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GI 2 > Clin Med - Gallbladder & Pancreas > Flashcards

Clin Med - Gallbladder & Pancreas Flashcards

1
Q

Cholelithiasis

A

The condition of having stones in the gall bladder

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2
Q

Two types of gallbladder stones

A
  • Cholesterol

- Pigmented (have bilirubin)

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3
Q

Cholelithiasis Risk Factors

A
  • Increasing age (over 40)
  • Females more prevalent than males
  • Pregnancy
  • Oral Estrogens (BCP and HRT)
  • Diabetes (esp. Type 2)
  • Obesity
  • Familial tendency
  • Rapid weight loss (diet or surgery)
  • Excessive alcohol consumption
  • Native Americans and Mexican Americans
  • Cirrhosis
  • Hemolytic anemia-sickle cell
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4
Q

Cholelithiasis – Clinical Manifestations

A

-Most are asymptomatic (up to 15% of people have asx stones)

In symptomatic patients:

  • No fever or low grade fever
  • Lab tests: no leukocytosis or mildly elevated
  • ROS may reveal recent bloating, fullness, maybe nausea
  • Episodic pain
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5
Q

Describe episodic pain with cholelithiasis

A
  • D/t intermittent obstruction of the cystic duct.
  • Pain in RUQ with radiation to right side of back or right shoulder (phrenic N irritation)
  • Pain can be nocturnal.
  • Pain is described as wavelike, cramping pain that develops between 15 minutes - 2 hours after eating a fatty meal.
  • Pain may last up to 4 hours with concomitant nausea and vomiting;

*physical exam is normal between episodes

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6
Q

Complications - Cholelithiasis

A
  • Acute cholecystitis
  • Chronic cholecystitis
  • Common bile duct stones
  • Cholangitis
  • Pancreatitis
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7
Q

Cholelithiasis - Diagnosistic Tests

A
  • US
  • HIDA scan
  • CT/MRI
  • ERCP
  • Oral cholecystography
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8
Q

Cholelithiasis - Diagnosis (HIDA scan)

A

Hepatobiliary scintigraphy (HIDA): radioactive substance and cholecystokinin injected venously to test contractility and bile secretion of gb

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9
Q

Cholelithiasis - Diagnosis (US)

A

Greater than 95% sensitivity in detecting gallstones

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10
Q

Cholelithiasis - Diagnosis (ERCP)

A

Endoscopic Retrograde CholangioPancreatography (ERCP): rarely performed without therapeutic intent, i.e. to remove stone from bile duct

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11
Q

Cholelithiasis - Tx

A

-If asymptomatic and patient healthy, the gallstones should be left alone (treat nausea, keep them NPO, treat dehydration, etc.)

Surgical therapy –> some patients will opt to do this

  • -Laparoscopic cholecystectomy: Rx of choice
  • -Open cholecystectomy: painful recovery; longer hospital stay
  • Nonsurgical therapy
  • Ursodeoxycholic acid (UCDA or ursodiol)-decreases cholesterol absorption, dissolves stones (Stones greater than 1.5 cm or pigmented stones are not responsive to treatment via this method.)
  • -Expensive and symptoms reoccur when drug is stopped.
  • Extracorporeal shock wave lithotripsy
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12
Q

Acute Cholecystitis

A

Due to sustained (several hours) obstruction of the cystic duct, from a stone or sludge.

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13
Q

Acute Cholecystitis - Manifestations

A
  • Pain is severe, located in the RUQ, but can start as mid-epigastric pain that refers to RUQ as well as right shoulder (lasts longer than 6 hours).
  • On exam, there is RUQ tenderness with positive Murphy’s sign; also guarding and rebound.
  • Loss of appetite, malaise, nausea and vomiting.
  • Fever may be present.
  • Lab tests reveal a leukocytosis and mild elevation in liver function tests.
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14
Q

Acute Cholecystitis - Diagnosis

A

Ultrasonography - detect stones, gallbladder wall thickening, or pericholecystic fluid.
Pericholecystic fluid is highly specific for acute cholecystitis and not chronic disease.

HIDA scan - uses a radioactive isotope to detect obstruction of cystic duct.
–Failure of the isotope to appear in the gallbladder in 4 hours is highly specific for acute cholecystitis.

