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Clin Med 3 > E2: Biliary Disease > Flashcards

E2: Biliary Disease Flashcards

1
Q

What is the main function of bile?

A
  • Digestion and absorption of fats

- vehicle for excretion of bilirubin, excess cholesterol and metabolic byproducts

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2
Q

What is cholelithiasis?

A

Stones in the gallbladder

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3
Q

What is cholecystitis?

A

Inflammation of the GB

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4
Q

What is choledocholithiasis?

A

Stones in the common bile duct

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5
Q

What is cholangitis?

A

Inflammation of the bile ducts

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6
Q

What is cholestasis?

A

Disruption of bile flow, regardless of cause

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7
Q

What are the 4 Fs that are risk factors for cholelithiasis?

A

Female
Forty
Fluffy
Fertile

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8
Q

What is the most common type of stone seen with cholelithiasis? What are the other types of stones?

A
  • Cholesterol stones are most common

- Pigment stones (black pigment and brown pigment)

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9
Q

What are the 3 clinical manifestations of cholelithiasis?

A
  • Asymptomatic gallstones (majority)
  • Uncomplicated gallstone disease (biliary colic)
  • Complicated gallstone disease
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10
Q

What is the test of choice to diagnose cholelithiasis?

A

US

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11
Q

What is the treatment for asymptomatic gallstones?

A
  • Majority of patients do not require treatment
  • managed expectantly
  • referred for cholecystectomy if symptoms develop

** these patients are surgically treated IF they have increased risk of gallbladder cancer or hemolytic disorders

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12
Q

What is the etiology of biliary colic?

A
  • There is NO inflammation of the GB
  • As the GB contracts, it forces a stone against the GB outlet or cystic duct opening. This increases intra-GB pressure which results in pain. As the GB relaxes, the pain improves
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13
Q

What is the clinical presentation of biliary colic?

A
  • Intense RUQ pain that may radiate to the R shoulder blade

- Postprandial pain that lasts at least 30 minutes (usually lasts less than 5-6 hours)

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14
Q

Will a patient with biliary colic have a positive Murphys sign?

A

No

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15
Q

What is the recommended management of biliary colic?

A

-Cholecystectomy is recommended to prevent recurrent symptoms and complications

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16
Q

What is a functional gallbladder disorder?

A

Characterized by biliary type pain in the absence of gallstones, sludge, microlithiasis, or microcrystal disease
-Thought to be a results from GB dysmotility

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17
Q

How is functional GB disorder diagnosed?

A
  • Diagnosis of exclusion

- If no other causes of identified, order a HIDA

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18
Q

What HIDA results will support a diagnosis of functional GB disorder?

A

A GB ejection fraction <35-40% is considered low and supports the diagnosis

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19
Q

What does the Rome IV criteria require for a diagnosis of functional GB disorder to be made?

A

Requires: biliary pain and absence of gallstones

-criteria that support diagnosis but not requires: low GBEF and normal liver enzymes

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20
Q

What is biliary pain?

A
  • pain in the epigastric and/or right upper quadrant that meets all of the following criteria
  • lasts at least 30 minutes
  • occurs at variable intervals
  • severe enough to interrupt daily activity’s
  • Not significantly relieved by BMs, postural changes or acid suppression
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21
Q

What is the management of functional GB disorder?

A
  • Education and reassurance
  • referral
  • Cholecystectomy for topical biliary type pain and low GBED (< 40%)
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22
Q

What are the 3 types of complicated gallstone disease?

A
  • Cholecystitis
  • Choledocholithiasis
  • acute cholangitis
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23
Q

What is acute cholecystitis?

A

Acute inflammation of the GB, predominately a complication of gallstone disease

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24
Q

When does a calculus cholecystitis occur?

A

In the setting of cystic duct obstruction

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25
Q

Will a patient with acute cholecystitis have a positive Murphys sign?

A

Yes

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26
Q

What will you see on US that supports a diagnosis of acute cholecystitis?

A
  • Presence of gallstones
  • wall thickening or edema
  • pericholecystic fluid
  • positive sonography could murphys sign
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27
Q

What HIDA result would support a diagnosis of acute cholecystitis?

A

Failure to visualized the gallbladder in setting of cystic duct obstruction

28
Q

What are the possible complications of acute cholecystitis and which is the most common?

A
  • Gangrene is the most common
  • perforation (often after development of gangrene)
  • cholecystoenteric fistula
  • gallstone ileus
  • emphysematous cholecystitis
  • Mirizzi syndrome
29
Q

What is the Mirizzi syndrome?

A

A complication of acute cholecystitis, occurs when a gallstone impacted in the distal cystic duct causing extrinsic compression of the CBD, may cause jaundice

30
Q

What is the management of acute cholecystitis?

A
  • Admit, NPO, IV fluids, IV pain control, IV abx

- Cholecystectomy is mainstay of treatment

31
Q

What is acute acalculus cholecystitis?

A

Acute necroinflammatory disease of the gallbladder in the absence of gallstones

32
Q

What is the pathogenesis of acute acalculus cholecystitis?

A
  • GB stasis and ischemia leading to local inflammatory response in the gallbladder wall
  • secondary bacterial infection is common
33
Q

What is the clinical presentation of acute acalculous cholecystitis?

