gallbladder

Question 1

incidence of gallstones

Answer 1

by age 75, 35% of women and 20% of men

30% of people will have symptomatic disease

Question 2

.what is acute cholecystitis

organisms

Answer 2

gallstone obstruction of the cystic duct

leads to chronic inflammation

e coli most common. klebsiella and gm neg organisms

Question 3

.colicky epigastic pain or RUQ pain becoming steady and increases in intensity. often occurs after a high fat or large meal

*post prandial abdominal pain, assoc with N/V

Answer 3

acute cholelcystitis symptoms

Question 4

.+ BOAs sign

Answer 4

acute cholecystitis

referred pain of right shoulder or subscapular area (phrenic nerve irritation)

Question 5

.labs and imaging to order for acute cholecystitis

Answer 5

*HIDA scan most accurate test (cholecystitis present if no visualization of gallbladder)

u/s initial test of choice

bilirubin levels with increase after 24hrs and leukocytosis common, increased LFTs and alk phos

Question 6

HIDA scan and ERCP for what

Answer 6

gallstone

HIDA to confirm

ERCP to identify cause, location, and extent of biliary obstruction

Question 7

what is acute ascending cholangitis

Answer 7

potentially deadly condition of “common bile duct” obstruction combined with ascending infection due to gallstones or malignancy

Question 8

.charcots triad

Answer 8

RUQ tenderness, jaundice, fever/chills. occurs in 50-70% of acute cholangitis

Question 9

pt has charcots triad and also altered mental status and hypoTN

Answer 9

sepsis with acute cholangitis

Question 10

elderly presentation of acute cholangitis

Answer 10

confusion, falls, and incontinence

Question 11

.incidence of acute ACALCULOUS cholecystitis

describe

r/f

Answer 11

10% of acute cholecystitis

gallballer stasis and ischemia

critically ill pts

Question 12

.initial management tx for acute cholangitis (3)

Answer 12

antibx (FQ+flagyl, piperacillin/tazobactram, ampicillin/sulbactram, gentamycin + ampicillin, ceftriaxone + flagyl)

followed by CBD decompression and stone extraction once stable ERCP

Question 13

.what is primary sclerosing cholangitis

r/f

Answer 13

diffuse fibrosis of the intra and extrahepatic biliary ducts

IBS: UC 90%

Question 14

.80% of primary sclerosing cholangitis is associated with what

Answer 14

inflammatory bowel disease, generally UC

10% of pts with UC will develop PSC

Question 15

ge.nder and age of primary sclerosing cholangitis

Answer 15

men 20-40

Question 16

.sx of primary sclerosing cholangitis

Answer 16

jaundice and pruritis most common

hepatomegaly and/or splenomegaly on exam

fatigue, malaise, wt loss

Question 17

.primary sclerosing cholangitis

accurate test

labs

avoid what

Answer 17

labs: increased alk phos and ggt. ast/alt, bilirubin, igM increased

hallmark: positive P-ANCA

MRCP, ERCP(most accurate test) “beading” mulitiple bile duct strictures

avoid liver bx

Question 18

.tx for primary sclerosing cholangitis

Answer 18

localized strictures relieved with balloon dilation and stent placement

cholestyramine for pruritis

liver transplant is the only tx with a known survival benefit

Question 19

complications of gallstones

Answer 19

cholecystitis

pancreatitis

acute cholangitis

Question 20

tx of acute cholecystitis

non op pt

Answer 20

fluids, antibiotics(ceftrixone + flagyl), then ccy sx

cholecystostomy (perc drainage)

Question 21

acute cholelcystitis symptoms

radiation

other mild symptoms

Answer 21

colicky epigastic pain or RUQ pain becoming steady and increases in intensity. often occurs after a high fat meal

radiation to rt shoulder or subscapular area

N/V, low fever are common

constipation and mild paralytic ileus may occur

Question 22

acute cholangitis organisms

other causes

Answer 22

E coli, enterococcus, klebsiella, enterobacter

can lead to sepsis and death

most often caused by choledocholithiasis,

or neoplasms, post op strictures, other causes of obstruction

Question 23

reynolds pentad

Answer 23

charcot triad

altered mental status

hypotension and shock

all indicate sepsis!! fatal!!

think cholangitis

Question 24

primary sclerosing cholangitis is strongly associated with what

Answer 24

cholangcarcinoma (10-30% of pts) as well as with an increased risk of pancreatic and colorectal carcinoma

Question 25

secondary tx for acute cholangitis

Answer 25

[ECRP for drainage and cholecystectomy] ECRP for drainage, sphincterotomy, stone removal, and stent placement when pt is stable percutaneous transhepatic biliary drainage or surgical biliary drainage may be required cholecystectomy should be performed after the acute syndrome is resolved when a stone is present

Question 26

.5 F's for gallstones

Answer 26

female fat forty fertile fair

Question 27

additional risk factors: OCP use, rapid wt loss, TPN, chronic hemolysis(pigment stones in sickle cell disease), small bowel resection(loss of enterohepatically circulated bile)

Answer 27

gallstones

Question 28

.acute cholecystitis symptoms(3) and exam(1)

Answer 28

RUQ pain, N/V, low fever murphy sign, boa's sign

Question 29

.murphy sign

Answer 29

inspiratory arrest with deep palpation of RUQ acute cholecystitis

Question 30

risk factors: native american DM pregnancy crohns female obesity

Answer 30

risk factors for cholecystitis

Question 31

RUQ ultrasonography increased alk phos and bilirubin leukocytosis with left shift ERCP: "beading" mulitiple bile duct strictures liver bx: "onion skinning" periductal sclerosis

Answer 31

tests for primary sclerosing cholangitis

Question 32

.why are most gallstones not radiopaque

Answer 32

cholesterol

Question 33

confusion, falls, and incontinence

Answer 33

elderly presentation of acute cholangitis

Question 34

.incidence of acute ACALCULOUS cholecystitis dx test and tx

Answer 34

u/s initial test contrast enhanced abd CT if u/s is uncertain HIDA is still uncertain supportive tx

Question 35

.acute ascending cholangitis organisms s/s

Answer 35

e coli most common. klebsiella 2nd. charcots triad and reynolds pentad

Question 36

.acute ascending cholangitis dx labs/imaging cholestasis

Answer 36

u/s initial cholangiography via ERCP is gold standard labs: leukocytosis with poss left shift. cholestasis: increased alk phos and ggt, increased bilirubin > increased ast/alt

Question 37

.ERCP can be performed when

Answer 37

once the patient has been afebrile/stable for 48 hours after IV antibx

Question 38

.what is cholelithiasis

Answer 38

gallstone in biliary tract without inflammation. may get colic abruptly with fatty meal.

Question 39

.what are black and brown stones

Answer 39

black: hemolysis or alcohol related cirrhosis: increased in asian population, parasitic, or bacterial infections

Question 40

.what is choledocholithiasis s/s and tx

Answer 40

gallstone in common bile duct prolonged biliary colic, jaundice ercp for dx(after u/s) and tx

Question 41

.primary biliary cirrhosis/cholangitis disorder of what age/gender

Answer 41

intrahepatic bile ducts that leads to decreased bile salt excretion, cirrhosis, end stage liver ds women middle aged

Question 42

.primary biliary cirrhosis/cholangitis disorder s/s PE

Answer 42

most asymptomatic, incidental finding of high alk phos fatigue 1st symptom, pruritis, RUQ discomfort PE: hepatomegaly, jaundice.

Question 43

.primary biliary cirrhosis/cholangitis disorder hallmark dx

Answer 43

antimitochondrial antibody. u/s initial imaging test bx definitive