Biliary Tract Disease Flashcards
1
Q
who has a high incidence of cholesterol gallstones?
A
mexican americans, American indian tribes women multi-parity pregnancy prolonged TPN
2
Q
what continuously secretes bile?
A
liver
3
Q
Between meals, _______ ___ ______contracts and diverts bile into gallbladder
A
sphincter of Oddi
4
Q
______ stimulates contraction of the gallbladder and relaxation of the sphincter of Oddi in response to fats in duodenum
A
CCK
5
Q
what stores and concentrates bile?
A
gallbladder
6
Q
what are the most common biliary stones?
A
Mixed
7
Q
what are stone from infected bile that usually present in the common bile duct (primary- formed w/i common bile duct)
A
brown stones
8
Q
where do most stone that get in the primary bile duct come from?
A
gallbladder
9
Q
what normally causes common bile duct stones?
A
stasis or infection
10
Q
what will you see on US w/ cholecystitis?
A
posterior shadowing
11
Q
when can you see gallstones on a plain film?
A
cholesterol and calcium
12
Q
if you suspect GB disease what do you need to get?
A
US
no need for plain film or CT scan
13
Q
what is the recommended tx for asymptomatic gallstones?
A
observation
14
Q
what do you do for a person w/ cirrhosis with gallstones?
A
careful observation
15
Q
when is a cholescystectomy recommended with hemolytic anemia?
A
at time of splenectomy
16
Q
with somatonstatinoma when is a cholecystectomy recommened?
A
At time of tumor resection
17
Q
what has a higher risk of gallbladder cancer and needs to be taken out?
A
calcified gallbaldder (porcelain gallbladder)
18
Q
with obese patients undergoing bariatric surgery when should you remove the gallbladder
A
during the bariatric surgery as it adds minimal M and M
19
Q
is there any inflammation with biliary colic?
A
none
20
Q
how long does biliary colic last?
A
1-4 hours
21
Q
what causes pain with biliary colic
A
pain is from distention of the gallbladder
22
Q
location of biliary colic
A
RUQ, less likely epigastric. May go to back. May radiate to right shoulder
23
Q
what are associations of biliary colic?
A
N/V
24
Q
what will vitals be with for biliary colic?
A
normal
25
will there be a Murphy's sign with biliary colic?
No, because there is no inflammation
26
what are precipitating factor for biliary colic?
large fatty meals
27
when do a lot of biliary colic patients present?
in between attacks so they will have a normal exam
28
if a person presents with biliary colic then goes away what should you do?
follow up as an outpatient w/ surgeon to have an elective cholecystectomy
29
what will biliary colic look like on US?
gallstones w/o GB wall thickening or pericholocystic fluid and nl CBD
30
what is gallbladder dysfunction
In pts with sx suggestive of biliary colic but no stones
31
what do you do on patients w/ gallbladder dysfunction?
nuclear cholescintigraphy (HIDA, PPIDA< radionuclide biliary scan w/ CCK stimulation) to evaluated GB ejection fraction
32
what is a normal GB ejection fraction?
Normal >35%
33
what causes acute cholecystitis?
Persistent stone impaction in the cystic duct causes the gallbladder to become distended and progressively inflamed
34
what associations are there with acute cholecystitis?
N/V, fever, chills
35
vitals w/ acute cholecystitis?
+/- fever, +/- tachycardia, +/- hypotension
36
what will LFTS probably look like w/ acute cholecystitis?
normal, could have minimal elevation
37
what will the CBD look like with acute cholecystitis?
normal
38
what will US look like w/ acute cholecystitis?
US - gallstones w/ distended GB
| GB wall thickening, pericholocystic fluid and US Murphy’s sign
39
what will acute cholecytitis look like on abdominal exam?
tender mass in RUQ
localized guarding or rebound
+ US murphy's sign
40
TX for acute cholecystitis
```
NPO
IV fluids
IV abx
IV pain meds
antiemetics
early cholecystectomy (w/i a few days of onset)
```
41
what can you do for poor surgical canidates who have acute cholecystitis?
cholecystectomy tube
42
what levels will differentiate acute cholecystitis and acute pancreatitis?
amylase, lipase
43
what differes Perforated peptic ulcer from acute cholecystitis?
peritonitis
44
what is the distinction b/w acute biliary colic and acute cholecystitis?
time. symptoms will not go away with acute cholecystitis
45
who is acute acalculous cholecytistis common in?
patient who is acutely ill for other reasons
| common in ICU patients
46
what will you see on US w/ acute acalulous cholecystitis?
no stones but other findings of acute cholecystitis
47
what test do you need to get for acute acalculous cholecystitis?
Nuclear cholescintigraphy (HIDA, PPIDA, radionuclide biliary scan)
48
Tx for acute acalculous cholecystitis for a patient sick in the ICU
cholecystectomy tube
49
Bacterial proliferation in the obstructed GB
empyema
50
what is seen in empyema
high fever and leukocytosis
| need early decompression (tube to drain pus)
51
presentation w/ GB perforation?
high, fever, chills, rigors, septic shock
| may have a fistula
52
caused by gas forming oragnisms and higher chance of gangrene. More often in older patients, DM.
emphysematous cholecystitis
53
Over-distended gallbladder with mucoid or clear and watery content
From gallstone disease
Non-inflammatory
presents similar to biliary colic w/ longer symptoms
hydrops (mucocele) of the gallbladder
54
tx for emphysematous cholecystitis
emergency cholecystectomy after stabilization
55
what is the gold standard for cholecsystectomy?
