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GI > Disorders of the Biliary Tract - Exam 4 > Flashcards

Disorders of the Biliary Tract - Exam 4 Flashcards

1
Q

What are the 2 components of the common bile duct?

A

common hepatic duct and cystic duct

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2
Q

**What are the components of the Calot’s triangle? Why is it important clinically?

A

Medial-common hepatic duct

Inferior-cystic duct

Superior-inferior surface of the liver

important to verify in a lap chole to take into account any anatomical variation and allow cystic duct/artery to be delineated

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3
Q

What is the main function of a gallbaldder?

A

concentrate and store bile that is produced in the liver

to release bile after a meal that contain fats

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4
Q

What is the physiology of bile? The presence of lipids in the duodenum stimulates the release of _____ which in turn stimulates ______ and relaxation of ______

A

cholecystokinin (CCK)

gallbladder wall contraction

Sphincter of Oddi

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5
Q

Where does bile get released? Then where does it go?

A

release of the bile into the cystic duct and common bile duct

Bile then flows into the second part of the duodenum and causes emulsification of large fat droplets into small ones (Micelles)

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6
Q

What are the 5 main functions of bile?

A
  1. Aids in the digestion of fat via fat emulsification
  2. Absorption of fat and fat-soluble vitamins
  3. Excretion of bilirubin and excess cholesterol
  4. Provides an alkaline fluid in the duodenum to neutralize the acidic pH of the chyme that comes from the stomach
  5. It provides bactericidal activity against microorganisms present in the ingested food
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7
Q

What 4 things are in bile? What is the highlighted one?

A

Water
**Cholesterol
Bile Salts
Bilirubin

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8
Q

_______ A hormone which is secreted by cells in the duodenum and stimulates the release of bile into the intestine and the secretion of enzymes by the pancreas. What is an additional role?

A

Cholecystokinin (CCK)

inhibits gastric emptying and also acts a hunger suppressant. stimulates bile production in liver

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9
Q

What is the effect of CCK on the GI tract?

A

Cholecystokinin is secreted by I-cells in the small intestine and induces contraction of the gallbladder
Relaxes the sphincter of Oddi, increases bile acid production in the liver
Delays gastric emptying
Induces digestive enzyme production in the pancreas.

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10
Q

Gallstones form as a result of what 3 processes?

A

Ratio of cholesterol too high

Ratio of bilirubin too high

Gallbladder not emptying bile enough

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11
Q

What are the 2 different types of gallstones? Which one is the MC?

A

Cholesterol gallstones - m/c

Calcium Bilirubinate (pigmented) gallstones

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12
Q

What is the technical name for gallstones? Are they MC in men or women?

A

Cholelithiasis

MC in women, think excess estrogen from pregnancy, hormone replacement and OCPs

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13
Q

A ____ diet and a ____ diet as well as physical activity and cardiorespiratory fitness may help prevent gallstones. _____ appears to protect gallstones in women

A

low-carb

Mediterranean

caffeinated coffee

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14
Q

What is another name for biliary colic? What is happening?

A

Symptomatic Cholelithiasis

Gallbladder contracts in response to stimulation, forces gallstones to move blocking the cystic duct

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15
Q

**What is the hallmark symptom for biliary colic? **What is important to note about the pt’s appearance? **Where does the pain often radiate?

A

**RUQ pain

**Pt do NOT appear ill, just intense, dull discomfort, often associated with diaphoresis, nausea and vomiting that is usually constant often followed by a fatty meal

**may radiate to the RIGHT shoulder blade

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16
Q

**What is the time frame associated with a biliary colic attack? **How long is the total attack?

A

The severe pain lasts about 30 minutes
Plateaus in an hour, total attack about 6 hours

usually episodic!

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17
Q

What will the lab results be like in cholelithiasis? Will the pt have any guarding?

A

Lab results generally wnl:

Cbc, LFTs, amylase/lipase, alkaline phosphatase

NO GUARDING!

