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Spring Round II Exams > clin med- third set lectures > Flashcards

clin med- third set lectures Flashcards

1
Q

Cystic duct comes from:

A

gallbladder

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2
Q

Common hepatic duct comes from:

A

liver

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3
Q

Common bile duct consists of:

A

Cystic and Common Hepatic duct joining.

The Common bile duct then empties into duodenum thru sphincter of Oddi

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4
Q

What organ does the Common bile duct pass thru before it empties into duodenum?

A

Pancreas

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5
Q

Who makes bile?

A

Liver

then stored and concentrated in the Gallbladder

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6
Q

Function of bile

A

Digest/absorb fats

Vehicle to excrete: bilirubin, extra cholesterol, and met byproducts

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7
Q

inflammation of the BILE DUCTS

A

Cholangitis

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8
Q

Inflammation of the Gallbladder

A

Cholecystitis

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9
Q

Stones in the Gallbladder

A

Cholelithiasis

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10
Q

Stones in the Common Bile Duct

A

CholeDOCHOlithiasis

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11
Q

Disruption of bile flow

A

Cholestasis

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12
Q

The Four F’s of Cholelithiasis (Gallstones)

Risk factors

A

Female
Fluffy
Forty
Fertile

Also: Pregnant, Estrogen use, Rapid weight loss, Fam hx/genetics, DM

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13
Q

What type of stone is most common?

A

Cholesterol

other types: Pigment, Black pigment (underlying hemolytic anemia), Brown pigment (bacterial infection)

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14
Q

Do most gallstone pts have sx?

A

NO

If they do, Biliary colic and possibly leading to Gallstone related complications

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15
Q

Test of choice for Cholelithiasis (gallstones)

A

US

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16
Q

Do you have to treat Gallstones if you have no sx?

A

No, UNLESS:

  • increased risk of GB CA
  • Hemolytic disorder
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17
Q

Uncomplicated Gallstone dz

A

Biliary colic in the absence of complications

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18
Q

Biliary colic

NO gallbladder inflammation

A

Gallbladder contracts forcing stone/sludge against GB outlet or duct opening, increased pressure–> pain, pain slowly subsides as gallbladder relaxes

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19
Q

Biliary colic sx

A

RUG or epigastric pain radiates to R shoulder blade

constant and steady
at least 30 min, often peak at 1 hour

post-prandial

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20
Q

Other sx with Biliary colic

A

n/v
diaphoresis

unchanged by movement
Nocturnal pain common (awakes pt from sleep)

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21
Q

Biliary colic PE

A

NO FEVER or tachy
vitals normal
no jaundice
Negative murphys

Basically, everything is normal besides

POSSIBLE RUQ or EPIGASTRIC tenderness

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22
Q

Biliary colic

order labs and US

A

labs: normal
US: expect Gallstones or Sludge

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23
Q

If pt has Stones and Biliary colic

A

Cholecystectomy recommended

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24
Q

Functional Gallbladder disorder

gallbladder DYSMOTILITY

A

Biliary type pain but NO stones, sludge, or dz

Normal labs, Normal imaging

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25
Q

Functional Gallbladder disorder dx

look at Ejection Fraction via HIDA scan

A

Diagnosis of exclusion

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26
Q

HIDA scan tells Ejection Fraction

CCK given to stimulate gallbladder contraction, if ejection fraction is <35-40%

A

Considered LOW

Supports dx of Functional gallbladder dz

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27
Q

Rome 4 Criteria required for Functional GB dz

A

Biliary Pain
Absence of stones or other structural path

Supportive:
Low EF, Normal liver enzymes

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28
Q

Biliary colic type pain must last at least

A

30 minutes

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29
Q

Tx for Functional gallbladder dz if EF <40

A

Cholecystectomy

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30
Q

Complicated gallstone dz

A

Cholecystitis
CholeDOCHOlithiasis
Acute cholangitis

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31
Q

Acute calculous cholecystitis

A

acute inflammation of gallbladder

usually a COMPLICATION from a STONE

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32
Q

What does Acalculous vs Calculous cholecystitis mean?