Laperoscopic cholecystectomy
56
What are reasons you may need to open w/ a cholecystectomy?
```
Adhesions
poor visualization of critical structures
hemorrhage
bile duct injury
injury to another organ
```
57
how is a patient positioning for a cholecystectomy?
patient supine w/ arms out
58
where does the surgeon stand for a cholecystectomy?
on the left
| assistant on right
59
what is a Intraoperative Cholangiogram used for?
Used to identify CBD stones and delineate biliary anatomy
60
border of triangle of calot?
Common hepatic duct, cystic duct, and edge of the liver
61
complications of lap chole?
```
CBD injury (serious)
bowel injury
bleeding
infection bile
bile leak
```
62
tiny ducts that drain from the liver into the body of the GB or cystic duct stump leak
duct of Luschka
63
how do you evaluate a bile leak?
Evaluate with labs and PIPIDA +/- other imaging to look for fluid collection
64
Tx for bile leak
Treated with perc drainage or ERCP stent placement or combination or surgical drain placement
65
what is post-op cholecystectomy syndrome?
Epigastric or RUQ pain after cholecystectomy
40% of patients have minor GI complaints
Gas, bloating, abdominal pain, or diarrhea
66
when does post-op cholecystectomy syndrome resolve?
a few weeks
| if still have persistent symptoms probably due to a preop dx
67
what is the term for Common bile duct stones
Choledocholehiasis
68
where do most stones in the CBD come from?
GB
69
symptoms of choledocholehiasis
intermittent jaundice
| pain in RUQ= dull
70
associated symptoms w/ choledocholethiasis
Pruritis, clay colored stools, tea colored urine
71
what labs will be elevated with choledocholethiasis
elevated LFTs (alk pos and GGT)
mild elevation so AST and ALT
elevated conjugated bilirubin
72
what will you see on US w/ choledocholethiasis?
gallstones +/- CBD stone. Dilated intra- and extra- hepatic ducts. Dilated CBD >6-8mm.
73
the CBD should be how large?
a mm per decade
| ex- 8 mm if in 80s
74
what special imaging can you get for CBD stones?
MRCP- less invasive not therapeutic
ERCP- can grab stone
intraoperative cholangiogram (IOC)
75
TX for CBD stones
lap chole to prevent future stones
76
do CBD stones often pass on their own?
Yes- usually on a day or 2
| look for bilirubin to go down
77
if a stone doesn't pass through the CBD what can be done?
ERCP with sphinterotomy and stone extraction may be performed if pt has lab or imaging finding concerning for CBD stones
78
what is a septic process of the biliary tree?
acute ascending cholangitis
79
most common cause of acute ascending cholangitis?
```
CBD stones or benign strictures
malignancy
pancreatitis
mirizzi's syndrome
viral infection
parasitic infeciton
duodenal ulzer
```
80
what is mirizzi's syndrome
a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice.
81
pain quality with acute ascending cholangitis
parietal, dull, aching
82
what is Charcot's triad
fever, jaundice, RUQ pain
| associated w/ acute ascneding cholangitis
83
what is REynold's Pentad?
Charcot’s triad +
Mental status changes (Delirium)
Hypotension (Shock)
84
immediate treatment for acute ascending cholangitis
NPO
IVFs
broad-spectrum abx
85
drainage for acute ascendign cholangitis
ERCP (GI) or percutaneous transhepatic
| - PTC (radiologist)
86
a large gallstone (2 cm) causes a SBO by lodging in the distal ileus
gallstone ileus
87
how does a large gallstone get from the gallbaldder into the small intestine?
fistula
88
what will you see on imaging w/ a gallstone ileus
dilated small bowel
air within biliary tree
stone in terminal ileum
89
Tx for gallstone ileus?
NGT
IVF
enterotomy w/ stone extraction +/- cholecystectomy and fistula repair
(often leave gallbladder and fistula alone)
90
risk factors for gallbaldder cancer
```
cholesterol stones
single large gallstone
porcelain GB
biliary slmonella typhi infection
biliary polyps <1cm
```
91
symptoms of gallbaldder cancer (advanced)
vague RUQ pain
weight loss and malaise
jaundice in 50%
hard mass in RUQ (may be non-tender)
92
what is cancer of the bile duct?
Cholangiocarcinoma
93
tumor that Occur at the bifurcation of right and left hepatic ducts
Klatskin tumor
94
risk factors for cholangiocarcinoma
UC
Sclerosing cholangitis
Choledochal cysts
Parasitic disease
95
what is the most common symptoms of cholangiocarcinoma?
```
progressive jaundice
pruritis
weight loss
abdominal pain
cholangitis
```
96
what is curvoisier's sign?
tumor blocks off common bile duct so everythign upstream is dilated
can feel their GB on PE
non-tender palpable GB
97
what will a person with cholangiocarcinoma look like on PE?
yellow
hepatomegaly
curvoisier's sign
