pt has a GB POLYP >1 cm or they have PSC and a GB POLYP >8 mm, whats the NEXT step?

A

CHOLECYSTECTOMY

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8
Q

On imaging, pt has a GB POLYP < 1 cm and no PSC, whats the NEXT step?

A

US every 6 MONTHS for 1-2 YEARS

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9
Q

Fundus of GB with DEEP SINUSES and muscular HYPERPLASIA that should only be treated if SYMTPOMATIC?

A

ADENOMYOMATOSIS

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10
Q

What process is ASSOCIATED with CHOLESTEROL POLYPS in the GB?

A

CHOLESTEROLOSIS (macrophages with fat)

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11
Q

What DISEASE is GB CANCER (5 yr 10% survival) closely associated with?

A

PSC (IBD, anomalous pancreaticobiliary junction, gallstones, adenomatous polyps, chronic SALMONELLA, porcelain GB, adenomyomatosis)

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12
Q

Acute ASCENDING CHOLANGITIS no matter how sick (acidotic, hypoxic, hypotensive on pressors, septic) requires what besides antibiotics?

A

ERCP < 48 HRS
if SEPTIC in < 24 HRS

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13
Q

TRANSFER for ERCP if?

A

-Imaging shows CBD stone
OR
-T.Bili >4 AND dilated CBD (>6 mm pre-choly or >8 mm post-choly)
OR
-ASCENDING CHOLANGITIS

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14
Q

Abnormal LFTs, Age >55 yo, CBD dilation?

A

EUS or MRCP or Lap Choly w/IOC

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15
Q

If a patient ONLY has presentation of BILIARY COLIC but nothing else, whats the recommendation?

A

Lap CHOLY, no IOC

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16
Q

Recommendation for removal of >1 cm CBD stones via ERCP?

A

Sphincterotomy + Balloon Dilation or mechanical lithotripsy or plastic stent + URSO 6 weeks - 6 months

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17
Q

FUSIFORM CBD with ANOMAOUS union of the PANCRETIC duct to the CBD can cause which cancers EXCEPT HCC?

A

GB cancer
Cholangiocarcinoma
Pancreatic cancer

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18
Q

Easter ASIA (China, Japan, Korea), pain, jaundice, pancreatitis, PALPABLE MASS and almost ALL associated with ANOMALOUS pancreatico-biliary JUNCTION?

A

CHOLEDOCHAL CYST

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19
Q

Which is the ONLY CHOLEDOCHAL CYST type that has NOT risk of CANCER and is treated by SPHINCTEROTOMY?

A

TYPE 3 (A & B)

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20
Q

Which is the ONLY CHOLEDOCHAL CYST type that is called CAROLI’s disease?

A

TYPE 5 (multiple cysts)

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21
Q

Which are the TWO CHOLEDOCHAL CYST types that have MULTIPLE cyts?

A

TYPES 4 & 5

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22
Q

Post CHOLY pt has BILE LEAK but CD is stapled SHUT, whare is it coming from?

A

RIGHT HEPATIC DUCT abnormal communication with the GB - DUCT of LUSHKA

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23
Q

How is a BILE LEAK best treated?

A

ERCP with PLASTIC stent placement for 4 WEEKS or SPHINCTEROTOMY (if there is large biloma also needs percutaneous drain)

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24
Q

WHEN should a patient with UNCOMPLICATED ACUTE CHOLECYSTITIS undergo CHOLECYSTECTOMY?

A

SAME HOSPITALIZATION

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25
Q

WHEN should you do an ERCP in a patient with ACUTE BILIARY PANCREATITIS?

A

< 48 HRS if OBSTRUCTED or CHOLANGITIS
>48 HRS without these complicating factors

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26
Q

In a patient that is a POOR SURGICAL CANDIDATE with ACUTE CHOLECYSTITIS, what can be done?

A

EUS-guided GB drainage (AXIOS)

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27
Q

Majority (75%) of biliary strictures in adults are what?

A

MALIGNANT

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28
Q

When performing EUS/FNA/FNB, what is PREFERRED when biopsying suspected pancreatic CANCER?

A

EUS/FNB or EUS/FNA with ROSE (Rapid on-Site Cytology Evaluation)

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29
Q

What is the RECOMMENDED EUS approach to a suspected HILAR CHOLANGIOCARCINOMA?

A

EUS/FNB/FNA of associated LYMPHADENOPAHTY not of the primary mass itself because it SEEDS the peritoneum

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30
Q

What is the BEST approach to SAMPLING a biliary STRICTURE for diagnosis?