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15
Q

Acute Cholecystitis - Treatment

A
  • Laparoscopic cholecystectomy
  • Open cholecystectomy
  • Broad-spectrum antibiotics: cephalosporins, -floxacins, possibly vancomycin
  • Probable organisms:
    1. Gram-negative bacilli: E coli , Klebsiella, and Enterobacter
    2. Gram-positive cocci: Enterococcus;
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16
Q

HIDA Scan

A

A radioactive tracer is injected through any accessible vein, then allowed to circulate to the liver, where it is excreted into the biliary system and stored by the gallbladder and biliary system.

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17
Q

When should the gallbladder be visualized on the HIDA scan?

A

A healthy gallbladder should be visualized within 1 hour of the injection of the radioactive tracer.

If the gallbladder is not visualized within 4 hours after the injection, this indicates either cholecystitis or cystic duct obstruction.

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18
Q

First line diagnostic test for acute cholecystitis

A

Ultrasound is first line, then HIDA with continued RUQ pain without known etiology.

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19
Q

What is the physical exam finding associated with acute cholecystitis?

A

Murphy’s Sign

20
Q

Chronic Cholecystitis Characteristics

A
  • Episodes of mid-epigastric/RUQ pain in a patient with known gall bladder disease
  • May not be a good candidate for surgery due to age or other diseases
  • Treat conservatively unless signs of acute infection
21
Q

Cholangitis Definition

A

Also called ascending cholangitis or acute cholangitis. A medical emergency

Usually arises from bacteria in the duodenum ascending back into the common bile duct, usually because of a gallstone obstruction.

22
Q

Cholangitis can be caused by

A
  • benign stricture
  • post operative narrowing (d/t any surgery around the liver or gallbladder)
  • cancer of gb, bile duct, pancreas, or duodenum
  • ERCP
23
Q

Cholangitis Symptoms

A
  • abdominal pain, fever, jaundice (Charcot’s triad)
  • also can see hypotension and mental confusion;
  • can rapidly develop septic shock and multiple organ failure, esp. kidney and respiratory.
24
Q

Cholangitis Diagnosis

A
  • elevated wbc and CRP(inflamm. marker)
  • elevated LFT’s as in obstruction: bili, alk phos, y-glutamyl transpeptidase.
  • early on, you may look like hepatitis with elevated ALT and AST
  • *Gold standard is ERCP with intent to remove stone
  • U/S and MRCP also used but can miss stone in the common bile duct.
25
Q

Cholangitis Tx

A
  • Hosp. w/ IV fluids

- Broad spectrum antibiotics until cultures back (PCN, aminogycosides, ciprofloxan, metronidazole; rx 7-10 days)

26
Q

Cholangitis - Possible Organisms

A

Gram-negative bacilli: E coli , Klebsiella, and Enterobacter

Gram-positive cocci, Enterococcus

27
Q

Acute pancreatitis is…

A

Inflammatory disease of the pancreas.

28
Q

Acute pancreatitis etiology

A
  1. Heavy alcohol - most common cause
  2. Gallstones are the 2nd most common cause
  3. Metabolic: hypertriglyceridemia, 3rd most common
  4. Pancreatic obstruction-stones, CA
  5. Drugs/toxins
29
Q

Acute pancreatitis drugs/toxins

A

-Major drugs involve the immunosuppressants (azathioprine), Didanosene(for HIV), furosemide (diuretic), angiotensin-converting enzyme (ACE) inhibitors, and estrogens.

Due to activation of digestive enzymes and autodigestion.

30
Q

Acute Pancreatitis - Clinical Manifestations

A

These patients are usually very sick!! May be emergency situation.

Patients typically present with abdominal pain, nausea, and vomiting.

  • Quickly become dehydrated!
  • Pain is constant, located in the epigastric region with radiation to the mid back (straight through to the back); described as “boring pain”
  • Abdominal examination results vary from minimal tenderness to marked generalized rebound tenderness with guarding and rigidity.
  • Bowel sounds may be diminished.
  • In severe necrotizing pancreatitis, may note large ecchymoses on the flanks (Grey Turner’s sign) or periumbilical (Cullen’s sign).
31
Q

Acute Pancreatitis Lab Results

A

*Elevated serum amylase and lipase

  • Elevated serum amylase noted the first 2 to 12 hours with a decrease in levels over 3 to 5 days.
  • Elevated serum lipase noted first 12 hours with decreasing levels over 7 to 10 days.
  • Amylase and lipase are also elevated in intestinal injury/obstruction, biliary stone, and renal failure.
32
Q

