Gall Bladder Disease Flashcards
Enumrate causes of biliary obstruction?
مراهقه طلعت بنص اليولي لبارتي تركت ناقذه شوي مفتوحه عشان تدخل منها بس انصدمت يوم جات انها صارت مرره ضيقه وعالقه مثل الفايبروسز السكليروسز حاولت تدخل مثل الدوده وتعصر نفسها ، حاولت تعبي نفسها ماي عشان تنزلق حاولت ترمي حصيان على مافذه اختها عشان تفتح لها قالت بتدخل من القبو بس خافت لان كله عقارب
Primary: 1- gall stone حصوات نافذه اختها 2- biliary stricure نافذه ضيقه 3- cyst غرقت نفسها ماي - pseudopancrtic cyst - choleuctal cyst 4- cancer عقارب القبو Head if pancrease- Peri ampula cancer- Cholngiovarcionma- 4- biliary cirhosis 5- worm تتحرك مثل الدوده - fasciole hepatica -ascaris lumbricodosis- Clonirchis sinensis - 6- liver abcess 7- mirrizi syndrome 8- primary sclerosing cholngitis
Biliary obstruction symptoms?
1- Jaundice
2- Clay color stool
3- Dark urine
4- pruritis
Risk factors of gall stone?
Fatty Female Fourty Fertile ( pregnency ) Rapid weight loss or gastric bypass ( biartric surgery ) TPN Hormonal therapy, OCP High triglycide level Dm Disease of gall bladder
One of the complication of gall stone is malignancy, which type if mailgnancy?
Gall bladder carcinoma
What are the finding of acute Cholecystitis in US?
- gall bladder stone
- acoustic shadow( differente stone from polyps)
- thick wall (>3mm)
- pericystic fluid( mild or absent in chronic)
- murphy sign ultrasongraphy
What the mist important investigation in patient with biliary colic disease?
- CBC
- urine anylsis ( urobilin)
- LFT including bilirubin
- ESR, CRP
-US is intial and can be confirmatory in acute calcular Cholecystitis
What the exast potion of Murphy sign?
At the tip of 9th costal margin in midclivicular line
Or
The junction betweeen Lateral border of rectus sheath with the rip cage
All the following is correct regarding biliary colic except?
- RUQ pain excerpated by fatty food
- normal WBC count , mildly elvated or normal LFT , stone in GB in US
- presence of murphy sign
- managed with analgesic and elective cholecystectomy
- first line analgesic is paracetamol
Presense if murphy sign
It us charceterastic of acute Cholecystitis, absent in biliary colic
Since there is no inflammation, only trainsent stone in the cyst duct
How would you treat px with biliary colic?
- rusistation
- analgesic ( 1st line paracetamol)
- avoid heavy food
- elective cholecystectomy
True ir false
Abx is given to patient with biliary colic?
False
No need
Whart are the indication of cholecystectomy in asymptomatic gall stone ?
HDB PY
هدب بي
1- biaretric sugery 2- DM 3- hemolytic anemia? 4- young , fit patient 5- porecelain GB
How would you manage patient with acute calcular Cholecystitis?
- rusustation
- NPO
- pain killer
- Abx
- exclude complication
- cholecystectomy
- within 72: do it early
- after 72:
Stable px: interval cholecystectomy
Detorating surgery fit : dont delay
Deterorting unfit: PTC
احط زي التوب عشان يخفف الانفلاميشن ولما تستقر اسوي العمليه
In patient present with splenomegaly and acute Cholecystitis, splenectomy and cholecystectomy is indicated both , which will you do first?
Splenectomy
لان لو شفت القال بادر قبل ، وماقدرا اشيل السبلين بعدها
فالسبلين ممكن يسبب حصوات بسبب الهيمولتد ويحطها بالكومون دكت
فانا ابدي السبلينكتومي عشان مايسبب لي من البدايه حصوات
Managment of acute acalulcar Cholecystitis? A- ERCP B- cholecystectomy C- PTC D- nothing
B : cholecystectomy
Chronic Cholecystitis characterized by the following except?
1- common in critically ill , burn px, ICY
2– present as atypical dyspepsis ir repreated biliary coloc pain
3- managed by laperscopic cholecystectomy
4- seen with thick GB wall and sever pericystic fluid
4 - no pericystic fluid ir mild, wall not thicken much
Degree of thckness of GB in US to consider as thick is ?