A

MULTIMODAL: brush cytology, fluoro-guided forceps biopsy, cholangioscopy-guided biopsies, FISH, confocal microscopy, gene sequencing

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31
Q

What MUST you obtain PRIOR to an ERCP for a biliary STRICTURE?

A

PRE-PROCEDURAL IMAGING (inject only which liver segments you will attempt to drain - at least 50% of viable liver)

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32
Q

Whenever performing an ERCP for HILAR or INTRAHEPATIC biliary STRICTURES, what MUST be done prior?

A

PROPHYLACTIC ANTIBIOTICS

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33
Q

For BENIGN biliary STRICTURE resolution, what is the RECOMMENDED stent to be used for reasons of reduced cost and less repeat ERCPs as efficacy and adverse events are SIMILAR?

A

FULLY COVERED METAL stents (possible cholecystitis if occludes CD and possible pancreatitis if no sphincterotomy is performed)

34
Q

After how long will a FULLY COVERED METAL stent become EMBEDED and epithealized?

35
Q

For a BENIGN biliary STRICTURE, if no metal stents are available, how can you use plastic instead?

A

MULTIPLE PARALELL plastic stents

36
Q

When treating BENIGN biliary STRICTURES, when is the ONLY time multiple PLASTIC stents are recommended over metal?

A

If the GB is still in place and the CD cannot be AVOIDED (so as not to risk cholecystitis by blocking the CD)

37
Q

How LONG must a BENIGN biliary STRICTURE be treated for when using PLASTIC and METAL stents?

A

12 MONTHS for PLASTIC
6 MONTHS for METAL

38
Q

What is one of the most COMMON causes of a BENIGN biliary stricture?

A

CHRONIC PANCREATITIS

39
Q

What are the INDICATIONS for treatment of a BENIGN biliary STRICTURE?

A

CBD >12 mm OR ALP >3x NL
If untreated, can cause CIRRHOSIS

40
Q

What features of CHRONIC PANCREATITIS cause a resulting biliary STRICTURE to NOT resolve with STENT placement (recurs)?

A

CALCIFIED PANCREATITIS (surgery hepaticojejunostomy)

41
Q

Years after liver surgery, a patient presents with symptoms of cholangitis or biliary obstruction or atrophied portion of the liver, what happened?

A

RIGHT SEGMENTAL INTRAHEPATIC duct STRICTURE

42
Q

SURGICAL injuries to these bile ducts require MULTIPLE stenting sessions?

A

CBD and CHD

43
Q

What is the RECOMMENDED treatment for post liver TRANSPLANT biliary STRICTURE?

A

ERCP with COVERED metal stent

44
Q

What is the RECOMMENDED PRIOR to ERCP treatment for post liver TRANSPLANT SUSPECTED biliary STRICTURE?

A

MRCP (for diagnosis and planning) - UNLESS very HIGH pre-test probability of stricture or cholangitis

45
Q

What MUST you give when treating BILIARY STRICTURES by ERCP?

A

PROPHYLACTIC ANTIBIOTICS (especially in transplant patients - immunocompromised)

46
Q

What is the RECOMMENDED treatment for SOD types I&II?

A

ERCP with SPHINCTEROTOMY

47
Q

If a patiet whom already had a CT showing a HILAR MASS, before procedures (EUS) what do they STILL need first?

A

MRI/MRCP (multiple-imaging studies) - need to well define liver biliary drainage PRIOR to stenting

48
Q

WHEN is ERCP with STENTING (drainage) recommended in patients with RESECTABLE cholangiocarcinoma or pancreatic cancer?

A

Neoadjuvant Chemotherapy, T.Bili >14, PRURITUS, CHOLANGITIS

49
Q

If SURGERY is anticipated after CHEMO, how should a METAL stent be paced in the CBD?

A

1.5 cm BELOW the bifurcation (confluence)

50
Q

How are UNRESECTABLE malignant hilar obstructing masses stented?

A

IMAGING to determine >50% drainage (don’t drain an ATROPHIC lobe) of liver (each lobe drains ~30%), then PLASTIC FIRST to prove GOOD DRAINAGE, then UNCOVERED METAL

51
Q

Should PTC be performed to DRAIN the liver if the patient is a SURGICAL CANDIDATE?

52
Q

In a patient who is having ACUTE IDIOPATHIC PANCREATITIS episodes with negative imaging, no smoking or alcohol, and NO FH, what’s NEXT?

53
Q

What improves diagnostic value for pancreatitis in a patient having MRI done?

54
Q

What is RECOMMENDED for diagnosis in a patient >40 yo who presents with ACUTE IDIOPATHIC PANCREATITIS?

A

EUS (21% cancer)

55
Q

In a patient with MULTIPLE recurrent attacks of ACUTE IDIOPATHIC PANCREATITIS once had MRCP and EUS, cleared for any other cause, what can provide 50% chance of resolution?

