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GI II Exam 2 > DSA 3 - Hepatobiliary Patient Gallbladder Biliary (McGowan) > Flashcards

DSA 3 - Hepatobiliary Patient Gallbladder Biliary (McGowan) Flashcards

1
Q

What is the clinical test used to test for acute cholecystitis? How does it work?

A

Murphy’s Sign

Patient exhales, physician places hand below costal margin on the right side at mid-clavicular line, patient inspires. It’s positive if the patient stops breathing in and winces with a “catch” in their breath due to pain.

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2
Q

Cholelithiasis (gallstones) can have two major types, which are made of what?

A

– Cholesterol (80%) - contains cholesterol monohydrate

– Pigment stones (20%) - composed primarily of calcium bilirubinate

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3
Q

Many gallstones are asymptomatic, but symptoms start to occur when stones trigger inflammation or cause obstruction of the cystic or common bile duct. The major symptoms include…

A

1) Biliary colic

2) N/V

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4
Q

This symptom of cholelithiasis is a severe steady ache in the RUQ or epigastrium that begins suddenly. Often occurs 30-90 min after meals.

A

Biliary Colic

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5
Q

What is a very characteristic area that biliary colic pain radiates to?

A

Right scapula

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6
Q

For diagnosis, only 10% of cholesterol gallstones are radiopaque and will show up on _______. Therefore, the best method is _________, which shows the gallstones as an “acoustic shadow” that they cast.

A

X-ray

Ultrasonography

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7
Q

This test can be used to assess the potency of the cystic duct and gallbladder emptying function.

A

HIDA scan

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8
Q

________ pigment gallstones tend to form in bile ducts as a result of bacterial infection, and may account for 30-90% of gallstones in Asian populations.

A

Brown

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9
Q

What are the “F’s” of gallstones?

A
    • Family hx
    • Fair
    • Fat
    • Female
    • Fertile
    • Forty
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10
Q

This can occur when a gallstone pops into the bile duct or without stones, and presents with a steady, severe pain. There is tenderness in the RUQ or epigastrium with N/V, fever, and leukocytes.

A

Acute Cholecystitis

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11
Q

_________ acute cholecystitis occurs in over 90% of cases and is due to gallstones impacted in the cystic duct. There is inflammation of the gallbladder that develops behind the obstruction.

A

Calculous

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12
Q

________ acute cholecystitis is true cholecystitis with no stones. It has many causes, including acute illness and infections.

A

Acalculous

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13
Q

In acute cholecystitis, a large fatty meal can cause an acute attack as well as RUQ tenderness with a Murphy sign. There is muscle guarding and rebound tenderness, and sometimes palpable gallbladder. Jaundice is sometimes present. What is the appearance of urine and stool?

A

Tea-colored urine and acholic (pale) stools

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14
Q

What are the lab results for acute cholecystitis?

A
    • Leukocytosis
    • Bilirubinemia
    • Increased ALP and GGT

***Also increased AST and amylase, but not as prominent as the other tests!

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15
Q

What is the best diagnostic imaging for acute cholecystitis?

A

RUQ abdominal ultrasonography

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16
Q

Findings from RUQ abdominal US suggestive of acute cholecystitis include…

A
    • Gallbladder wall thickening
    • Pericholecystic fluid
    • Sonographic Murphy sign
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17
Q

CT scan can show what complications of acute cholecystitis?

A

Perforation or gangrene

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18
Q

In acute cholecystitis, the complication of gallbladder gangrene can progress into what?

A

Gangrene –>
Gallbladder perforation –>
Formation of a pericholecystic abscess –>
Rarely to generalized peritonitis

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19
Q

This is another serious acute complication of acute cholecystitis that can be defined as a secondary infection with a gas-forming organism.

A

Emphysematous cholecystitis

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20
Q

This disorder consists of biliary pain with or without jaundice, N/V, and has stones in the common bile duct.

A

Choledocholithiasis

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21
Q

What are signs and symptoms of Choledocholithiasis?

A

1) Frequent recurring attacks of severe RUQ pain for hours
2) Chills and fever with severe pain
3) Hx of jaundice with episodes of abdominal pain

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22
Q

What are the lab results for Choledocholithiasis?

A
    • Increase in AST and ALT (often greater than 1000)
    • Hyperbilirubinemia (direct)
    • ALP and GGT rise slowly
    • INR (prior to ERCP)
23
Q

What is the most direct and accurate means of determining the cause, location, and extent of obstruction for Choledocholithiasis?

A
    • ERCP
    • Percutaneous transhepatic cholangiography

***EUS can also be helpful!

24
Q

What is it vital to check before an ERCP?

A

INR (always check this before invasive procedures)

25
Q

What are the treatment options for Choledocholithiasis and Ascending Cholangitis?

A

– ERCP with sphincterotomy and stone extraction/stent placement (procedure of choice)

– Cholecystectomy

– Antibiotics, pain meds, IVF

26
Q

What is the main complication that Choledocholithiasis can lead to?

A

Ascending Cholangitis

27
Q

What disorder should we suspect when the patient presents with fever, gram-negative shock, jaundice, and leukocytosis? Also can have biliary pain and N/V.

