Clinical DSA 3: Hepatobiliary - Biliary Tree and Gallbladder Flashcards
Presentation is consistent with which diagnosis?
Acute onset RUQ or epigastric pain that worsens after meals
Pain radiates to rt scapula
+N/V
Cholelithiasis (symptomatic)
many gallstones are asymptomatic
RUQ ultrasound that shows an “acoustic shadow” is suggestive of
Cholelithiasis
*RUQ US is the best diagnostic test for gallstones
Protective factors that help prevent gallstones
Cardiorespiratory fitness/Physical activity
Low carb diet
Caffeine (in women)
High intake of Mg and unsaturated fats (men)
High fiber diet
Statin therapy
ASA and NSAIDs
Risk factors for cholelithiasis (6 Fs)
Family history Fair Fat Female Fertile Forty
Presentation is consistent with which diagnosis?
Gallstone in cystic duct on RUQ US
RUQ pain worsens after meals
Tea colored urine or acholic (pale) stools
Leukocytosis, hyperbilirubinemia, increased ALP and GGT
Acute cholecystitis
*RUQ US may also show gallbladder wall thickening and provide a sonographic Murphy sign
Treatment for acute cholecystitis
Lap chole
NPO, Abx, pain meds, IVF
Complications of acute cholecystitis
Gangrene of the gallbladder (may lead to perf, abscess, peritonitis)
Emphysematous cholecystitis (secondary infection with gas producing organism, diabetes is risk factor!)
Who is at risk of emphysematous cholecystitis?
A diabetes mellitus patient with acute cholecystitis
Presentation is consistent with which diagnosis?
Acute cholecystitis without the presence of stones
Acute acalculous cholecystitis (acalculous = without stones)
*caused by gallbladder trauma, burns or infection
Presentation is consistent with which diagnosis?
May be asymptomatic for years
Repeated acute or subacute cholecystitis, or prolonged irritation of the gallbladder
Porcelain gallbladder seen on xray
Chronic cholecystitis
*Porcelain gallbladder = incidental calcified lesion of gallbladder seen on xray
When should cholecystectomy be done on a pt with chronic cholecystitis?
symptomatic chronic cholecystitis or porcelain gallbladder
Porcelain (calcified) gallbladder is a risk factor for
gallbladder cancer (poor prognosis)
What is a Courvoisier’s sign?
Enlarged, palpable nontender gallbladder with jaundice secondary to a tumor on the head of the pancreas
Presentation is consistent with which diagnosis?
Stones in the common bile duct
Frequently recurring severe RUQ pain, fever and chills
Jaundice (direct hyperbilirubinemia)
AST/ALT elevations
Choledocholithiasis
What can arise secondary to choledocholithiasis?
pancreatitis
*will see elevated serum lipase and amylase
Treatment of choice for choledocholithiasis
ERCP with sphincterectomy and stone extraction/ stent placement
- diagnostic and therapeutic
- can also do cholecystectomy
What should be done prior to ERCP?
*INR
Pregnancy test
Kidney function (BUN, Cr) due to contrast
Complication of choledocholithiasis
acute ascending cholangitis
Presentation is consistent with which diagnosis?
Pt with choledocholithiasis RUQ pain, fever, jaundice (Charcot triad) [+altered mental status, hypotension (Reynold pentad] Leukocytosis \+ blood cultures Increased ALT/AST Increased ALP and GGT Direct hyperbilirubinemia
Ascending cholangitis
*Reynold pentad signifies acute suppurative cholangitis (emergeny endoscopy!)
Complications of ascending cholangitis
Acute pancreatitis from ERCP
*serial lipase monitoring post ERCP for prevention
Treatment for ascending cholangitis
ERCP with sphincterectomy and stone extraction/ stent placement
culture bile after sample taken
*measure INR before procedure!!!!
Charcot triad
RUQ, fever, jaundice
*suggests ascending cholangitis
Reynold pentad
Charcot triad (RUQ, fever, jaundice) + altered mental status and hypotension
*suggests acute suppurative cholangitis
Presentation is consistent with which diagnosis?
Frustrated pt with episodic RUQ pain + nausea that affects ADLs
Normal RUQ US and labs
CCK-HIDA scan shows abnormal ejection fraction (<35-38%)
Biliary dyskinesia
(functional disorder of gallbladder with unknown etiology)
*if dx confirmed by CCK-HIDA, cut that sucker out
Presentation is consistent with which diagnosis?
Male patient with IBD (ulcerative colitis) Pruritis, fatugue and jaundice RUQ pain MRCP or ERCP shows "beads on a string" Liver biopsy shows "onion skinning"
Primary sclerosing cholangitis
Treatment for primary sclerosing cholangitis
No proven therapy exists :(
Treat symptoms
Consider liver transplant
Complications of primary sclerosing cholangitis
*Cholangiocarcinoma risk
Colon ca risk (from UC)
Ascending cholangitis
Presentation is consistent with which diagnosis?
Asymptomatic with isolated elevation in ALP
Elevated GGT
Antimitochondrial abs (AMA)
Pruritus, jaundice, xanthelasma***
Primary biliary cholangitis
(autoimmune destruction of small intrahepatic bile ducts)
Risk factors include UTIs, smoking, HRT, hair dye use
