Exam 2 - Biliary Disease Flashcards
What is the term for stones in the gallbladder?
Cholelithiasis
What is the term for inflammation of the gallbladder?
Cholecystitis
What is the term for stones in the common bile duct?
Choledocholithiasis
What is the term for inflammation of the bile ducts?
Cholangitis
What is the term for disruption of bile flow, regardless of cause?
Cholestasis
What are some risk factors of cholelithiasis?
The Four F’s
- Female
- Fluffy
- Forty
- Fertile
What is the initial test of choice for cholelithiasis?
Ultrasound
What is uncomplicated gallstone disease also known as?
Biliary colic
What signs/symptoms are associated with biliary colic?
- Constant and steady RUQ/epigastric pain that may radiate to right shoulder blade
- Pain lasting at least 30 mins, but less than 5-6 hours
- Postprandial pain, commonly after eating fatty or greasy foods
- Nocturnal pain
- Associated nausea, vomiting, diaphoresis
Is biliary colic associated with a positive or negative Murphy’s sign?
Negative Murphy’s sign
What is the preferred initial test in biliary colic?
What is an expected finding?
Ultrasound
Gallstones and/or gallbladder sludge expected
What is the recommended management for uncomplicated gallstone disease?
Cholecystectomy to prevent recurrent symptoms and complications
What is Functional Gallbladder Disorder characterized by?
Characterized by biliary-type pain in the absence of gallstones, sludge, microlithiasis, or microcrystal disease
What is the possible etiology of Functional Gallbladder Disorder?
Gallbladder dysmotility
How is Functional Gallbladder Disorder diagnosed?
Diagnosis of exclusion
HIDA scan with CCK
- GBEF < 35-40% is considered low and supportive of diagnosis
What is the ultimate management for Functional Gallbladder Disorder?
Cholecystectomy
What are some gallstone related complications?
- Acute cholecystitis
- Choledocholithiasis with or without acute cholangitis
- Gallstone pancreatitis
What is acute (calculous) cholecystitis?
Acute inflammation of the gallbladder which occurs in the setting of cystic duct obstruction
What are signs/symptoms associated with acute (calculous) cholecystitis?
- Biliary pain that progressively worsens
- Prolonged (> 4-6 hours) of steady and severe RUQ/epigastric pain that may radiate to back or shoulder
- Fever
- Tachycardia
- Ill appearing and may be lying still on table
Is acute (calculous) cholecystitis associated with a positive or negative Murphy’s sign?
Positive Murphy’s sign
What will be seen on labs in acute (calculous) cholecystitis?
- Leukocytosis with a left shift
- May see mild elevation in serum AST/ALT
- Serum amylase may be elevated
What is the preferred initial study for acute (calculous) cholecystitis diagnosed?
Ultrasound
What will likely be seen on ultrasound to support the diagnosis of acute (calculous) cholecystitis?
- Presence of gallstones
- Gallbladder wall thickening
- Pericholecystic fluid
- Positive “sonographic Murphy’s sign”
What is the most common complication of acute (calculous) cholecystitis?
Gangrene (older patients, DM, those that delay seeking therapy)
What is the mainstay of treatment for acute (calculous) cholecystitis?
Cholecystectomy
What is the management of acute (calculous) cholecystitis?
- Admit to hospital
- NPO
- IV fluids, pain control, and antibiotics
- Cholecystectomy
What is acute (acalculous) cholecystitis?
Acute necroinflammatory disease of the gallbladder in the absence of gallstones
In what populations is acute (acalculous) cholecystitis most common in?
Hospitalized and critically ill patients
What is the treatment for acute (acalculous) cholecystitis?
- Blood cultures
- Initiate antibiotics
- Cholecystectomy vs. gallbladder drainage
When should you suspect acute (acalculous) cholecystitis?
- Critically ill patients with sepsis without clear source or jaundice
- Patients with postoperative jaundice
What is choledocholithiasis?
Gallstones in the common bile duct
What are signs/symptoms associated with uncomplicated choledocholithiasis?
- Biliary-type pain
- Jaundice (due to blockage of bile flow)
- RUQ or epigastric tenderness
- Courvoisier sign (palpable gallbladder) may be seen
What lab findings are expected in a patient with uncomplicated choledocholithiasis?
- No leukocytosis on CBC
- Elevated liver tests (AST, ALT)
What is the initial imaging study for choledocholithiasis and what will typically be seen?
Ultrasound
- Cholelithiasis
- CBD stone
- CBD dilation (> 6 mm)
If ultrasound is still unclear for choledocholithiasis, what could you consider ordering?
MRCP or endoscopic ultrasound
What is the management for choledocholithiasis?
- Identify and treat complications (acute cholagitis, acute pancreatitis)
- ERCP to remove CBD stone
- Cholecystectomy
What is the primary cause of acute cholangitis?
