DSA 3: Approach to Hepatobiliary Patient (Biliary, Gallbladder)

Question 1

What sign is present when deep inspiration or cough during palpation of the RUQ produces increased pain or inspiratory arrest?

Answer 1

Murphy’s sign

Question 2

What are the two major types of choleltihiasis?

Which is more common?

Answer 2

1) Cholesterol stones are more common

2) Calcium bilirubinate (pigment stones)

Question 3

What is biliary colic?

Where can it radiate?

Answer 3

1) A severe steady ache in the RUQ or epigastrium

2) Right scapula

Question 4

What is the best diagnostic test for cholelithiasis?

What can be seen?

Answer 4

1) US

2) Stones cast acoustic shadow

Question 5

What are the risk factors for gallstones?

Answer 5

1) Family history
2) Fair
3) Fat
4) Female
5) Fertile
6) Forty

Question 6

90 percent of the time what is the problem causing acute cholecystitis?

Answer 6

Calculous (Gallstones)

Question 7

What often precipitates acute cholecystitis?

What is a major symptom of acute cholecystitis?

Answer 7

1) Large fatty meal

2) Tea-colored urine or acholic stools

Question 8

What labs indicate acute cholecystitis?

Answer 8

1) Leukocytosis
2) Bilirubinemia
3) Alkaline phosphatase (ALP) and GGT levels increased

Question 9

What is the imaging used to diagnose acute cholecystitis?

Answer 9

RUQ abdominal US

Question 10

What complications can arise from acute cholecystitis?

Answer 10

1) Gangrene of the gallbladder

2) Emphysematous cholecystitis (secondary infection with a gas-forming organism)

Question 11

Stones in the common bile duct leads to?

Answer 11

Choledocholithiasis

Question 12

What can choledocholithiasis lead to?

Answer 12

Ascending Cholangitis

Question 13

What is a diagnostic and therapeutic tool for choledocholithiasis and ascending cholangitis?

Answer 13

ERCP

Question 14

How does ascending cholangitis present?

Answer 14

1) Charcot triad: RUQ pain, fever, and jaundice

2) Reynold pentad: Charcot triad along with altered mental status and hypotension

Question 15

What should be done if a patient presents with Reynold pentad?

Answer 15

Endoscopic emergency

Question 16

Ascending cholangitis has positive blood cultures for?

Answer 16

1) E. Coli
2) Klebsiella
3) Enterococcus

Question 17

What should be done before Endoscopic Retrograde Cholangiopancreatography (ERCP)?

What is a potential complication of this procedure?

Answer 17

1) Measure INR and Pregnancy test

2) Acute pancreatitis

Question 18

What are the treatment options for acute cholecystitis?

Answer 18

1) Antibiotics

2) Laparoscopic cholecystectomy

Question 19

What are the treatment options for choledocholithiasis?

Answer 19

1) ERCP

2) Laparoscopic cholecystectomy

Question 20

What are the treatment options for cholangitis?

Answer 20

Urgent ERCP to remove stones

Question 21

What should be done for primary sclerosing cholangitis that is severe and progresses to an end stage cirrhosis?

Answer 21

Liver transplant

Question 22

What diagnostic tool is used to determine biliary dyskinesia as the cause?

Answer 22

HIDA scan

Question 23

What is found with HIDA scan that points towards biliary dyskinesia?

Answer 23

An abnormal ejection fraction (less than 35-38%)

Question 24

What complications can arise from chronic cholecystitis?

Answer 24

1) Porcelain gallbladder

2) Increased risk of gallbladder cancer

Question 25

What does primary sclerosing cholangitis look like on MRCP or ERCP?

What does liver biopsy show in primary sclerosing cholangitis?

Answer 25

1) Beads on a string

2) Onion skinning

Question 26

What population is affected most with primary sclerosing cholangitis?

Answer 26

Males 20-50 yo

Question 27

What is primary sclerosing cholangitis associated with?

Answer 27

IBD (mostly UC)

Question 28

How does primary sclerosing cholangitis present on H&P?

Answer 28

Pruritus and jaundice

Question 29

What are complications associated with primary sclerosing cholangitis?

Answer 29

1) Increased risk of cholangiocarcinoma

2) Increased risk of colon carcinoma due to UC