DSA 3: Gallbladder & Biliary Tree Flashcards

1
Q

What part of the abd will hurt for GB dzs (what are all the DDx related to this)

A

RUQ: GB disease

  1. Acute cholecystitis
  2. Choledocholithiasis
  3. Ascending cholangitis
  4. Biliary dyskinesia
  5. Chronic cholecystitis
  6. Primary sclerosing cholangitis
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2
Q

How do you perform Murphy’s sign and what is a (+) sign

A

ask pt to exhale, examiner places hands below costal margin on R side at mid-clavicular line; ask pt to inspire

Pt stop breating in and winces w/ a “catch” in breath bc of inflammed GB palpation on inspiration

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3
Q

what are the types of stones in cholelithiasis

A

2 major types of gallstones =

  1. cholesterol (80%)- >50% cholesterol monohydrate
  2. pigment stones (20%)- primarily Ca2+ bilirubinate; brown stones form in bile duct bc of bacterial infxn (30-90% gallstones in Asians)
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4
Q

what are signs and symptoms of cholelithiasis

A
  1. biliary colic - severe steady ache in RUQ/epigastrium suddenly (often after meal)- occasionally radiate to R scapula
  2. N/V
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5
Q

what imaging and labs will confirm the diagnosis for cholelithiasis

A

Lab = normal or occasionally (mild/transient) elevation in bilirubin

Imaging: Ultrasongraphy is the best Dx test (RUQ US/hepatobiliary US) - stones seen as “acoustic shadow” that they cast

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6
Q

What are complications of cholelithiasis

A

cholecystitis, pancreatitis, cholangitis

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7
Q

what are RFs for gallstones

A

6 F’s: FHx, Fair, Fat, F, Fertile and Forty

Female, increase w/ age, obesity, pregnancy

american indians > mexican americans > non-hispanic whites > african-americans

DM, glucose intolerance, insulin resistance, hyper triglycerides, high intake of carb

MALE > FEMALE IF CIRRHOSIS & HEP C

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8
Q

What are protective factors for gallstones

A

low carb diet, high fiber diet, statins, ASA & NSAIDs

consumption of coffee (in women)

physical activity, cardioresp fitness

high intake Mg2+ and polyunsaturated & monosaturated fats (in men)

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9
Q

what are the 2 types/causes for acute cholecystitis

A

caculous: > 90% , impacted in the cyst duct; inflam GB develops behind the obstruction

acalculous: true cholecystitis + no stones; many acute illnesses, vascultitis, carcinoma, some GB infxns

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10
Q

What are signs and symptoms of acute cholecystitis

A

large fatty meals can cause acute attack

epigastric/RUQ tenderness (often w/ murphy’s sign)

sometimes jaundice

tea-colored urine or acholic stools

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11
Q

What labs and imaging help to diagnose acute cholecystitis

A

labs: leukocytosis, bilirubinemia, increase ALP & GGT
imaging: RUQ abd ultrasonography - GB wall thickening, pericholecystic fluid & sonographic Murphys sign

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12
Q

what are complications of acute cholecystitis

A

gangrene of the GB - may lead to GB perforation –> pericholecystic abscess –> generalized peritonitis

emphysematous cholecystitis (2ndary infxn w/ gas-forming organism)

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13
Q

What is essential for diagnosis of choledocholithiasis

what signs will be added to make you think ascending cholangitis

A

choledocholithiasis: stones in common bile duct (CBD) - most reliably detected by ERCP or EUS, N/V, biliary pain +/- jaundice

AC - fever, N/V, jaundice & leukocytosis, biliary pain +/- jaundice & gram-neg shock

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14
Q

What are signs/symptoms of choledocholithiasis

A
  1. freq recurring attacks of severe RUQ pain x hours
  2. chills/fever associated w/ severe pain
  3. Hx of jaundice associated with episodes of abd pain

(can lead to acute ascending cholangitis - AC)

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15
Q

what imaging/labs help to Dx choledocholithiasis

A

imaging: most direct, accurate = ECRP - help determine cause, location and extent of obstruction *do INR prior to ERCP*
labs: increase in AST/ALT, slow increase in ALP and GGT

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16
Q

how do you treat choledocholithiasis and ascending cholangitis

A

ERCP w/ sphincterotomy & stone extraction/stent placement

Cholecystectomy

17
Q

What are Charcot Triad and Reynold pentad?

