Clinical DSA 3: Hepatobiliary - Biliary Tree and Gallbladder

Question 1

Presentation is consistent with which diagnosis?

Acute onset RUQ or epigastric pain that worsens after meals
Pain radiates to rt scapula
+N/V

Answer 1

Cholelithiasis (symptomatic)

many gallstones are asymptomatic

Question 2

RUQ ultrasound that shows an “acoustic shadow” is suggestive of

Answer 2

Cholelithiasis

*RUQ US is the best diagnostic test for gallstones

Question 3

Protective factors that help prevent gallstones

Answer 3

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

Question 4

Risk factors for cholelithiasis (6 Fs)

Answer 4

Family history
Fair
Fat
Female
Fertile
Forty

Question 5

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

Answer 5

Acute cholecystitis

*RUQ US may also show gallbladder wall thickening and provide a sonographic Murphy sign

Question 6

Treatment for acute cholecystitis

Answer 6

Lap chole

NPO, Abx, pain meds, IVF

Question 7

Complications of acute cholecystitis

Answer 7

Gangrene of the gallbladder (may lead to perf, abscess, peritonitis)

Emphysematous cholecystitis (secondary infection with gas producing organism, diabetes is risk factor!)

Question 8

Who is at risk of emphysematous cholecystitis?

Answer 8

A diabetes mellitus patient with acute cholecystitis

Question 9

Presentation is consistent with which diagnosis?

Acute cholecystitis without the presence of stones

Answer 9

Acute acalculous cholecystitis (acalculous = without stones)

*caused by gallbladder trauma, burns or infection

Question 10

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

Answer 10

Chronic cholecystitis

*Porcelain gallbladder = incidental calcified lesion of gallbladder seen on xray

Question 11

When should cholecystectomy be done on a pt with chronic cholecystitis?

Answer 11

symptomatic chronic cholecystitis or porcelain gallbladder

Question 12

Porcelain (calcified) gallbladder is a risk factor for

Answer 12

gallbladder cancer (poor prognosis)

Question 13

What is a Courvoisier’s sign?

Answer 13

Enlarged, palpable nontender gallbladder with jaundice secondary to a tumor on the head of the pancreas

Question 14

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

Answer 14

Choledocholithiasis

Question 15

What can arise secondary to choledocholithiasis?

Answer 15

pancreatitis

*will see elevated serum lipase and amylase

Question 16

Treatment of choice for choledocholithiasis

Answer 16

ERCP with sphincterectomy and stone extraction/ stent placement

• diagnostic and therapeutic
• can also do cholecystectomy

Question 17

What should be done prior to ERCP?

Answer 17

*INR
Pregnancy test
Kidney function (BUN, Cr) due to contrast

Question 18

Complication of choledocholithiasis

Answer 18

acute ascending cholangitis

Question 19

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

Answer 19

Ascending cholangitis

*Reynold pentad signifies acute suppurative cholangitis (emergeny endoscopy!)

Question 20

Complications of ascending cholangitis

Answer 20

Acute pancreatitis from ERCP

*serial lipase monitoring post ERCP for prevention

Question 21

Treatment for ascending cholangitis

Answer 21

ERCP with sphincterectomy and stone extraction/ stent placement

culture bile after sample taken

*measure INR before procedure!!!!

Question 22

Charcot triad

Answer 22

RUQ, fever, jaundice

*suggests ascending cholangitis

Question 23

Reynold pentad

Answer 23

Charcot triad (RUQ, fever, jaundice) + altered mental status and hypotension

*suggests acute suppurative cholangitis

Question 24

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%)

Answer 24

Biliary dyskinesia

(functional disorder of gallbladder with unknown etiology)

*if dx confirmed by CCK-HIDA, cut that sucker out

Question 25

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"

Answer 25

Primary sclerosing cholangitis

Question 26

Treatment for primary sclerosing cholangitis

Answer 26

No proven therapy exists :(

Treat symptoms

Consider liver transplant

Question 27

Complications of primary sclerosing cholangitis

Answer 27

*Cholangiocarcinoma risk

Colon ca risk (from UC)

Ascending cholangitis

Question 28

Presentation is consistent with which diagnosis?

Asymptomatic with isolated elevation in ALP
Elevated GGT
Antimitochondrial abs (AMA)
Pruritus, jaundice, xanthelasma***

Answer 28

Primary biliary cholangitis

(autoimmune destruction of small intrahepatic bile ducts)

Risk factors include UTIs, smoking, HRT, hair dye use