Cholecystitis/cholelithiasis, Pancreatitis, Peritonitis

Question 1

what makes up calots triangle and when is this of clinical importance

Answer 1

• Medial-common hepatic duct
• Inferior-cystic duct
• Superior-inferior surface of the liver
• cinically important when completing a cholecystectomy to allow safe ligation of the cystic duct and artery

apex of triangle is pointed at liver

Question 2

what are the most common type of gallstones

Answer 2

cholesterol gallstones

Question 3

what are the 3 things that can cause gallstones

Answer 3

1. high cholesterol
2. high bilirubin
3. slow emptying gallbladder

Question 4

what factors would put someone at increased risk for cholelithiasis

Answer 4

• being a woman (OCPs, pregnancy, hormone replacement, anything causing increased estrogen)
• pragnancy
• obestity (increased cholesterol)
• advanced age
• rapid weight loss
• certain medical illnesses (high LDL or TG, DM, liver disease, anemia)

Question 5

what can protect against gallstones

Answer 5

• meditteranean diet
• caffienated coffee (???)

Question 6

what is the pathophys behind symptomatic cholelithiasis

Answer 6

• stones blocking cystic duct/gallbladder outlet
• creates inflammation of gallbladder = pain

Question 7

what are the s/s of biliary colic secondary to cholelithiasis

Answer 7

• RUQ pain radiating to R shoulder
• diaphoresis, nausea, vomiting
• pain at night/following meals

Question 8

what is the diagnostic modality of choice for cholelithiasis

Answer 8

Abdominal US

can follow up with CT

Question 9

what is the treatment of choice for cholelithiasis

Answer 9

laparoscopic cholecystectomy

give NSAIDs for pain

Question 10

when do you treat cholelithiasis

Answer 10

only when symptomatic

Question 11

What is an intraoperative cholangiogram?

Answer 11

An Xray of your bile ducts, usually done during a cholecystectomy.Viewing the bile ducts before removal of gallbladder helps ensure the surgeon does not accidentally cut or damage CBD.

Question 12

what is the nonsurgical treatment for symptomatic cholelithiasis

Answer 12

Ursodeoxycholic acid (Ursodiol, Actigall)

for NONsurgical canditates

Question 13

what is the MC cause of cholecystitis

Answer 13

gallstones (get lodged in cystic duct)

Question 14

what is the presentation of cholecystitis

Answer 14

• ill appearing
• RUQ pain rad to shoulder
• fever, tachycardia, NV
• • murphys sign

Question 15

what laboratory findings will you see in cholecystitis

Answer 15

• leukocytosis w L shift
• high serum bilirubin

Question 16

what is the first line diagnotic for cholecystitis and what would it show

Answer 16

• abdominal US
• shows stone lodged in cystic duct and wall thickening (>4-5mm)

Question 17

If abdominal US is positive what diagnostic modality should be used to confirm diagnosis

Answer 17

HIDA scan

Question 18

what is the treatment plan for cholecystitis

Answer 18

1. admit for IV pip/taz OR cipro+metro
2. lap chole w/i 24 hours.

Question 19

Continuous or progression of RUQ abd pain, tenderness, muscle guarding, fever, leukocytosis after 24-48 hours

Answer 19

Gangrenous Gallbladder

Question 20

calcification of the gallbladder wall suggests what diagnosis

Answer 20

porcelain gallbladder

Question 21

what is choledocolithiasis

Answer 21

gallstone in COMMON bile duct

Question 22

what are the symptoms of choledocolithiasis

Answer 22

• RUQ pain
• Jaundice (sometimes w/o other symptoms)
• N/V
• epigastic ternderness

Question 24

what lab findings would you see in choledocolithiasis

Answer 24

• high AST/ALT
• high Alk phos
• high GGT
• hyperbilirubinemia

Question 25

what is the first line diagnostic for choledocolithiasis

what would it show

Answer 25

transabdominal US showing CBD dilation and impaired flow with stones.

Question 26

what is the treatment of choice for choledocolithiasis

Answer 26

ERCP with sphincterotomy and stone extraction/stent replacement

Question 27

What is cholangitis

Answer 27

inflammation of the common bile duct

Question 28

what is the MCC of cholangitis

Answer 28

obstruction with e coli infection

Question 29

what is the clinical presentation of acute cholangitis

Answer 29

charcots triad:
1. jaundice
2. RUQ pain
3. fever

reynolds pentad adds hypotension and AMS!

Question 30

what laboratory results wil be positive in cholangitis

Answer 30

• leukocytosis
• ^CRP/ESR
• ^Alk phos and bilirubin
• AST/ALT

Question 31

what is the diagnostic procedure of choice for acute cholangitis

Answer 31

ERCP

this is also the treatment obv

Question 32

what is the MC complication of ERCP

Answer 32

pancreatitis

Question 33

what additional treatment is used for acute cholangitis

Answer 33

1. ERCP
2. lap chole after
3. IV ABX w pip/taz + metro OR cipro+metro

Question 34

if you see beads on a string on MRCP what is the likely diagnosis

Answer 34

primary sclerosing cholangitis

Question 35

what medication is used in patients undergoing rapid weight loss to prevent gallstone formation

Answer 35

ursodeoxycholic acid (bile salt)

Question 36

what is the MC cause of pancreatitis

Answer 36

• gallstone MC
• heavy alcoholism next common

Question 37

what is the clinical presentation of pancreatitis

Answer 37

• epigastric abdominal pain radiating to the back. improves w leaning forward
• NV
• fever, weakness, sweating

Question 38

what diagnostics are used for pancreatitis diagnosis

Answer 38

serum amylase and lipase elevation.

Question 39

what is the treatment for pancreatitis

Answer 39

• mild - NPO, NG tube, hydromorphone
• severe - admit to ICU and get surgical consult

Question 40

what antibiotic is indicated in a patient with a pancreatitis abscess

Answer 40

imipenem