A

Ascending Cholangitis

28
Q

Acute Cholangitis has a characteristic of symptoms called Charcot Triad, which includes…

A
    • RUQ pain
    • Fever (and chills)
    • Jaundice
29
Q

If Acute Cholangitis develops into Acute Suppurative Cholangitis, it presents with something called Reynold Pentad. What does this include?

A

– Charcot Triad (RUQ pain, fever, jaundice)

+

– Altered mental status (confusion) and hypotension

30
Q

What are the lab results for Ascending Cholangitis?

A

– Leukocytosis

– Positive blood cultures for E. coli, Klebsiella, Enterococcus

– Increase in AST and ALT (greater than 1000)

– ALP and GGT rise slowly

– INR (prior to ERCP)

31
Q

What is the best diagnostic imaging technique for Acute Cholangitis?

A

ERCP

***Remember to check INR beforehand!

32
Q

What is a complication of Ascending Cholangitis?

A

Death

33
Q

This type imaging is an invasive procedure that is diagnostic and therapeutic for the biliary tree and pancreatic duct. Complications can include acute pancreatitis, bleeding, infection, and perforation.

A

ERCP (Endoscopic Retrograde Cholangiopancreatography)

34
Q

What tests must be done before performing and ERCP?

A
    • INR

- - Pregnancy test (prior to procedure in women of child bearing age)

35
Q

In asymptomatic patients with cholelithiasis, the treatment is a low-fat diet. Elective cholecystectomy should be reserved for…

A

1) Symptomatic patients
2) Persons with previous complications of cholelithiasis
3) Underlying condition predisposing to increased risk of complications
4) Patients with gallstones >3 cm

36
Q

What is the best treatment for acute cholecystitis?

A
    • Antibiotics

- - Urgent cholecystectomy for patients with suspected or confirmed complication

37
Q

_________ cholecystectomy is minimally invasive and is the procedure of choice for elective cholecystectomy (urgent gets this or open depending on needs).

A

Laparoscopic

38
Q

What is the best treatment for PSC (Primary Sclerosing Cholangitis)?

A

There is no satisfactory therapy, just treat particular symptoms.

39
Q

This is a symptomatic function disorder of the gallbladder. It presents with a symptom complex that is similar to those with biliary colic, such as RUQ pain, severe pain that limits activities of daily living, and nausea associated with the pain.

A

Biliary Dyskinesia

40
Q

What is the best imaging to perform for Biliary Dyskinesia diagnosis?

A

– There will be a NORMAL ultrasound for this, so other diagnostics are preferred.

***Liver enzymes will also be normal!

41
Q

For patients who are suspected to have Biliary Dyskinesia, the ________ diagnostic criteria for functional gallbladder disorders should be considered. Other supportive criteria include association of pain with N/V, radiation of pain to infrascapular region, and pain that wakes the patients in the middle of the night.

A

Rome III

42
Q

Another tool to diagnose Biliary Dyskinesia is a _________, which if results in an abnormal ejection fraction (less than 35-38%) then a cholecystectomy needs to be done.

A

CCK-HIDA (Cholecystokinin Hepatobiliary Iminodiacetic Scan)

43
Q

This disorder is chronic inflammation of the gallbladder, and almost always is associated with gallstones. Results from repeated acute/subacute cholecystitis or prolonged mechanical irritation of gallbladder wall.

A

Chronic Cholecystitis

***Symptoms very similar to acute! Can be asymptomatic for years.

44
Q

What is the best diagnostic tool for Chronic Cholecystitis?

A

US, because it shows gallstones within a contracted gallbladder

45
Q

What is the main complication we should be worried about with Chronic Cholecystitis?

A

Porcelain Gallbladder – seen on plain X-ray

46
Q

This is a calcified gallbladder that greatly increases the risk of gallbladder cancer (poor prognosis).

A

Porcelain Gallbladder

47
Q

What is the best treatment for Chronic Cholecystitis?

A

Surgery, if patient is symptomatic or has Porcelain gallbladder

48
Q

This is the term for an enlarged, palpable nontender gallbladder with jaundice. It is associated with cancer of the head of the pancreas.

A

Courvoisier Gallbladder

49
Q

This disorder has the appearance of “beads on a string” and most often occurs in males 20-50 yo, and is associated with IBD, primarily ulcerative colitis. Present with pruritus, jaundice, fatigue, and maybe osteoporosis.

A

Primary Sclerosing Cholangitis (PSC)

50
Q

What labs are elevated with PSC?

A

ALP

Bilirubin

51
Q

For PSC, what are the diagnostic tools used to show the segmental fibrosis of bile ducts with accular dilatations between strictures (beads on a string)?

A

MRCP or ERCP

52
Q

For PSC, a liver biopsy is not needed, but if done it shows a periductal fibrosis that looks like…

A

Onion-skin

53
Q

No therapy exists for PSC, only symptomatic treatment. What complication does PSC increase the risk for?

A

Cholangiocarcinoma

GI II Exam 2 (7 decks)

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