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gallbladder Flashcards

1
Q

Choledocholithiasis is

A

formation and migration of stones inside the biliary tree or common bile
duct

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2
Q

pigment stones

A

– contain bilirubin and

calcium - radiopaque

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3
Q

Risk factors for pigment gallstones:

A

1) hemolytic conditions (sickle cell anemia (beta chain issue),
hereditary spherocytosis, thalassemia (absence of 1 globulin))
2) liver cirrhosis
3) intraductal stasis (choledochole cyst, postsurgical billiary stricture)

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4
Q

Risk factors for mixed gallstones:

A

1) Crohn’s disease
2) partial removal of ilium
3) decreased gallbladder motility:
- severe trauma (e.g. car accident)
- severe burns
- paralysis

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5
Q

gallstones are asymptomatic in what percent of patients

A

70-80%

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6
Q

gall stone attack

A
  • sudden acute pain in the right upper quadrant,
    lasts 30 minutes to several hours, until the
    gallbladder relaxes
  • pain radiates to back, between blades, right
    shoulder, behind sternum
  • change of posture, defecation do not relieve
    pain
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7
Q

_____ is positive in Cholelithiasis

only when it is complicated with Cholecystitis

A

Murphy’s sign

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8
Q

Murphy’s sign is negative with

A

the stone

in the bile duct (Choledocholithiasis)

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9
Q

Cholelithiasis signs and symptoms

A
  • tachycardia
  • nausea, vomiting (vomiting does not relieve pain)
  • increased production of gas
  • fat intolerance
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10
Q

Signs and Symptoms in

Choledocholithiasis:

A
  • the Charcot triad (indicates the ascending cholangitis)
    = severe right upper quadrant pain
    = jaundice
    = fever
  • acute constant pain in the upper part of the
    abdomen
  • obstructive jaundice
  • Murphy’s sign is negative
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11
Q

Cholelithiasis diagnosis

A
  • Blood tests are informative in the cases of exacerbation:
  • increased WBC (during migration only)
  • increased common bilirubin content (left shift)
  • increased alkaline phosphatase (enzyme present in liver and bile, synthesized by pregnant women)
  • High ALP
  • ultrasound
  • CT
  • MRI
  • ERCP (endoscopic retrograde cholangiopancreatography)
  • xray (porcelain gallbladder)
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12
Q

ALP

A

-Alkaline phosphatase (ALP) is an enzyme presenting in all tissues of the body, but is particularly concentrated in: liver, bile duct, kidneys, bones, placenta

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13
Q

-High ALP can show:

A
  • liver disease
    • bile duct obstruction
    • presence of Paget’s disease with osteoblastic
      activity
    • presence of pregnancy
    • presence of Celiac disease
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14
Q

gold standard for exam and diagnosis of gallbladder stones

A

ultrasound

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15
Q

“porcelain

gallbladder”

A

characterized by calcification of gallbladder wall, developing usually in cholelithiasis complicated by chronic cholecystitis

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16
Q

Radiologic exam can be used for differential diagnosis
between gallbladder and kidney stones.
On lateral lumbar X-ray film:

A
  • the gallstones locate in front of lumbar spine - the kidney stones overlap L2 or locate posterior to it
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17
Q

acute cholecystitis

A

when the cystic duct is obstructed

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18
Q

chronic cholecystitis,

A

when long-term
presence of gallstones (“silent” stones)
leads to fibrosis of the gallbladder wall,
with further its calcification (“porcelain
gallbladder”)

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19
Q

complications of cholelithiasis

A
  • acute cholecystitis
  • chronic cholecystitis
  • gallbladder gangrene
  • perforation of rupture
  • cholangitis
  • acute pancreatitis
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20
Q

perforation or rupture of

the gallbladder

A

with
development of bile peritonitis
and high level of mortality

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21
Q

cholangitis

A

when the common bile duct
is obstructed before joining
the pancreatic duct

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22
Q

acute pancreatitis

A

when the hepatopancreatic duct or pancreatic duct is obstructed

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23
Q

Cholecystitis

A

is defined as inflammation

of the gallbladder wall.

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24
Q

the two forms of cholecystitis?