A

-Critically ill patients with sepsis without a clear source, or jaundice

34
Q

Patient presents with biliary type pain. On physical exam, patient appears jaundiced. Upon abdominal palpation, patient has RUQ tenderness and Courvoisier sign. What are you suspicious of?

A

Choledocolithiasis

35
Q

What is Courvoisier sign?

A

Palpable gallbladder

36
Q

What will liver function tests show if a patient has choledocholithiasis?

A

-Elevated ALT and AST in the early course of biliary obstruction. Later, liver tests are elevated in a cholestatic pattern

37
Q

If you are unable to confirm a diagnosis of choledocholithiasis with US, what should you order next?

A

MRCP is used to confirm dx of CBD stone

38
Q

What is the management of Choledocholithiasis?

A
  • Removal of stone
  • Identify and treat complications (acute cholangitis, acute pancreatitis)
  • ERCP (therpeutic and diagnostic)
  • Cholecystectomy
39
Q

What causes acute cholangitis?

A
  • caused primarily by a bacterial infection in a patient with biliary obstruction (choledocholithiasis, benign biliary stricture, s/p ERCP, malignancy)
  • bacteria typical ascend from the duodenum
40
Q

What is the clinical manifestation of acute cholangitis?

A

Fever, abdominal pain, and jaundice

-possible mental status change and hypotension, which are signs of significant morbidity

41
Q

What is Charcots triad?

A

Fever, abdominal pain and jaundice

42
Q

What is Reynolds Pentad?

A

Fever, abdominal pain, jaundice, mental status changes, and hypotension

43
Q

What is the management of acute cholangitis?

A
  • admit
  • monitor for and treat sepsis (empiric abc coverage)
  • emergent consult with GI and surgery (establishing biliary drainage, typically with ERCP)
44
Q

How can biliary drainage be established in acute cholangitis?

A

-ERCP with sphincterotomy and stone extraction

45
Q

Which two biliary problems would have leukocytosis?

A

Acute cholecystitis and acute cholangitis

46
Q

What is primary biliary cholangitis (PBC)?

A

Autoimmune destruction of the intrahepatic bile ducts which causes cholestasis
-may result in cirrhosis and liver failure

47
Q

What is the clinical presentation of PBC?

A
  • ma be asymptomatic
  • fatigue and pruritis are the most common
  • RUQ pain, skin hyperpigmentation, hepatomegaly, jaundice
48
Q

What lab tests should you order if you suspect PBC?

A
  • Antimitochondrial antibodies (AMA) is the serologic hallmark of PBC
  • elevated liver tests in a cholestatic pattern
49
Q

What are the possible complications associated with PBC?

A

-Cirrhosis, hepatocellular carcinoma, malabsorption, and metabolic bone disease

50
Q

What is the criteria to diagnose PBC?

A
  • No extrahepatic biliary obstruction
  • No comorbidity affecting the liver
  • and at least two of the following are present: elevated alk phos, positive AMA, and histological evidence of PBC (liver biopsy)
51
Q

What is primary sclerosis cholangitis (PSC)?

A
  • A sclerosing, inflammatory, obliterative process involving the intrahepatic and/or extrahepatic biliary tree
  • chronic and progressive disorder of unknown etiology
52
Q

What is PSC commonly associated with?

A

IBD ( UC more than CD)

53
Q

What are the symptoms of PSC?

A

Asymptomatic, fatigue, pruritis, jaundice, and hepatomegaly

54
Q

Will PSC have a positive AMA?

A

No

55
Q

How is PSC diagnosed?

A
  • Elevated liver tests in a cholestatic pattern
  • cholangiography (MRCP or ERCP showing multifocal strictures and dilation of intrahepatic and/or extrahepatic ducts)
  • Liver biopsy
56
Q

What are the possible complications of PSC?

A
  • ESRD
  • vitamin deficiency
  • metabolic bone disease
  • Hepatobiliary cancer
  • colon cancer
57
Q

What is Gilbert syndrome?

A
  • And inherited disorder that results in deficiency in the enzyme for glucuronidation of bilirubin in the liver
  • results in unconjugated hyperbilirubinemia in the absence of hemolysis
58
Q

What is the clinical presentation of Gilbert syndrome?

A
  • Mild intermittent episodes of jaundice triggered by dehydration, fasting, menstruation, etc
  • otherwise more are asymptomatic with a normal PE
59
Q

What is the most common cancer arising in the biliary tract?

A

Gallbladder cancer

60
Q

What are the risk factors for GB cancer?

A
  • Gallstone disease
  • porcelain GB
  • GB polyps
  • PSC
  • chronic infection
  • obesity
61
Q

What is cholangiocarcinoma?

A

Cancer that arise from the epithelial cells of the bile duct

62
Q

What is cholangiocarcinoma commonly associated with?

A

PSC and choledochal cysts

63
Q

What is the clinical presentation of cholangiocarcinoma?

A
  • Jaundice, pruritis, abdominal pain, weight loss, fever, and rarely a palpable gallbladder
  • labs may indicate cholestasis
64
Q

Where does ampullary carcinoma occur?

A

-arise in the vicinity of the ampulla of vater, distal to the bifurcation of the distal CBD and pancreatic duct

65
Q

What condition increases the risk of ampullary carcinoma?

A

Familial adenomatous polyposis

Clin Med 3 (17 decks)

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