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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
**WHEN** should you do an **ERCP** in a patient with **ACUTE BILIARY PANCREATITIS**?
**< 48 HRS** if **OBSTRUCTED** or **CHOLANGITIS** **>48 HRS** without these complicating factors
26
In a patient that is a **POOR SURGICAL CANDIDATE** with **ACUTE CHOLECYSTITIS**, what can be done?
**EUS**-guided GB drainage (AXIOS)
27
**Majority** (75%) of **biliary strictures** in adults are what?
**MALIGNANT**
28
When performing **EUS/FNA/FNB**, what is **PREFERRED** when biopsying suspected pancreatic **CANCER**?
**EUS/FNB** or **EUS/FNA with ROSE** (Rapid on-Site Cytology Evaluation)
29
What is the **RECOMMENDED EUS** approach to a suspected **HILAR CHOLANGIOCARCINOMA**?
**EUS/FNB/FNA** of associated **LYMPHADENOPAHTY** not of the primary mass itself because it **SEEDS** the peritoneum
30
What is the **BEST** approach to **SAMPLING** a biliary **STRICTURE** for diagnosis?
**MULTIMODAL**: **brush cytology**, **fluoro-guided** forceps **biopsy**, **cholangioscopy**-guided biopsies, FISH, confocal microscopy, gene sequencing
31
What **MUST** you obtain **PRIOR** to an **ERCP** for a biliary **STRICTURE**?
**PRE-PROCEDURAL IMAGING** (inject only which liver segments you will attempt to drain - at least 50% of viable liver)
32
Whenever performing an **ERCP** for **HILAR** or **INTRAHEPATIC** biliary **STRICTURES**, what **MUST** be done prior?
**PROPHYLACTIC ANTIBIOTICS**
33
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**?
**FULLY COVERED METAL** stents (possible cholecystitis if occludes CD and possible pancreatitis if no sphincterotomy is performed)
34
After how long will a **FULLY COVERED METAL** stent become **EMBEDED** and epithealized?
**~1 year**
35
For a **BENIGN** biliary **STRICTURE**, if no metal stents are available, how can you use plastic instead?
**MULTIPLE PARALELL** plastic stents
36
When treating **BENIGN** biliary **STRICTURES**, when is the **ONLY** time multiple **PLASTIC** stents are recommended over metal?
If the **GB** is still in place and the **CD** cannot be **AVOIDED** (so as not to risk cholecystitis by blocking the CD)
37
How **LONG** must a **BENIGN** biliary **STRICTURE** be treated for when using **PLASTIC** and **METAL** stents?
**12 MONTHS** for **PLASTIC** **6 MONTHS** for **METAL**
38
What is one of the most **COMMON** causes of a **BENIGN** biliary stricture?
**CHRONIC PANCREATITIS**
39
What are the **INDICATIONS** for treatment of a **BENIGN** biliary **STRICTURE**?
**CBD >12** mm **OR** **ALP >3x NL** If untreated, can cause CIRRHOSIS
40
What features of **CHRONIC PANCREATITIS** cause a resulting biliary **STRICTURE** to **NOT** resolve with **STENT** placement (**recurs**)?
**CALCIFIED PANCREATITIS** (surgery hepaticojejunostomy)
41
**Years** after liver **surgery**, a patient presents with symptoms of **cholangitis** or biliary **obstruction** or **atrophied** portion of the liver, what happened?
**RIGHT SEGMENTAL INTRAHEPATIC** duct **STRICTURE**
42
**SURGICAL** injuries to these bile ducts require **MULTIPLE** stenting sessions?
**CBD** and **CHD**
43
What is the **RECOMMENDED** treatment for post liver **TRANSPLANT** biliary **STRICTURE**?
**ERCP** with **COVERED** metal stent
44
What is the **RECOMMENDED PRIOR** to **ERCP** treatment for post liver **TRANSPLANT SUSPECTED** biliary **STRICTURE**?
**MRCP** (for diagnosis and planning) - **UNLESS** very **HIGH** pre-test probability of stricture or cholangitis
45
What **MUST** you give when treating **BILIARY STRICTURES** by **ERCP**?
**PROPHYLACTIC ANTIBIOTICS** (especially in transplant patients - immunocompromised)
46
What is the **RECOMMENDED** treatment for **SOD** types **I&II**?
ERCP with **SPHINCTEROTOMY**
47
If a patiet whom already had a **CT** showing a **HILAR MASS**, before procedures (EUS) what do they **STILL** need first?
**MRI/MRCP** (multiple-imaging studies) - need to well define liver biliary drainage PRIOR to stenting
48
**WHEN** is **ERCP** with **STENTING** (drainage) recommended in patients with **RESECTABLE** cholangiocarcinoma or pancreatic cancer?
**Neoadjuvant Chemotherapy**, **T.Bili >14**, **PRURITUS**, **CHOLANGITIS**
49
If **SURGERY** is anticipated after **CHEMO**, how should a **METAL** stent be paced in the **CBD**?
**1.5 cm BELOW** the bifurcation (confluence)
50
How are **UNRESECTABLE** malignant hilar obstructing masses **stented**?