- > 3mm
- > 7.5mm
- > 2.5
> 3 mm
One of the complication of gall stone is gall stone illius , which from the following is correct?
1- present as pneumomedistinum
2- commonly stone impacted in ilieojujnal junction
3- caused by external compression in CBD
4- present as bowel obstruction
4 : present as bowel obstruction
The rest is false
present as pneumobilia
commonly stone impacted in iliocecal valve ( terminal illium)
Mirrizi dynromd is external compression in CBD
HIDA scan is best used to diagnose?
- biliary atersia
- pancreatic milgnancy
- stone in hepatic duct
- therpuetic to put tube for drainge
Biliary atersia
هو افضل شي عشان اشوف الفنكشن او الداينك للقال بلدر بحيث اعرف وين ودت السكريشن فيه
حلو بعد for strictures
Endoscopic us scan is best used tofor all the follwing except?
A- show in great detailt the upper common bile duct and hepatic duct
B- dtermine stage of milgnancy by the relation or extent to surrounding structures
C- take biposy and remove stone
D- therpuetic to put tube for drainge
A-
It show in great details low common bile duct and head of pancrease or ampulla
The intial test of gall bladder disease is ….., only limitation….?
US
Impage obscured by doudenum gas
If ERCp fail to remove the stone of CBD in obstructive jaundice, what will be your second option?
- PTC
- cholecystectomy
- repeat ERCP
- endoscopic US with T tube
PTC
Scapular pain or hypersethia in acute Cholecystitis is known as….. by the intervation of …. Phernic berve dermatome?
Boas sign
C3,C4
True ir false
Patient with RUQ pain duration lasting more than 24 hours , the diagnosis is biliary voluc
False
Think of acute Cholecystitis
صلي
1- GB filled with mucose , painful palbable but no fever
2- GB filled with pus with swining pyrexia, painful palbale
3- stone impacted in teriminal illum followin fistula formation
A. Emptma
B. Mucocele
C. Suphernic absess
D. Gallstone ilius
- B
- A
- D
How to manage px with Gallstone ilius?
تخيلي عندك ستون ساده الامعاء بسبب فستولا كيف بتصلحين الوضع
اسيل هالستون ، اعدل هالفستولا ، اشيل القال بلدر
من الاسلس لانها ممكن تعيدها
Endoscopic Stone extraction
Fistula repair
Cholecystectomy
Primary sclerosing chomgitis is risk factor to whuch milgnancy? Head of pancrease Chaligocarcinoma Gall bladder carcinoma Perampul cancet
Chalngocarcinoma
Merceds sign in cray indicate presence of?
1- gall bladder radiolaque stone
2- air in biliiary tract
3- perocrle gall nladder
4- emphyma
1 stone in GB
A 38 years old female undergone full check up , procelen Gall bladder was found , what would be her risk to develope milgnancy? What are the indication for cholecystectomy?
5% risk
Indication
- comorbidty
- symptomatic
- old age
Gass in FB wall known as….. Commonly caused by …..
consider as emergency
Emphyma
Clostridium perfingens
Emergent surguer is indicated
45 years old femal has undergone ERCP sphinrctomy for obstructive juandice, few days after her procedure, xray eas done and air in biliary tree was detected , what could be the cause
It coould be retained air following the ERCP
Can occur after surgical anastomoses as well
Extent of primary milgnancy of biliary tree best with? Can detect LN, vessels, surrounded irgan involvment
CT
Patient undergoing PTC , what should be the preacusion?
Abx
Rule out couglopathy by PT
PTC advantage?
- place stent dor drainge
- show good visulization of intrahepatic duct
- allow analysis of bile cytolgy
- used as alterntive for ERCP if fail or there is hilar obstruction
Main Aterial and venous supply og GB is ?
- cystic artery , no venous
- accessory cystic artery , cysteic vein
- hepatic artery , hepatic vein
Cystic artery , no vein
First organ in metestic biliary treee milgnancy is ?
Liver
Since they share lymphatic draing of subserosa of GB and subcapsular in liver
Name of lymphatic drainge in CYStid ln of GB
Lymph of lund
Normal level of total bilirubin?