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18
Q

**What is the imaging of choice for cholelithiasis?

A

Abdominal Ultrasound (RUQ)

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19
Q

What is the tx of choice for cholelithiasis? _____ are given for pain control

A

Laparoscopic Cholecystectomy

NSAIDs for pain control

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20
Q

Do you need to treat asymptomatic cholelithaisis?

A

NOPE!

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21
Q

When do you need to do prophylactic cholecystectomy in asymptomatic cholelithaisis?

A

gallbladder is calcified

stones 3cm or greater in diameter

or the patient is a Native American (d/t higher rate of cholesterol stones)

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22
Q

When can cholecystectomy be preformed in a pregnant person?

A

can be performed in 2nd trimester preferably in pregnant women after conservative approach fails for repeated attacks

threat of harm during 1st semester, DO NOT DUE IN FIRST TRIMESTER

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23
Q

What is the surgeon actively trying to avoid damaging when preforming an lap chole?

A

common bile duct

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24
Q

What is the pharm tx for cholelithiasis if pt is NOT a surgical candidate? What is it?

A

Ursodeoxycholic acid (Ursodiol, Actigall)

bile salt given PO for up to 2 years and helps to dissolve cholesterol stones

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25
Q

What are the 3 different types of cholecystitis?

A
  1. Acute Calculous Cholecystitis
  2. Acute Acalculous Cholecystitis
  3. Chronic Cholecystitis
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26
Q

______ is due to gallstones and with a sudden, severe onset. What is the MC cause?

A

Acute Calculous Cholecystitis

stones becomes lodged in cystic duct

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27
Q

______ results from gallbladder stasis and ischemia, which then causes a local inflammatory response in the gallbladder wall. When is it commonly seen? What secondary infection is common?

A

Acute Acalculous Cholecystitis

Generally seen in critically ill patients/post op after major surgery

E. coli

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28
Q

________ result of mechanical irritation or recurrent attacks of acute cholecystitis.
Episodes of biliary colic. Stone becomes lodged, inflammation of gallbladder develops, stone moves, symptoms resolve

A

chronic cholecystitis

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29
Q

What is the MC cause of acute cholecystitis? What happens next?

A

> 90% d/t gallstones

Stone becomes impacted at cystic duct, causes inflammation, inflammatory mediators are released in response

have the potential to get infected if the pt is immunocompromised

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30
Q

What is the common presentation for acute cholecystitis? **Where is the pain located? **How long will the pain be present?

A

**ILL APPEARING

RUQ pain: that will be steady, sharp and severe pain that is precipitated by fatty meal

**May present as epigastric or shoulder blade pain

** >4-6hrs, up to 18, lasts LONGER than 6 hours

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31
Q

Will the pt want to move in acute cholecystitis? Will there be guarding present?

A

the pt will NOT want to move

GUARDING WILL BE PRESENT

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32
Q

What is murphy sign?

A

Inhibition of inspiration by pain on palpation of RUQ
Ask pt to inspire deeply, which makes gallbladder descend toward and press against examining fingers leading to discomfort
Associated with muscle guarding and rebound tenderness

aka pain on inspiration

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33
Q

What will the lab findings be in acute cholecystitis?

A

Leukocytosis with left shift

elevated serum bilirubin, Aminotransferases, Alkaline Phosphatase are NOT COMMON

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34
Q

____ is the first line imaging in acute cholecystitis. What will it show?

A

Ultrasound

Stone lodged at cystic duct
Gallbladder wall thickening
Greater than 4-5mm

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35
Q

What is sonographic murphy’s sign?

A

similar to abdominal palpation except use an US probe so you can indeed verify that the source of the pain is the gallbladder

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36
Q

_____ is used in acute cholecystitis if US is inconclusive. more _____. What is a very good at showing?

A

HIDA scan

sensitive

Useful in showing an obstructed cystic duct

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37
Q

What is a HIDA scan? What is generically going on during the procedure? What are you looking for?

