Gallbladder and Bile Duct Flashcards
What are the classic symptoms and signs of gallstone disease?
Classic gallstone disease symptoms include postprandial colicky pain in the right upper quadrant with bloating and/or nausea and vomiting. The pain usually begins 15 to 60 minutes after a meal (especially a fatty meal). Look for the Murphy sign (palpation of the right upper quadrant under the rib cage causes arrest of inspiration because of pain) as the main physical examination finding for cholecystitis.
What are the six Fs of cholecystitis? How do the demographics of patients with pigment stones differ from those of patients with cholesterol stones?
The first five Fs summarize the demographics of individuals with cholesterol gallstones: fat, forty, fertile, female, and flatulent; the sixth F is febrile, which indicates that such patients have now developed acute cholecystitis. Patients with pigment (i.e., calcium bilirubinate) stones are classically young patients with hemolytic anemia (e.g., sickle cell disease, hereditary spherocytosis)
How is a clinical suspicion of cholecystitis confirmed and treated?
Ultrasound is the best first imaging study for suspected gallbladder disease. It may show gallstones, a thin layer of fluid around the gallbladder (termed pericholecystic fluid), and/or a thickened gallbladder wall. A more specific ultrasonographic Murphy sign using direct visualization of the gallbladder can be obtained (variant anatomy and significant obesity can create uncertainty). A nuclear hepatobiliary scintigraphic study (e.g., hepatoiminodiacetic acid [HIDA] scan) confirms the diagnosis for a nonvisualized gallbladder. The treatment comprises pain control and cholecystectomy (antibiotics may be indicated if infection is suspected); a laparoscopic approach is generally preferred over an open procedure.
What are the types of biliary tract obstruction commonly tested in the USMLE?
Bile duct obstruction, cholestasis, cholangitis, primary biliary cirrhosis, and primary sclerosing cholangitis.
What signs and symptoms suggest biliary tract obstruction as a cause of jaundice?
• Elevated conjugated bilirubin (conjugated bilirubin is more elevated than unconjugated bilirubin because the liver still functions and can conjugate bilirubin, but conjugated bilirubin cannot be excreted because of biliary tract disease) • Markedly elevated alkaline phosphatase • Pruritus • Clay-colored stools • Dark urine that is strongly positive for conjugated bilirubin (unconjugated bilirubin is not excreted in the urine because it is tightly bound to albumin)
Who typically gets primary sclerosing cholangitis?
Primary sclerosing cholangitis usually occurs in young adults with inflammatory bowel disease (usually ulcerative colitis). The symptoms are similar to bacterial cholangitis. Fever, chills, pruritis, and abdominal pain in the right upper quadrant are common.
What usually precipitates cholangitis? What is the tip-off to its presence? How is it treated?
Cholangitis is usually precipitated by a gallstone that blocks the common bile duct, with subsequent infection of the bile duct system. The tip-off is the presence of the Charcot triad: fever, right upper quadrant pain, and jaundice. Treatment is as described in the previous question.
Define cholangitis. How does it differ from cholecystitis? How is it treated?
Cholangitis is inflammation of the bile ducts, whereas cholecystitis is inflammation of the gallbladder. Cholangitis is classically due to biliary obstruction with subsequent bile stasis and infection. Choledocholithiasis (a gallstone in the common bile duct) and malignancy are common causes of obstruction. Autoimmune cholangitis (e.g., sclerosing cholangitis) and primary infection (e.g., Clonorchis sinensis and other parasite infections common in some parts of Asia) are other causes. Cholangitis classically involves the Charcot triad: (1) right upper quadrant pain, (2) fever or shaking chills, and (3) jaundice. As patients worsen and develop sepsis from their cholangitis, they can develop the Reynold pentad, which also includes (4) hypotension and (5) altered mental status. Patients may have a history of gallstones. Start broad-spectrum antibiotics to cover bowel flora (e.g., piperacillin with tazobactam), then manage more definitively depending on the circumstances (treatment of cholangitis caused by gallstones is endoscopic retrograde cholangiopancreatography [ERCP] to remove stones in the common bile duct, with subsequent cholecystectomy to remove the gallbladder; biliary stent placement is the most common treatment for unresectable obstruction caused by malignancy).
What are the two major causes of common bile duct obstruction? How are they distinguished?
The most common cause is obstruction by a gallstone (choledocholithiasis). Look for a history of gallstones or the four Fs (female, forty, fertile, and fat). Ultrasound often images the stone; if not, use magnetic resonance cholangiopancreatography (MRCP) or ERCP. Treatment involves endoscopic removal of the stone. The second major cause of common bile duct obstruction is cancer. Look for weight loss. Pancreatic cancer is the most common type; look for the Courvoisier sign (jaundice with a palpably enlarged gallbladder). Sometimes cholangiocarcinoma or bowel cancer blocks the common bile duct.
What clues suggest a diagnosis of primary biliary cirrhosis?
This condition is usually seen in middle-aged women with no risk factors for liver or biliary disease. It causes marked pruritus, jaundice, and positive antimitochondrial antibodies. The rest of the workup is negative. Cholestyramine helps with symptoms, but the only treatment is liver transplantation.
What are the two common causes of cholestasis?
Medications (e.g., birth control pills, trimethoprim-sulfamethoxazole, phenothiazines, androgens) and pregnancy.
Which diseases can cause elevated levels of alkaline phosphatase? What laboratory test is used to distinguish among these diseases?
Alkaline phosphatase can be elevated in biliary disease, bone disease, and pregnancy (the placenta produces alkaline phosphatase). If the elevation is due to biliary disease, gamma-glutamyltranspeptidase (GGT) and/or 5′-nucleotidase (5′-NT) should also be elevated; however, both values are normal in bone disease and pregnancy.