**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
Should **PTC** be performed to **DRAIN** the liver if the patient is a **SURGICAL CANDIDATE**?
**NO**
52
In a patient who is having **ACUTE IDIOPATHIC PANCREATITIS** episodes with negative imaging, no smoking or alcohol, and **NO FH**, what's **NEXT**?
**EUS**
53
What improves **diagnostic value** for pancreatitis in a patient having **MRI** done?
**SECRETIN**
54
What is **RECOMMENDED** for diagnosis in a patient **>40 yo** who presents with **ACUTE IDIOPATHIC PANCREATITIS**?
**EUS** (21% cancer)
55
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?
**ERCP** with **SPHINCTEROTOMY**
56
What can be considered for treatment of patients with **SYMPTOMS** of **PAIN** from **CHRONIC PANCREATITIS** who have intraductal **STONES** and **STRICTURES**?
**ERCP** with clearance of stones and stenting (no endoscopic therapy in ASYMPTOMATIC patients)
57
How **LONG** post **ERCP** should **ANTICOAGULATION** be **RESTARTED**?
**72 HOURS**
58
What are the **COMMON RISKS** of developing **POST-ERCP PANCREATITIS**?
**PRIOR POST-ERCP** pancreatitis, **FEMALE**, **PREVIOUS** pancreatitis episodes, **SOD**, **YOUNG**, normal pancreas, normal LFTs
59
**PANCREATIC** duct **SPHINCREROTOMY**, **BALLOON DILATION** of **CBD** **without** sphincterotomy are common causes of what?
**POST-ERCP PANCREATITIS**
60
In order to **AVOID POST-ERCP PANCREATITIS**, what is **RECOMMENDED**?
**PRE-PROCEDURAL RECTAL INDOMETHACIN** or **DICLOFENAC** (unless **ALLERGY, RENAL DISEASE, PUD**) - aggressive periprocedural **hydration** with **LR**
61
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**?
**NO**
62
In a **NON-OUTBREAK** setting, does **ETHYLENE OXIDE** sterilization of endoscopes reduce bacterial contamination rates?
NO
63
What are the **THREE** setps that need to be taken in an **OUTBREAK** setting of bacterial contamination of endoscopes?
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
Which **GENETIC** marker is associated with a **GIST**?
KIT (CD117)
65
Which **GENETIC** marker is associated with **LYNCH** syndrome (**H**ereditary **N**on-**P**olyposis **C**olon **C**ancer - **HNPCC**)
**MSH6**
66
What is the **STK11 GENETIC** marker associated with?
**Peutz-Jeghers** syndrome
67
Do **SUBMUCOSAL** gastric lesions with a **CENTRAL UMBILICATION** require removal?
**NO** - pancreatic **RESTs** have NO malinant potential
68
Do pancreatic **RESTs** and **LIPOMAs** require **EUS** evaluation?
**NO**
69
What is the **IMAGE**?
**LIPOMA**
70
What is the **IMAGE**?
**DUPLICATION CYST** (has **ALL** the mucosal **LAYERS** not just one)
71
What is the **IMAGE**?
**GIST**
72
Are **BYTE** on **BYTE** biopsies of **SUBMUCOSAL** lesions recommended by the ACG?
**NO** (makes these difficult to resect)
73
What is the **TEST** of **CHOICE** as per the ACG for **SUBMUCOSAL** GI lesions?
**EUS**
74
Which **SUBMUCOSAL LESIONS** does the ACG require a **BIOPSY** of?
**ALL** SUBMUCOSAL LESIONS that are **NOT LIPOMAS**
75
What is the **RECOMMENDED BIOPSY** modality on **EUS** by the ACG for **SUBMUCOSAL LESIONS**?
**FNB** or **FNA w/ROSE**
76
What **GISTs** are **RECOMMENDED** for **RESECTION** by the ACG?
**ALL GASTRIC GISTs >2 cm** (surveillance if < 2 cm) **ALL NON-GASTRIC GISTs** of **ANY SIZE** (esophageal, duodenal, etc.)
77
What is the **DIFFERENCE** between a **TYPE-1** vs **TYPE-3** gastric **NEUROENDOCRINE TUMOR**?
**TYPE-1:** most **COMMON**, caused by **HYPER**gastrinemia, CHRONIC **atrophic** gastritis, excellent prognosis **TYPE-3:** **SPORADIC**, **POOR** survival, **SPREAD** early
78
What **METHOD** does the ACG recommend for resection of a **TYPE-1** gastric **NEUROENDOCRINE TUMOR**?
**EMR** or **ESD**
79
What **METHOD** does the ACG recommend for resection of a **TYPE-3** gastric **NEUROENDOCRINE TUMOR**?
**ESD** (unless surgical candidate)
80
Which **EUS/FNA/FNB** is associated with **INFECTION** for which antibiotic **PROPHYLAXIS** is recommended?
EUS/FNA/FNB of **CYSTs**
81
The most **FREQUENTLY** noted **EUS** procedure to result in **PANCREATITIS** is what?
**EUS** with **FIDUCIAL** placement

GI Boards November 20th 2024 (11 decks)

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