A

Hepatobiliary Iminodiacetic Acid Scan (Cholescintigraphy)

IV injection of Technetium-labeled iminodiacetic acid

liver takes up the dye, then watch move to gallbladder (15-30 minutes), biliary ducts, & duodenum (60 minutes)

watch for filling defects

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38
Q

What does a nonvisualized gallbladder indicate on a HIDA scan?

A

acute cholecystitis

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39
Q

HIDA scan can also measure _______. How does it work? What is considered normal? What is considered gallbladder disease?

A

gallbladder ejection fraction

Cholecystokinin (CCK) is injected which stimulates contraction of the gallbladder

Normal is considered 35-75%

< 35% is indicative of gallbladder disease

40
Q

What do you do if the gallbladder ejection fraction on HIDA scan is found to be less than 35%?

A

Indication for cholecystectomy

41
Q

What are indications for a HIDA scan?

A

and inconclusive US

42
Q

Is a HIDA scan safe in pregnancy? What is the pt education?

A

HIDA scan NOT safe in pregnancy

fast for 4 hrs before - can have clear liquids
need current list of medications

43
Q

What are the 5 complications of acute cholecystitis?

A

Gangrenous Gallbladder
Gallbladder perforation
Hydrops of the gallbladder
Mirizzi syndrome
Porcelain gallbladder

44
Q

______ results when acute cholecystitis subsides but cystic duct obstruction persists producing distention of the gallbladder with a clear mucoid fluid

A

Hydrops of the gallbladder

45
Q

______ stone in neck of gallbladder may compress common hepatic duct and cause jaundice. Seen as one of the five complications of acute cholecystitis

A

Mirizzi syndrome

46
Q

______ calcification of gallbladder wall due to chronic inflammation due to gallstones which results in scarring and calcification

A

Porcelain gallbladder

47
Q

What is this?

A

porcelain gallbladder

48
Q

What is the tx for acute cholecystitis?

A

ADMIT!!

IV Piperacillin/Tazobactam (Zosyn) OR
2nd or 3rd generation Cephalosporin or Cipro + metronidazole

NPO, IV fluids

IV meperidine or NSAIDs

lap cholecystectomy within 24- 48 hours

49
Q

What is the new tx for acute cholecystitis? Who is commonly used on?

A

Percutaneous cholecystostomy

Drainage under radiologic guidance via a percutaneous cholecystostomy tube
Decompressing the gallbladder allows both local inflammation and systemic illness to resolve. Tube left in place until resolved

high risk pts: elderly and dm

50
Q

What is choledocolithiasis?

A

occurs when gallstones are present in the common bile duct

51
Q

What is considered “uncomplicated” Choledocholithiasis? What is the MC symptom?

A

passes on their own

RUQ pain

52
Q

What is cholangitis?

A

gallstones becomes lodged and causes obstruction in common bile duct and then become infected!

53
Q

What is the MC pathogen to cause cholangitis? From what location?

A

E. Coli

ascend from the duodenum

54
Q

About ____ of patients with symptomatic gallstones will develop choledocolithiasis. Risk increases with _____

A

15%

risk increases with age

55
Q

Intermittent biliary colic symptoms (RUQ pain);
severe and persists for hours
Jaundice (sometimes without pain)
Intermittent N/V
Epigastric tenderness

What am I?

A

Choledocholithiasis

aka RUQ pain WITH jaundice

56
Q

in choledocholithiasis, _____ typically elevated early in course. Followed by ______, ______ and ______

A

AST/ALT

Alkaline Phosphatase, Gamma-glutamyl Transpeptidase

57
Q

______ is another enzyme found in liver that raises in response to liver damage/bile duct damage

A

GGT

58
Q

Patients are often suspected of having _______ when they present with RUQ pain with elevated liver enzymes with elevation of alkaline phosphatase, gamma-glutamyl transferase, and bilirubin. What is the imaging of choice?

A

choledocholithiasis

transabdominal U/S first

59
Q

What will an US show in Choledocholithiasis? Where is NOT good for visualization? Why?