A

ERCP with SPHINCTEROTOMY

56
Q

What can be considered for treatment of patients with SYMPTOMS of PAIN from CHRONIC PANCREATITIS who have intraductal STONES and STRICTURES?

A

ERCP with clearance of stones and stenting (no endoscopic therapy in ASYMPTOMATIC patients)

57
Q

How LONG post ERCP should ANTICOAGULATION be RESTARTED?

58
Q

What are the COMMON RISKS of developing POST-ERCP PANCREATITIS?

A

PRIOR POST-ERCP pancreatitis, FEMALE, PREVIOUS pancreatitis episodes, SOD, YOUNG, normal pancreas, normal LFTs

59
Q

PANCREATIC duct SPHINCREROTOMY, BALLOON DILATION of CBD without sphincterotomy are common causes of what?

A

POST-ERCP PANCREATITIS

60
Q

In order to AVOID POST-ERCP PANCREATITIS, what is RECOMMENDED?

A

PRE-PROCEDURAL RECTAL INDOMETHACIN or DICLOFENAC (unless ALLERGY, RENAL DISEASE, PUD) - aggressive periprocedural hydration with LR

61
Q

In a NON-OUTBREAK setting, do MULTIPLE High-Level Decontamination sessions - HLD (scope washig sessions) make a difference in preventing bacterial contamination vs SINGLE SESSION?

62
Q

In a NON-OUTBREAK setting, does ETHYLENE OXIDE sterilization of endoscopes reduce bacterial contamination rates?

63
Q

What are the THREE setps that need to be taken in an OUTBREAK setting of bacterial contamination of endoscopes?

A
  1. Use ETHYLENE OXIDE sterilization (do not use in non-outbreak setting) - TERMINATES the outbreak
  2. Perform ENVIRONMENTAL SAMPLING
  3. REPORT infections (to patient, infection control, physicians, publich health, FDA, equipment manufacturer)
64
Q

Which GENETIC marker is associated with a GIST?

A

KIT (CD117)

65
Q

Which GENETIC marker is associated with LYNCH syndrome (Hereditary Non-Polyposis Colon Cancer - HNPCC)

66
Q

What is the STK11 GENETIC marker associated with?

A

Peutz-Jeghers syndrome

67
Q

Do SUBMUCOSAL gastric lesions with a CENTRAL UMBILICATION require removal?

A

NO - pancreatic RESTs have NO malinant potential

68
Q

Do pancreatic RESTs and LIPOMAs require EUS evaluation?

69
Q

What is the IMAGE?

70
Q

What is the IMAGE?

A

DUPLICATION CYST (has ALL the mucosal LAYERS not just one)

71
Q

What is the IMAGE?

72
Q

Are BYTE on BYTE biopsies of SUBMUCOSAL lesions recommended by the ACG?

A

NO (makes these difficult to resect)

73
Q

What is the TEST of CHOICE as per the ACG for SUBMUCOSAL GI lesions?

74
Q

Which SUBMUCOSAL LESIONS does the ACG require a BIOPSY of?

A

ALL SUBMUCOSAL LESIONS that are NOT LIPOMAS

75
Q

What is the RECOMMENDED BIOPSY modality on EUS by the ACG for SUBMUCOSAL LESIONS?

A

FNB or FNA w/ROSE

76
Q

What GISTs are RECOMMENDED for RESECTION by the ACG?

A

ALL GASTRIC GISTs >2 cm (surveillance if < 2 cm)
ALL NON-GASTRIC GISTs of ANY SIZE (esophageal, duodenal, etc.)

77
Q

What is the DIFFERENCE between a TYPE-1 vs TYPE-3 gastric NEUROENDOCRINE TUMOR?

A

TYPE-1: most COMMON, caused by HYPERgastrinemia, CHRONIC atrophic gastritis, excellent prognosis
TYPE-3: SPORADIC, POOR survival, SPREAD early

78
Q

What METHOD does the ACG recommend for resection of a TYPE-1 gastric NEUROENDOCRINE TUMOR?

A

EMR or ESD

79
Q

What METHOD does the ACG recommend for resection of a TYPE-3 gastric NEUROENDOCRINE TUMOR?

A

ESD (unless surgical candidate)

80
Q

Which EUS/FNA/FNB is associated with INFECTION for which antibiotic PROPHYLAXIS is recommended?

A

EUS/FNA/FNB of CYSTs

81
Q

The most FREQUENTLY noted EUS procedure to result in PANCREATITIS is what?

A

EUS with FIDUCIAL placement

GI Boards November 20th 2024 (11 decks)

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