A
  • calculous

- acalcolous

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25
Q

calculous

A

when stones in the

gallbladder are formed – 90%

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26
Q

acalcolous

A
  • without formation of stones
  • 10%
  • most severe
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27
Q

Risk factors for calculous cholecystitis:

A
  • female sex
  • obesity
  • rapid weight loss
  • multiple pregnancies
  • increasing age >35-40
  • ethnic groups (Hispanic, Scandinavian)
  • drugs (especially hormonal therapy
    in women)
28
Q

Etiology of acalculous cholecystitis

A 
- critical illness (HIV, diabetes mellitus,
myocardial infarction) 
- major surgery or severe trauma/burns 
- sepsis 
- long-term total parenteral nutrition 
- prolonged fasting 
- Salmonella infection
29
Q

Pathogenesis of acute cholecystitis

A 
etiological agents 
         ↓ 
decrease the gallbladder motility 
         ↓ 
delay of bile evacuation 
         ↓
increase of pressure inside gallbladder, increase of bile concentration, activation of opportunistic bacteria (e.g. E.coli)
         ↓ 
inflammation of gallbladder wall
30
Q

Pathogenesis of acute cholecystitis

A 
inflammation of gallbladder wall 
         ↓         ↑ 
edema of gallbladder wall
         ↓
compromising of blood flow and lymphatic drainage in
gallbladder wall and surrounding tissue 
        ↓ 
ischemia and necrosis of gallbladder wall
and surrounding tissue
31
Q

Pathogenesis of chronic cholecystitis:

A

Chronic cholecystitis occurs after repetitive mild
exacerbations of acute cholecystitis, and is
characterized by mucosal atrophy and fibrosis of
gallbladder wall

32
Q

Signs and symptoms of acute cholecystitis

A
  • acute pain in right upper abdomen that is severe
    and constant, may last for days (!)
  • this pain is increased with breathing
  • pain radiates to right shoulder, or right scapula,
    or right mid back (T8 –T9 levels)
  • changing position and passing gas do not
    relieve the pain
  • large amount of meal or fat meal can trigger the
    pain
  • pain occurs several hours after eating and
    awakens the patient during the night
  • fever and chills
  • nausea and vomiting
  • vomiting does not relieve the pain (unlike to
    peptic ulcer)
33
Q

Signs and symptoms of chronic cholecystitis:

A 
- the first symptoms are bitter taste and taste of
metal in the mouth in the mornings
- abdominal discomfort after meals 
- complaints of gas accumulation 
- nausea 
- chronic diarrhea
- presence of skin xanthomas
34
Q

skin xanthomas

A

Xanthomas represent focal accumulation of cholesterol, result from cholestasis or/and hyperlipidemia

35
Q

diagnosis of cholecystitis

A
  • ortner’s sign
  • georgievskiy-myussi’s sign
  • Murphy’s sign
  • Boas’sign
  • blood test
  • ultrasound sonography
  • MRI
  • CT-scan
  • HBS- hepatobiliary scintigraphy
36
Q

Differential diagnosis – for acute

cholecystitis:

A
  • acute peptic ulcer
  • perforated peptic ulcer
  • acute pancreatitis
  • ureteral colic
37
Q

Differential diagnosis – for chronic

cholecystitis:

A
  • peptic ulcer
  • hiatal hernia
  • colitis
  • chronic pancreatitis
38
Q

cholecystitis Complications:

A
  • perforation or rupture of gallbladder
  • ascending cholangitis
  • local abscess
  • peritonitis
39
Q

Management of acute cholecystitis:

A

cholecystectomy

40
Q

Management of chronic cholecystitis:

A
  • diet modification
  • antibiotics
  • restriction of physical activity
41
Q

Pancreatitis

A

when certain enzymes that normally do not
become active until they reach the small
intestine, become active in the pancreas
“digesting” this gland itself
-The enzyme Trypsin plays the most important role
in this process

42
Q

Types of pancreatitis:

A 
1) acute – is reversible disease, if does not turn
into chronic pancreatitis
2) chronic – is irreversible disease,
characterized by atrophy, fibrosis, and
calcification of pancreatic parenchyma
43
Q

Etiology for acute pancreatitis

A
  • alcohol use (even once)
  • gallstones
  • trauma of the abdomen
  • viral infections (e.g. Mumps)
  • pseudocysts
  • medications (corticosteroids, estrogen, statins)
44
Q

Etiology for chronic pancreatitis

A
  • alcoholism
  • cystic fibrosis
  • pseudocysts
  • idiopathic
45
Q

Signs and Symptoms for acute pancreatitis

A
  • sudden acute, severe pain in upper abdomen,
    lasts from short time to days, and resolves
    itself
  • pain worsens after food eating
  • pain may reach to across the back, level
    T8–L1 – so called “band-like” pain
  • pain could radiate to other areas:
    = umbilical
    = both flanks
    = left shoulder
  • pain worse when lying flat on the back
  • pain decreases with sitting and flexion
    forward (unlike to pain in cholelithiasis and acute cholecystitis)
  • this pain is always accompanied by high blood pressure and tachycardia
  • positive Cullen’s sign
  • positive Grey-Turner’s sign
  • nausea
  • vomiting
  • fever
46
Q

where is the band-like pain located from acute pancreatitis

A

T8-L1 across the back

  • pain could radiate to :
    • umbilical
    • both flanks
    • left shoulder
47
Q

when is pain worse in acute pancreatitis?