A

Will show CBD dilation and impaired flow with stones

Has poor sensitivity for stones in the distal CBD

b/c distal CBD is often obscured by bowel gas in imaging field

60
Q

What is the tx of choice for Choledocholilithiasis?

A

ERCP with sphincterotomy and stone extraction/stent replacement

61
Q

Choledocholilithiasis with _______, _______ and or should go directly to ERCP with cholecystectomy

A

Acute Cholangitis

Hyperbilirubinemia (>4mg/dL) and CBD dilation

> 50% chance of CBD stone

62
Q

What are the 3 factors that qualifies as an intermediate risk for Choledocholilithiasis? What is the next step?

A

Abnormal LFTs
Age >55
Dilated CBD on US

Go to MRCP or EUS for confirmation
stone present: ERCP
no stone present: laparoscopic cholecystectomy

63
Q

What is cholangitis? What is the MC pathogen?

A

inflammation in the bile duct caused by bacterial infection in pt with CBD obstruction

e. coli

think stasis which leads to infection

64
Q

**What is Charcot triad? **What dz is it associated with? Is it considered a medical emergency?

A

RUQ Pain
Fever (and chills)
Jaundice

acute cholangitis

YES! medical emergency

65
Q

**What is Reynolds Pentad? What does it indicate?

A

RUQ Pain
Fever
Jaundice
Hypotension
Mental Status Change

acute suppurative severe cholangitis

66
Q

What will the PE show on a pt with cholangitis?

A

RUQ tenderness
Hepatomegaly possible

67
Q

What are the diagnostic imaging in cholangitis? What will it reveal? **What is the diagnostic procedure of choice in acute cholangitis?

A

US/CT

reveal stones and dilated ducts

ERCP

68
Q

______ is a complication associated with ERCP. Why?

A

Pancreatitis

d/t mechanical injury of pancreatic duct and hydrostatic injury from contrast injection

69
Q

What is the dx criteria for cholangitis?

A

need ONE of the following:
●Fever and/or shaking chills.
●Laboratory evidence of an inflammatory response (abnormal white blood cell count, increased serum C-reactive protein, or other changes suggestive of inflammation).

AND BOTH of the following

●Evidence of cholestasis: Bilirubin ≥2 mg/dL or abnormal liver chemistries (elevated alkaline phosphatase, gamma-glutamyl transpeptidase, alanine aminotransferase, or aspartate aminotransferase, to >1.5 times the upper limit of normal).
●Imaging with biliary dilation or evidence of the underlying etiology (eg, a stricture, stone, or stent).

70
Q

What are the complications of cholangitis?

A

liver damage: cirrhosis and liver failure if left untreated

septic shock

71
Q

What is the tx for cholangitis? **What is the procedure of choice? What is the pt still have gallbladder?

A

ADMIT!!!

IV fluids, pain control, NPO

**ERCP with stone extraction & sphincterotomy is the procedure of choice for Acute Cholangitis within 48 hours

lap chole AFTER the ERCP

72
Q

What abx is given in mild/moderate cholangitis? Severe? What differenitiates mild/mod from severe?

A

mild/mod: Cipro plus Metronidazole (Flagyl)

severe: IV Zosyn plus Flagyl

organ damage equals severe

73
Q

________ is Chronic inflammatory disease of the biliary tract. What does it result from?

A

Primary Sclerosing Cholangitis

Results from increased immune response to intestinal endotoxins

74
Q

**What other dz is Primary Sclerosing Cholangitis associated with? Who is the MC pt type?

A

UC and Crohns but more so with ulcerative colitis

men age 20-50, some hereditary component

75
Q

What does Primary Sclerosing Cholangitis eventually lead to?

A

Inflammation can lead to obstructive symptoms and cholestasis, fibrosis, and strictures of biliary system

76
Q

_____ and _____ are helpful in primary sclerosing cholangitis

A

coffee consumption and statin use

77
Q

Asymptomatic phase
Obstructive jaundice
Progressive jaundice
Pruritus
Fatigue, anorexia, indigestion
Hepatomegaly/splenomegaly

What am I?