0.2-.07
قدير يقول شي ثاني
If patient with ibstructive haundice came , US was done , what eould you do in the following scenario: المرجع بركت Dilated duct: no dilation , what will be your next Dilated Gb:
Dilated duct: ERCP
بتشوفين اذا ستون وتشيلينهم
بس ليه ماخترتا MRCP احسه احسن🤷♀️
No dilation: Liver biopsy or laberscopy
ممكن تكون قلبرت سندروم اللي عو كونجينل دزيدز خلل بالانزيمز
Dilated GB: CT
ممكن تكون قال بلدر كانسر
stasis in the common duct occurs with chronic obstruction and dilatation and predisposes to bacterial infection.
- a potent cause of systemic sepsis.
Ascending cholngitid or acute cholngitis
How would you investigate patient with acute chopngitis
Laps: High WBC High LFT High Pancrease enzyme High bilirubin, CGT,ALp
RUQ Ultrasound (Best Initial Test): It Shows "Dilated CBD & Thickened Bile Duct Wall & Periductal Edema & Stone/Stricture/Tumor".
(ii) ERCP (Most Accurate Test & Therapeutic):
It Shows “ Dilated CBD & Smooth-Walled Intraluminal Filling Defect
Within The CBD & Etiology”. Note That, This Test Must Be Done After Stabilization Once Patient Has Been Afebrile For 48H, So That The Underlying Cause Can Be Identified & A Proper Treatment Plan Can Be Tailored.
Acute choolngitis nanagment
ثللث لشياء اساسيه
ريستيت
اشيل السبب
امنع الركرنيس
Best Initial Tx >
1- ICU Admission With Close Monitoring Of Hemodynamics, Blood Pressure, Urinary Output
2- Iv Fluid
3- Obtain Blood Culture Then Give Iv Broad-Spectrum Antibiotics. metronidazole ceftriaxone
Remove the cause:
Once The Patient Is Stabilized, CBD Decompression By ERCP ( Sphincterotomy +/- stent )
Unstable for ERCp: PTC (Catheter Drainage) Or Laparoscopy (T-Tube Insertion)
If The Patient Isn’t Responding
• Antibiotics, Performsurgical Decompression Emergently
3- cholecystectomy after 6 week ( admit dont discharge him till all three done)
Conplication of obstructive jaundice?
Fat malabsorption will result in - storrhea - vitamin K deficency Bradycardis due to high salt Hepatorenal syndrome
Conplication of acute chongitus
Sepsis Multiorgan failure Pertionitis Cholangitic abcess ( multiple intraheptic abcess when it soread to liver ) 2ed biliary curhosis
Ascending cholngitis triad , pentide
Triad
- jaundice
- ruq pain
- fever
Pentide
- Hypotension
- mental status
In px presenting with obstructive jaundice with low CBD dilation in US what would be your next step ?
ERCP
Will show filing defect
In px presenting with obstructive jaundice with upoer CBD dilation in US > 8cm what would be your next step ?
PTC
Visulize intrahepatic and extraheptic
فيه ثلاثه اندكشين مكتوبه له بمحاضره شريف بس مافهمتهم طلي عليهم 22
Hiw will you detect biliary leakage after ERCP?
Post operative T tube chaingogram allow detection of leakage and manage it, to ensure the patency of biliary system.
Pre-operative Precauation in patient with obstructive jaundice undergoing ERCP?
1 ) Prevent clotting dysfunction by giving iv vitamin k and FFP
2) Gaurd against liver cell failure by giving glauacose, abx
3) Gaurd against renal failure
By giving fluid and iv minnitol
كلهم على اثنين اثنين
How would you manage a patient with obstructive jaundice caused by stone or tumor
رجععي للمحاضره هالنقطه مهمه
How the stone is formed
By bile stasis, chemical inflmmation and bacterial infection اتوقع ذا الجواب بس شيكي على التجميعات في سوال زي كذا
Cloght triad border by different structure Cystic duct, inferior lobe of liver , hepatic duct , it is important to distinguish to prevemt injury to ?
Cystic artery which pass through this triangle
في كوز لت مهم تشيكين عليهم بالواتساب تجارب جابوا منهم سوالين تجميعات