A

signs of ascending choliangitis

Charcot triad: RUQ + fever/chills + jaundice

Reynold pentad: Charcot triad + altered mental status (confusion) & hypotension; signify acute suppurative cholangitis and = endoscopic emergency

18
Q

What are labs/imaging findings differentiate ascending cholangitis from choledocolithiasis

A

labs: (+) blood culture - e. coli, klebsiella, enterococcus
imaging: ERCP (diagnostic and therapeutic) (both)

19
Q

what are characterisitics of ERCP

A

diagnostic & therapeutic : biliary tree, pancreatic duct

measure INR & pregnancy test prior to procedures

if using contrast - consider kidney fxn, Ck BUN/Cr

complications: acute pancreatitis

20
Q

what are treatments for choleithiasis

A

asymp- monitor, recommend low fat diet.

Elective cholecystectomy for:

  1. symp pts (i.e., biliary colic despite low-fat diet)
  2. persons w/ previous complications of cholelithiasis
  3. presence of an underlying condition predisposing to an increased risk of complications (calcified or porcelain gallbladder)
  4. Pts with gallstones >3 cm
21
Q

what is the treatment for acute cholecystitis

A

NPO, IV fluids/electrolytes, analgesia

ABx (add anaerobic converage if complications of gangrenous/emphysmatous chelecystitis)

SRG: urgent cholecystectomy - appropriate in most pts w/ suspected or confirmed complications

delayed SRG for pt w/ high risk of emergent SRG and where Dx in doubt

22
Q

what is the treatment of choledocholithiasis

A

ERCP

Laparoscopic cholecystectomy

CBD stones are suspected prior to laparoscopic cholecystectomy, preoperative ERCP with endoscopic papillotomy and stone extraction is the preferred approach

CBD stones should be suspected in gallstone pts w/

  1. Hx of jaundice or pancreatitis
  2. abnormal LFT
  3. US evidence of a dilated CBD or stones in the duct
23
Q

What is the Tx for cholangitis

A

urgent ERCP (stones removed)

treated like acute cholecystitis: NPO, hydration, analgesia and ABx; cholecystectomy

24
Q

what is the treatment for PSC

A

no satisfactory therapy

cholangitis should be treated w/ urgent ERCP

Ursodeocycholic acid -improve liver tests but dont affect survivial

SRG relief may be needed but increase complications

liver transplant - for pt w/ end-stage cirrhosis

25
Q

what is Laparoscopic cholecystectomy

A

= minimally invasive & is the procedure of choice for elective cholecystectomy [urgent gets lap or open depending on needs]

26
Q

What is the Hx/PE of biliary dyskinesia

A

presents w/ symptoms similar to biliary colic - episodes of RUQ pain w/ nausea, severe & limit activites of daily like

27
Q

What is diagnostic for biliary dyskinesia

A

clinical: RUQ pain similar to biliary colic

NORMAL US

Rome III diagnostic criteria for fxnal GB

normal liver enzymes, conjugated bilirubin and amylase/lipase

HIDA scan- abnormal- GB not seen –> stone in cystic duct/cholecystitis; (+) CCK-HIDA = abnormal ejection fraction is considered to be < 35-38% –> choleycystectomy

28
Q

what is essential for diagnosis for chronic cholecystitis

A

chronic inflam of GB

almost always associated w/ gallstones

results from repeated acute/subacute cholecystitis or prolonged mechanical irritation

29
Q

What are complications of chronic cholecystitis

A

Porcelain GB on x-ray

KUB-kidney/ureter/bladder x-ray/thoracic/lumbar x-ray - show incidental calcified lesion

increased risk of GB CA (poor prognosis)

30
Q

how do you treat chronic cholecystitis

A

SRG if pt is symptomatic or if porcelain GB

31
Q

What is the etiology of PSC

A

beads on a string

Males (20-50 yo)

associated w/ IBD (UC)

32
Q

What is Hx/PE of PSC

A

clinical manifestation- pruritus, jaundice

fatigue, osteoporosis

can cause ascending cholangitis

33
Q

what is diagnostic of PSC

A

cholestasis: increased ALP & bilirubin

ERCP: segmental fibrosis of the bile duct w/ accular dilations btn strictures (beads on a string)

liver Bx - periductal fibrosis (onion skinning)

34
Q

what is the Tx/management for PSC

A

no proven therapy

symptomatic tx - steroids, bile salt chelators for pruritis (if acute treat like ascending cholangitis)

liver transplant

35
Q

what are complications of PSC

A

increased risk of cholangiocarcinoma

associated w/ increase colon CA (from UC)