Acute Pancreatitis Lab Results - other findings

A
  • Leukocytosis
  • Mild hyperglycemia
  • Hypocalcemia
  • Elevated serum bilirubin, alkaline phosphatase, and transaminases.
33
Q

Acute Pancreatitis Diagnosis

A

Ultrasound/CT scan

  • Ultrasound may note presence of gallstones and pancreatic edema.
  • CT scan is used to evaluate the extent and local complications.
34
Q

Acute Pancreatitis Tx

A
  • *Hospitalization is a necessity**
  • Main goal is supportive care.
  • Maintain fluid balance.
  • No oral fluids or food until abdominal pain resolved.
  • Pain control
  • Monitor kidney and respiratory functions
  • If gallstones are present, cholecystectomy is indicated.
  • Abstain from alcohol.
35
Q

What must be established in order to treat acute pancreatitis?

A
  • Must establish severity of pancreatitis to predict course and risk for complications.
  • Ranson’s criteria are commonly used.
  • -Patients with fewer than two criteria have a 1% mortality rate.
  • -Presence of three of more of the criteria predicts a complicated clinical course.
36
Q

What are the 2 local complications of acute pancreatitis?

A
  • Pancreatic necrosis

- Pseudocysts

37
Q

Acute pancreatitis local complications - pancreatic necrosis

A
  • Noted in patients who worsen after initial improvement.
  • Will develop signs of sepsis: fever, marked leukocytosis, and positive blood cultures (sepsis)

Treatment includes CT guided aspiration of fluid, and antibiotics.
-Antibiotics include imipenem, fluoroquinolones, and metronidazole.

38
Q

Acute pancreatitis local complications - pseudocysts

A
  • Noted in patients who show evidence of persistent pancreatitis
  • Diagnosis made with ultrasound or CT scan.
  • Small cysts will resolve without treatment, larger cysts require surgical drainage.
39
Q

What are the 2 Acute Pancreatitis systemic complications?

A

Renal failure

Respiratory failure

40
Q

Acute pancreatitis systemic complications - renal failure

A

As a result of hypovolemia and decreased renal perfusion.

41
Q

Acute pancreatitis systemic complications - respiratory failure

A
  • May develop acute respiratory distress syndrome.

- Respiratory insufficiency that is seen in acute pancreatitis is mediated through triglyceride elevations.

42
Q

Chronic Pancreatitis General

A
  • Permanent and progressive damage to the pancreas.
  • -Intermittent attacks of acute pancreatitis.
  • Major cause is alcohol consumption.
  • Also failure to decrease triglycerides and cholesterol
43
Q

Chronic Pancreatitis Clinical Manifestations

A
  • Abdominal pain is the major symptom - pain may improve as severity of pancreatitis worsens.
  • Other symptoms include weight loss, diarrhea and steatorrhea (secondary to malabsorption), and development of diabetes mellitus.
44
Q

Chronic Pancreatitis - Diagnosis

A

Suggested by history and confirmed by measurement of pancreatic function.

Assessment of pancreatic exocrine function

  • -72-hour fecal fat
  • -Secretin or cholecystokinin stimulation test

Assessment of pancreatic structure

  • -Plain abdominal x-ray to evaluate for calcification of the pancreas.
  • -Ultrasound
  • -ERCP is the most sensitive and specific test for the diagnosis of chronic pancreatitis.
45
Q

Chronic Pancreatitis Tx

A
  • Avoidance of alcohol.

- Pain control - opiates may be needed.

46
Q

Management of pancreatic insufficiency

A
  • Pancreatic enzyme replacement used to control steatorrhea.

- Dietary fat should also be reduced.

47
Q

Pancreatic Cancer

A
  • The 5th leading cause of cancer in the US.
  • There are no symptoms in the early stages.

As it develops, patients usually complain of:

  • Pain in the abdomen or middle back
  • -Not as severe as in acute pancreatitis!
  • Fatigue, weight loss, loss of appetite, nausea;
  • Dark urine, icteric(yellow) sclerae and skin, due to obstructive jaundice;
  • Fluid in the abdomen

This cancer still has a high 5-yr mortality rate.

GI 2 (11 decks)

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