A

Acalculous: no obstruction

Calclous: occurs in the setting of Cystic duct obstruction

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33
Q

Starts with biliary pain that prog worsens

Prolonged >4-6 hours, steady, severe, RUQ or epigastric pain

FEVER

A

sx of Acute calculous Cholecystitis

can also have n/v, anorexia, radiating to r shoulder, often hx of fatty food eating

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34
Q

PE of Acute calculous cholecystitis

A 
FEVER, tachy
Ill appearing
Lying still
Guarding
\+ Murphy's sign
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35
Q

Acute calculous Cholecystitis labs

A

+Leukocytosis w left shift

anytime we see “itis”, have an elevated WBC

36
Q

Elevated AMYLASE usually associated w

A

Pancreatitis

37
Q

If Total Bili and Alk Phos (ALP) are elevated, we should be concerned about

A

Cholangitis
Choledocholithiasis

both of which can result in Biliary obstruction

38
Q

Dx Acute calculous cholecystitis

A

US preferred initial

Can progress to HIDA if above not helpful

39
Q

+ “Sonographic Murphy’s sign”

A

US tech produced Murphy’s pain while obtaining the US

40
Q

Most common Complication of acute calculous cholecystitis

A

Gangrene

41
Q

Acute calculous cholecystitis tx

A

Admit, NPO, IVF, Pain meds, IV empiric Abx

Mainstay: CHOLECYSTECTOMY

42
Q

Gallbladder inflammation
Leukocytosis
RUQ pain
Fever

A

Acute Cholecystitis

43
Q

Acute ACALCULOUS Cholecystitis

A

Acute necro-inflammatory dz of gallbladder in ABSENCE of stones

High morbidity/mortality

44
Q

Pathogenesis of Acute ACALCULOUS cholecystitis

A

gallbladder stasis/ischemia –> local inf response

secondary bacterial infection is common

perforation in severe cases

45
Q

Acute ACALCULOUS cholecystisi

A

Hospitalized and Critically ill people

may have sepsis or jaundice

46
Q

Suspect Acalculous cholecystitis in

A

Critically ill, sepsis without clear source of jaundice

Post op jaundice

47
Q

Acalculous Cholecystitis tx

A

Start Abx

Cholecystectomy vs Gallbladder drainage

48
Q

Choledocholithiasis

A

Gallstones in Common bile duct

incidence increases w age

JAUNDICE if blocking flow of bile

49
Q

Biliary type pain and JAUNDICE

Vitals normal
RUQ /epigastric pain

Courvoiser sign (palpable gallbladder)

A

be thinking CholeDOCHOlithiasis

stone in common bile duct

50
Q

Choledocholithiasis labs

early vs late dz

A

early: elevated ALT and AST
late: elevated Bili, ALP, and GGT

51
Q

for Choledocholithiasis, if US is not helpful, next consider

A

MRCP or Endoscopic US

52
Q

What is the test to CONFIRM Choledocholithiasis (common bile duct stone)

A

MRCP

53
Q

Tx of Choledocholithiasis

A

ERCP is therapeutic and diagnostic !!

Cholecystectomy to follow if appropriate

54
Q

Acute cholangitis

A

Charcot’s triad:

Fever
RUQ pain
Jaundice

55
Q

Bacteria ascending from duodenum can cause

A

Acute cholangitis

“pus under pressure” surgical emergency

56
Q

Reynold’s Pentad

like Charcot triad, but more

A

+ AMS and Hypotension

57
Q

Reynold’s Pentad

A 
Fever
RUQ pain
Jaundice
AMS
Hypotension (low BP)

High morbidity and mortality

58
Q

Acute cholangitis Labs

A

Leuk w/ left shift
Elev CRP/ESR

Evidence of cholestasis: elevated Bili, ALP, GGT, maybe AST/ALT

Serum amylase/lipase can be 3-4x elevated (associated pancreatitis)

59
Q

Acute cholangitis tx

A

Admit
Monitor/tx for Sepsis
(EMPIRIC ABX)
Emergent consult w GI and Surgery

ERCP !!!