- Bacterial infection in a patient with biliary obstruction
- Bacteria typically ascend from duodenum
What is Charcot’s Triad and what condition is it associated with?
Fever, abdominal pain, jaundice
Acute Cholangitis
What is Reynolds Pentad and what condition is it associated with?
Fever, abdominal pain, jaundice + mental status change and hypotension
Acute Cholangitis
What lab findings are typically associated with acute cholangitis?
- Leukocytosis with left shift
- Elevated CRP
- Evidence of cholestasis (elevated bilirubin, alk. phos. and GGT)
- Serum amylase or lipase may be increased 3-4 times normal
- Positive blood cultures
What imaging studies can be used to diagnose acute cholangitis?
- Ultrasound
- CT
- MRCP (or EUS)
What is the management for acute cholangitis?
- Admit to hospital
- Empiric antibiotic coverage for sepsis
- Emergent consult with GI/Surgery
- ERCP with sphincterotomy and stone extraction (and/or stent insertion)
- Follow with cholecystectomy if appropriate
What is Primary Biliary Cholangitis (PBC)?
In what population is it most common?
Autoimmune destruction of the intrahepatic bile ducts which causes cholestasis.
Primarily women 30-65 y/o
What is the clinical presentation of PBC?
- May be asymptomatic
- Fatigue and pruritis (most common)
- RUQ discomfort, skin hyperpigmentation, hepatomegaly, xanthomas, jaundice
What lab results are typically associated with PBC?
Liver test (cholestatic pattern)
- Elevated Alk. Phos, GGT
- ALT/AST may be normal or slightly elevated
- Increased serum bilirubin (as disease progresses)
Antimitochondrial antibodies (AMA)
ANA
Hyperlipidemia
What is a serologic hallmark of PBC?
Antimitochondrial antibodies (AMA)
How is PBC diagnosed?
At least two of the following are present:
- Elevated Alk. Phos (1.5 times the upper normal limit)
- (+) AMA
- Histologic evidence of PBC (liver biopsy if needed)
No extrahepatic biliary obstruction or comorbidity affecting the liver
What is Primary Sclerosing Cholangitis (PSC)?
In what population is there a higher occurrence?
Sclerosing, inflammatory, obliterative process involving the intrahepatic and/or extrahepatic biliary tree.
Higher incidence in men.
What other disorder is PSC strongly associated with?
IBD (UC > CD)
What are signs/symptoms associated with PSC?
- Asymptomatic
- Fatigue
- Pruritis
- Jaundice
What lab results are typically associated with PSC?
- Liver tests demonstrate a cholestatic pattern
- Negative AMA
What will be seen on MRCP or ERCP to support the diagnosis of PSC?
Multifocal strictures and dilation of intrahepatic and/or extrahepatic bile ducts
What are possible complications of PSC?
- End-stage liver disease
- Hepatobiliary cancer
- Colon cancer (patients with UC)
What is Gilbert Syndrome?
- Deficiency in enzyme for glucuronidation of bilirubin in liver (conjugation)
- Unconjugated hyperbilirubinemia in the absence of hemolysis
What is the clinical presentation associated with Gilbert Syndrome?
- Post-puberty
- Mild intermittent episodes of jaundice (dehydration, fasting, menstuation)
- Asymptomatic otherwise
What is the most common cancer arising in the biliary tract?
Gallbladder cancer
What are risk factors for gallbladder cancer?
- Gallstone disease
- Porcelain gallbladder
- Gallbladder polups
- PSC
- Chronic infection
- Obesity
Where does Cholangiocarcinoma arise from?
Arise from epithelial cells of the bile ducts
What other disorders is Cholangiocarcinoma associated with?
PSC and choledochal cysts
What are signs/symptoms associated with Cholangiocarcinoma?
- Jaundice
- Pruritis
- Abdominal pain
- Weight loss
- Fever
- Courvoisier sign (rare)
What will labs show in Cholangiocarcinoma?
Cholestasis (obstructive pattern)
Where does Ampullary Carcinoma arise from?
Arise in the vicinity of the ampulla of Vater
What other disorders is Ampullary Carcinoma associated with?
- Familial Adenomatous Polyposis (FAP)
- Hereditary Nonpolyposis Colorectal Cancer (HNPCC)
What is the most common presentation associated withAmpullary Carcinoma?
Obstructive jaundice
The following is associated with what disorder?
- Biliary pain
- RUQ pain
- (+) Murphy sign
- Leukocytosis
Acute cholecystitis
The following is associated with what disorder?
- More common in women
- (+) AMA titer
Primary Biliary Cholangitis (PBC)
The following is associated with what disorder?
- More common in men
- Associated with IBD
- Negative AMA titer
Primary Sclerosing Cholangitis (PSC)