A
  • when laying flat on the back

- after eating food

48
Q

when is pain decreased in acute pancreatitis?

A

-with sitting and flexion forward

49
Q

Cullen’s sign

A

– is superficial edema
and bruising in the subcutaneous fatty tissue
around the umbilicus

50
Q

Grey-Turner’s sign

A

ecchymosis of flanks
-bruising of the flank, which may be indicative of
pancreatic necrosis with retroperitoneal or
intraabdominal bleeding

51
Q

what sign can predict acute pancreatitis

A

both Cullen’s and Grey-Turner’s signs can

predict acute pancreatitis

52
Q

Signs and Symptoms for chronic pancreatitis

A
  • acute pain is not resolved itself
  • pain increases after eating and drinking
  • change of position does not relieve the pain
  • band-like pain
  • nausea
  • severe vomiting
  • fatty stool
  • signs of diabetes mellitus II only: thirst, polyuria
  • weight loss
53
Q

Diagnosis:

A 
- blood amylase and lipase are 4-6 times higher
than normal variations
Lipase is better indicator!
- urine amylase is significantly increased
- blood glucose level increased
- ultrasound
- CT-scan
- MRI
54
Q

Complications for acute pancreatitis

A 
- pancreatic
abscess
- pancreonecrosis
- acute gastritis and duodenitis because they
are adjacent organs
- internal bleeding with development of
hypovolemic shock
- lung problems (enzymes may affect the lung
tissue causing its inflammation)
55
Q

Complications for chronic pancreatitis

A
  • diabetes mellitus
  • pancreatic cancer
  • calcification of pancreas
  • multiple cysts
56
Q

Pancreatic Cancer

A

-is a malignant neoplasm
originating from transformed cells of the pancreas
-The most common type is Adenocarcinoma (95%), arising from the exocrine component, from the cells that line the ducts of the pancreas

57
Q

Predisposing Factors for pancreatic cancer

A
  • chronic pancreatitis
  • smoking
  • family history
  • age over 60 years old - diet with high amount of red meat, soft drinks
  • obesity
  • partial gastrectomy as treatment of obesity
  • Helicobacter pylori infection
58
Q

pancreatic cancer Signs and Symptoms

A

-early is asymptomatic aka the “silent” disease
- unexplained weight loss
- anorexia
- nausea, vomiting
- steatorrhea (pooping fat)
-clinical depression
- painless jaundice, may be associated with
itching
- jaundice develops when the cancer locates
in the head of pancreas
-pain in upper abdomen, radiates to back if tumor is in body or tail
-trousseau sign
-pulmonary embolism

59
Q

what is the most common location for pancreatic cancer?

A

head -75%
body -15%
tail -10%

60
Q

Trousseau sign

A

unexplained thrombophlebitis of superficial veins anywhere in the body,
portal vein or deep veins of the extremities

61
Q

pulmonary embolism is a symptom of pancreatic cancer

A

because the pancreatic cancer produces the blood clotting chemicals

62
Q

Pancreatic cancer diagnosis

A

-blood CA-19-9 – this is a tumor marker that
is frequently elevated in pancreatic or liver cancer
- CT-scan
- endoscopic ultrasound (EUS)
- endoscopic ultrasound with endoscopic needle
biopsy

63
Q

pancreatic cancer Metastases steps

A 
#1 – to regional lymphatic nodes
#2 – liver-portal vein
#3 – lungs and pleura
64
Q

Endocrine Pancreatic Tumors

A
  • Insulinoma

- Zollinger-Ellison syndrome

65
Q

Insulinoma

A

-located in tail
-endocrine pancreatic tumor
- beta-cell tumor, generally
benign, is characterized by overproduction of
Insulin, which can result in hypoglycemia

66
Q

Zollinger-Ellison syndrome Gastrinoma

A

-arises in the duodenum, pancreas and
peripancreatic soft tissue
- It is characterized by overproduction of Gastrin
which stimulates extreme hydrochloric acid
secretion
- it causes multiple peptic ulceration not only in
the stomach and duodenum, but also in
jejunum
- it can metastasize to the liver leading to
significantly short life

67
Q

Zollinger- Ellison syndrome Diagnosis:

A
  • blood testing to detect increased gastrin levels
  • upper gastrointestinal (GI) endoscopy
  • imaging tests to look for gastrinoma
  • measurement of stomach acid
    (gastric pH less than 2.0; large gastric volume >140 mL)
    is highly suggestive of ZES

GE (6 decks)

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