60
Q

Acute cholangitis procedural tx

A

ERCP w/Sphincterotomy and stone extraction

Cholecystectomy after prn

61
Q

Progression of gallbladder dz, increasing severity

A 
A-sx gallstones
Sx gallstones
Acute cholecystitis
Chole-docholithiasis
Acute Cholangitis
62
Q

Tx for Gallstones and Acute cholecystitis

A

Cholecystectomy

with cholecystitis, add abx

63
Q

Tx for Choledocho and Acute cholangitis

A

ERCP w/stone extraction

For acute cholangitis, add Abx

64
Q

PBC: Primary Biliary Cholangitis

A

Women 30-65 YO

AUTOIMMUNE destruction of bile ducts in the Liver which cause Cholestasis

65
Q

Sx of PBC

A

Fatigue and Pruritis most common

Also, RUQ discomfort, skin hyperpigmentation, hepatomegaly, xanthomas, jaundice

Assoc w other autoimmune dz

66
Q

Autoimmune dz

A

be thinking of PBC- Primary Biliary Cholangitis

67
Q

PRURITIS and FATIGUE

A

PBC and PSC

68
Q

Elevated ALP
AMA !!!***
Hyperlipidemia may be strikingly elevated

A

Primary Biliary Cholangitis

AMA is a serologic hallmark of PBC

69
Q

Tx of PBC Primary Biliary Cholangitis

A

Refer to GI
Meds
Treat complications

70
Q

PSC Primary Sclerosing Cholangitis

A

Sclerosing, inflammatory, obliterative process involving Biliary tree

Chronic, progressive disorder

unknown etiology

71
Q

Higher incidence in MEN age ~40

Strong association with IBD (specifically ulcerative colitis)

A

Primary Sclerosing Cholangitis

72
Q

PSC

A

Men 40 YO

assoc w IBD (Ulcerative colitis)

73
Q

Complications of Primary Sclerosing Cholangitis

A

Cholestasis
End stage liver dz
Hepatobiliary CA
Colon CA

74
Q

Cholestatic pattern of liver labs

A

Elevated ALP, GGT, and Bili

75
Q

PSC primary sclerosing cholangitis labs

A

Elevated ALP, GGT, and Bili (cholestatic pattern)

but negative AMA

76
Q

What will you see on ERCP or MRCP with Primary sclerosing cholangitis?

A

Multifocal strictures and dilation of bile ducts

77
Q

Tx of PSC

A

Meds

Treat complications

78
Q

Gilbert syndrome

A 
Teen men (post puberty)
Unconjugated hyperbilirubinemia

Intermittent jaundice

79
Q

Gilbert syndrome

A

Deficiency in enzyme for Glucuronidation

NO hemolysis (CBC and other blood labs are normal)

80
Q

Presentation of Gilbert syndrome

A

Teen males
INTERMITTENT jaundice

Triggers: dehydration, fasting, menses

No specific tx

81
Q

Gallbladder CA

A

Most common CA of biliary tract
HIGHLY FATAL

often found incidentally

82
Q

Risk factors for GB CA

A

Porcelain bladder

83
Q

Cholangiocarcinoma (bile duct CA)

A

Arise from Epithelial cells of bile ducts

84
Q

CA that has jaundice, pruritis, Courvoiser sign

Cholestatic pattern labs

A

Cholangiocarcinoma

85
Q

Ampullary CA

A

Ampulla of Vater (right where it empties into duodenum)

Increased inc w FAP and HNPCC

86
Q

CA with these sx: Obstructive jaundice, occult GI bleed, microcytic anemia, abd pain

A

Ampullary CA

blocking where the GB usually empties into duodenum

Spring Round II Exams (10 decks)

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