A

primary sclerosing cholangitis

78
Q

What are some common lab findings seen with primary sclerosing cholangitis?

A
79
Q

What is the diagnostic imaging you should order for primary sclerosing cholangitis?

A

MRCP

can due ERCP if MRCP is inconclusive

80
Q

**What is the MRCP finding consistent with primary sclerosing cholangitis?

A

MRCP: “beads on a string”

81
Q

What will a detailed report show that is consistent with Primary Sclerosing Cholangitis?

A

The inflammation of the ducts show irregularity and tortuosity of ducts along with multifocal structuring

Segmental fibrosis with saccular dilatations between areas of stricture

82
Q

In primary sclerosing cholangitis, if the MRCP/ERCP is inconclusive, what do you do next? **What will it show?

A

liver biopsy

Periductal fibrosis “onion skinning”

83
Q

What are the essentials of diagnosis for primary sclerosis cholangitis?

A
84
Q

What are the complications of primary sclerosing cholangitis?

A

Cirrhosis/Liver Failure: Ultimate cause of death
Cholangiocarcinoma (10%)
Cholelithiasis, Cholecystitis
Acute Cholangitis

85
Q

What is the tx for primary sclerosing cholangitis?

A

no cure!!!

cipro for acute episodes, variety of immunosuppresives and anti-inflammatory agents have been studied

ERCP with dilation and stenting

liver transplant if advanced sz

have the potential to advance to cancer

86
Q

What is the prognosis in PSC? What is the health maintenance?

A

9 - 17 years from onset of diagnosis

some have argued for annual screening with imaging studies (MRCP) and a serum CA 19-9

87
Q

______ is the MC cancer of the biliary tract. _____ is the most deadly

A

Carcinoma of the gallbladder - most common

Cholangiocarcinoma (bile ducts) - most deadly

88
Q

What are the 3 co-exisitng factors for gallbladder carcinoma? Where does it often invade next?

A

-Chronic infection of gallbladder (Salmonella typhi)
-Gallbladder polyp (growths that protrude from lining of gallbladder); can be cancerous, but rare
-Calcification of the gallbladder (porcelain gallbladder)

liver

89
Q

Where does cholangiocarcinoma most commonly arise? What is a Klatskin tumor? What age range?

A

⅔ arise at confluence of right and left hepatic ducts, then 1/4 in common bile duct, then intrahepatic duct

hilar cholangiocarcinoma

50-70 years old

90
Q

Will find increased incidences of Cholangiocarcinoma with what 3 things?

A

Primary sclerosing cholangitis

Biliary cirrhosis (chronic obstruction)

immunocompromised states

91
Q

Progressive jaundice
RUQ pain/tenderness
Anorexia, weight loss
Acute cholangitis commonly develops
Pruritus
fever
chills
hepatomegaly
distended, palpable gallbladder
ascites

What am I?
**What is often the first sign? Especially in _____

A

Carcinoma of the Biliary Tract

progressive jaundice

Esp. in Cholangiocarcinoma

92
Q

What is the Courvoisier sign?

A

painless jaundice with palpable gallbladder

93
Q

What are common labratory findings with carcinomas of the biliary tract?**What is required for dx?

A

Elevated LFT’s
Elevated CA 19-9
Hyperbilirubinemia

ERCP with biopsy or US guided percutaneous biopsy required for diagnosis

94
Q

What is the tx for biliary tract carcinomas? What if the tumor is unresectable?

A

sx: curative if well localized

Biliary-enteric bypass surgery (roux-en-Y hepaticojejunostomy)

95
Q

What is a brief description of the Roux-en-Y procedure?

A

Biliary stent placement helps reduce stricture at the anastomosis. Once stent has been positioned, the small bowel is divided and distal small bowel brought up and sutured to the bile duct. An end-to-side bowel-bowel anastomosis completes the reconstruction.

Bypasses the bile duct to allow digestive juices to drain from liver directly to jejunum

96
Q
A

GI (12 decks)

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