G/I 2

Question 1

Choledocholithiasis – best initial study? Most accurate study?

Answer 1

1st = RUQ ultrasound

Most accurate = ERCP
PTC is alternative to ERCP

Question 2

Which is more sensitive to liver damage – ALT or AST?

Answer 2

ALT

Question 3

ALT & AST usually have similar increase except in what condition?

Answer 3

Alcoholic hepatitis – AST > ALT

Question 4

What to consider if Alk-phos is elevated but GGT is not?

Answer 4

Pregnancy or bone disease

Question 5

Cholelithiasis – what is it?

Answer 5

Stones in the gall bladder

e.g. gallstones

Question 6

Cholelithiasis – what causes black pigment stones?

other types of stones are cholesterol or mixed

Answer 6

Usually ass’d w/:
- Hemolysis (sickle cell, thalassemia, hereditary spherocytosis, artificial heart valves)
or
- Alcoholic cirrhosis

Question 7

What is Boas’ sign?

Answer 7

Referred right subscapular pain from biliary colic (cholelithiasis/cholecystitis)

Question 8

What to do if LFTs reveal cholestasis (inc’d Alk-phos or GGT)?

Answer 8

Abdominal or RUQ U/S

• high sensitivity & specificity (> 95%) for stones

Question 9

Signs of biliary obstruction?

Answer 9

• Elevated alk phos & GGT
• Elevated conjugated bilirubin
• Jaundice
• Pruritis
• Clay-colored stools
• Dark urine

Question 10

What is Acute Cholecystitis?

Answer 10

Acute inflammation of the gallbladder wall 2/2 obstruction of the cystic duct

NOT from infection

Question 11

Acute Cholecystitis – clinical features?

Answer 11

Pain in RUQ or epigastrum, sometimes radiates to right shoulder or scapula

• Nausea, vomiting, anorexia
• RUQ tenderness, rebound tenderness in RUQ
• Murphy’s sign is pathognomonic — inspiratory arrest during deep palpation of RUQ (usually not present)
• Hypoactive bowel sounds
• Low-grade fever, leukocytosis

Question 12

Acute cholecystitis – Dx test?

Answer 12

RUQ ultrasound

- if inconclusive, use HIDA scan & if this is normal, acute cholecystitis can be ruled out

Question 13

What is meant by a positive HIDA?

Answer 13

Means that the gallbladder is not visualized 4 hours after injection, confirming Dx of acute cholecystitis

** HIDA = Radionuclide scan (HepatoIminoDiacetic Acid) **

Question 14

Acute Cholecystitis – Tx?

Answer 14

Laparoscopic Surgery, or open surgery if there’s perforation of gallbladder

• If asymptomatic, can manage w/:
  Fluids, make NPO, IV antibiotics, analgesics, & correction of electrolyte abnormalities

Question 15

Choledocholithiasis – Tx?

Answer 15

1. ERCP w/ sphincterotomy & stone extraction w/ stent placement (successful in 90% of patients)
2. Laparoscopic choledocholithotomy (in select cases)

Question 16

What is Cholangitis?

Answer 16

Infection of biliary tract secondary to obstruction, which leads to biliary stasis & bacterial overgrowth

– requires emergent Tx!

Question 17

Cholangitis – presentation?

Answer 17

Charcot’s Triad: RUQ pain, Jaundice, Fever

Reynold’s Pentad: Charcot’s Triad + Septic shock & AMS (can be rapidly fatal)

Question 18

What does RUQ U/S detect well?

Gallstones, biliary tract dilatation, or CBD stones

Answer 18

Gallstones & biliary tract dilatation

NOT CBD stones

Question 19

Most serious & dreaded complication of acute cholangitis?

Answer 19

Hepatic abscess

Question 20

Cholangitis – Tx?

Answer 20

IV ABX & Fluids
2. Decompress CBD via PTC (catheter drainage). Then ERCP (sphincterotomy) or laparotomy (T-tube insertion) once the patient is stabilized (or emergently if pt doesn’t respond to ABX)

Question 21

What is “Porcelain Gallbladder”?

Answer 21

Intramural calcification of the gallbladder wall

- prophylactic cholecystectomy is rec’d b/c 50% of these progress to cancer

Question 22

Primary Sclerosing Cholangitis – pot’l complications?

Answer 22

Cirrhosis, Portal HTN, Liver failure

Question 23

Primary Sclerosing Cholangitis – ass’d more w/ UC or CD?

Answer 23

Moreso w/ UC (in 50-70% of cases, the pt has UC)

Question 24

Primary Sclerosing Cholangitis – presentation?

Answer 24

Jaundice (chronic obstructive) & pruritis

- Fatigue, malaise, weight loss

Question 25

Primary Sclerosing Cholangitis – Dx tests?

Answer 25

ERCP & PTC are diagnostic studies of choice

Question 26

What is PTC?

Answer 26

Percutaneous Transhepatic Cholangiography

• way of examining bile duct
• needle is inserted through the skin & liver into a bile duct. Then dye is injected, and the bile duct system is outlined on x-rays

Question 27

Primary Biliary Cirrhosis – Tx?

Answer 27

Symptomatic for pruritis (cholestyramine) & osteoporosis (calcium, bisphosphonates, vit D)

• Ursodeoxycholic acid (hydrophilic bile acid) slows progression of disease
• Liver transplantation = only curative Tx

Question 28

Hepatic encephalopathy – Sx?

Answer 28

Sx = Sleep pattern disturbances (insomnia, hypersomnia).

Progresses to cognitive deficits (memory, attention), mental status changes, & neuromuscular findings (asterixis)

Question 29

Hepatic encephalopathy – Tx?

Answer 29

Lactulose – nonabsorbable disaccharide sugar

Rifaximin – ABX that decreases the number of ammonia-producing bacteria in the colon
(usually added if lactulose doesn’t show improvement after 48 hrs)