Cholestatic disease that isnt gallstones

Question 1

Rate limiting step of bilirubin elimination?

Answer 1

UDP-glucuronosyltransferase
, the conjugating step

Question 2

What type of bilirubin would you see elevated in the case of a post hepatic jaundice?

Answer 2

DIRECT bilirubin

Question 3

Why is bile conjugated by hepatocytes?

Answer 3

Conjugation makes them more hydrophilic which makes them better for excretion

Question 4

On US you see the following: Pericholecystic fluid, thickened gallbladder wall, and gallstones

Most likely diagnosis

Answer 4

Acute cholecystitis

NO jaundice
POSITIVE murphy’s
RUQ pain

Question 5

Findings on US:
Pericholecystic fluid, thickened gallbladder wall, gallstones, and a dilated common bile duct

Most likely diagnosis?

Answer 5

Mirizzi’s syndrome, in which a gallstone obstructing the cystic duct (causing cholecystitis) also compresses and collapses the common bile duct (causing choledocholithiasis).

Question 6

On US: dialated CBD and gallstones in the gall bladder is consistent w/

Answer 6

Choledocolithiasis

Question 7

If a pt’s bilirubin is primarily conjugated, not unconjugated, is their problem pre, intra, or post hepatic?

Answer 7

conjugated hyperbilirubinemia, so this is a posthepatic problem

Question 8

predominantly unconjugated hyperbilirubinemia, are you looking for pre, intra, or post hepatic causes?

Answer 8

With predominantly unconjugated hyperbilirubinemia, you look for prehepatic causes—hematoma and hemolysis.

Question 9

Prehepatic causes of hyperbilirubinemia

Answer 9

Hemolysis or hemtoma

Question 10

CHronic cholestasis is normally caused by…

Answer 10

cancer, stricture, or an autoimmune cholangiopathies

Question 11

A lot of bilirubin accumulates (20s, 30s mg/dL) causing jaundice, dark urine, and, in cases of complete obstruction, clay-colored stools. All waste products in the bile accumulate, not just bilirubin. Pruritus is caused by bile acids. Xanthelasmas are caused by excess cholesterol. Unintended weight loss is likely due to cancer.

This is descriptive of…

Answer 11

Chronic cholestasis likely due to cancer, stricture, or one of the autoimmune cholangiopathies

Question 12

What is the difference in presentation between acute and chronic cholestasis?

Answer 12

Question 13

Modifiable and nonmodifiable risk factors for pancreatic cancer?

Answer 13

Modifiable risk factors are chronic pancreatitis and smoking cigarettes. Nonmodifiable risk factors are Ashkenazi descent and BRCA2 mutations.

Question 14

Where are pancreatic carcinomas normally found?

Answer 14

Head of the pancreas

Question 15

What serologic markers are used to monitor pancreatic cancer course?

Answer 15

CA 19-9 and CEA serologies

**Note that these are not diagnostic

Question 16

Pancreatic adenocarcinoma demonstrates mutations in ….

Answer 16

Pancreatic adenocarcinoma demonstrates mutations in KRAS (usually the first in the sequence), CDKN2A, and eventually p53.

Question 17

What surgery do we normally do for early disease state of pancreatic cancer?

Answer 17

Whipple (pancreaticoduodenectomy)

the procedure resects the entire pancreas (except the tail), the entire duodenum, the gallbladder and biliary tree near the cancer, the proximal jejunum, and the pyloric valve and antrum of the stomach. The remaining elements of the digestive unit are attached to the remaining jejunum—pancreaticojejunal, choledocojejunal, and gastrojejunal anastomoses.

Question 18

Answer 18

pancrearic adenocarcinoma

Question 19

Answer 19

Whipple procedure

Question 20

Answer 20

Cholangiocarcinoma

Question 21

When someone has a positive FIT but a negative colonoscopy, think of ______________________ and get an EGD. Treatment is with a Whipple procedure.

Answer 21

ampullary cancer (Carcinoma of the Hepatopancreatic Ampulla (“of Vater”))

Question 22

When BOTH cholecystitis and choledocholithiasis are present at the same time, think of …..

Answer 22

Mirizzi

Question 23

Answer 23

Mirrizzi

Question 24

What do we mean by “Obstructive Jaundice” ?

Answer 24

Obstructive jaundice is a colloquial term that refers to hyperbilirubinemia (elevated bilirubin in the blood deposits in the skin, causing jaundice, or yellowing of the skin) secondary to cholestasis (slowed or absent flow of bile through the biliary tree).

Question 25

Overview of pre, intra, and post hepatic causes of hyperbilirubinemia

Answer 25

Question 26

How do the work ups for acute vs chronic cholestasis differ?

Answer 26

Question 27

Trousseau’s sign

Answer 27

Migratory thrombophlebitis, s superficial vessel inflammation due to the formation of clots that appear and disappear in various areas.

Question 28

What predisposes a pt to acalculous cholecystitis?

Answer 28

recent surgery, severe trauma, mechanical ventialation, prolonged fasting or total parenteral nutrition

most often seen in hospitalized critically ill patients! It may be a cause of FEVER so watch out, its not one of the 5w’s.

Question 29

What labs are abnormal in a patient with primary sclerosing cholangitis?

Answer 29

Labs that are consistent with cholestasis so elevated alk phos, GGT, and bilirubin

Question 30

How do we dx primary sclerosing cholangitis?

Answer 30

MRCP which should show multifocal intrahepatic and/or extrahepatic biliary strictures and dialations

Question 31

a 32 asymptomatic male comes in with elevated Alk Phos, GGT, and bilirubin. Why might we want to get a colonoscopy for this guy?

Answer 31

This guy sounds like he has primary sclerosing cholangitis, we want a colonoscopy to check if he has underlying IBD which is associated with primary sclerosing cholangitis