Gallbladder And Pancreas Flashcards
Asymptomatic gallstones do not require treatment except if?
Large stones > 3cm
What is the gold standard test for acute cholecystitis
HIDA- if positive the gallbladder wont be visualized
In Advance liver failure HIDA scan will be false positive because liver is not functioning so the gall bladder is not visualized
What is Mirizzi’s syndrome
Present with Dilated common hepatic duct and Jaundice
This is a complication of cholecystitis due to impacted stone in the cystic duct/gall bladder neck —-> the stone compresses the hepatic duct—> this results in obstruction and jaundice
Ultrasound shows gallstone and dilated common hepatic duct
Treatment is surgical cholecystectomy
What is a choledochoduodenal fistula AKA Cholecystoenteric fistula?
Erosions of gallstones through the gallbladder wall, so the gallstone erodes through the wall into the duodenum, from there the stone can travel down and cause obstruction at the terminal ileum and ileocecal valve
High mortality requiring urgent cholecystectomy or urgent cholecytostomy
What is chronic a calculus cholecystopathy (AKA Gallbladder dyskinesia) and how is it Dx and treated?
There is decrease gallbladder emptying leading to gallbladder dyskinesia, this causes RUQ pain
Patient have symptoms of biliary coli with NL U/S we can Dx with Radionucleotide scintigraphy with the CCK-stimulated gallbladder ejection fraction (+ is <35%)
Treatment is cholecystectomy
What does U/S shows in Acute Acalculous cholecystitis
Large, tense, static gallbladder without stones with evidence of poor emptying
What is choledocholithiasis and what is its most feared complications
Stone in the CBD
cholangitis
What is charcot’s Triad for Cholangitis?
RUQ pain
Fever
Jaundice
Raynaud’s
+ Hypotension, AMS
How do we workup a gallbladder polyp
On u/S gallbladder polyps do not move whereas stone do.
Gallbladder polyps more than 10 mm are more likely malignant and are usually adenocarcinoma.
Findings of a gallbladder polyp warrants cholecystectomy
what is cholangiocarcinoma?
How does patient present?
this is a bile duct cancer. When it is located near the porta hepatic it is called Klatskin tumors
Patient typically present with obstructive jaundice
Courvoisier sign: Distended palpable gallbladder
How does Adenocarcinoma of the Ampulla of Vater present?
What kind of patients do we typically see this in?
The ampulla of Vater is in the duodenum, this cancer because it is located in the duodenum can present with a UGIB (Melaka, iron def anemia).
Also because its in the ampulla it can cause obstructive jaundice
Typically seen in patients with :
- FAP, especially Gardener syndrome
- Peutz-Jeghers
According to the revised Atlanta classification of pancreatitis what are the 2 types?
What are the 2 phases of acute pancreatitis?
How is severity classified?
- Interstitial edematous pancreatitis (MC)
- Necrotizing pancreatitis
2 Phases
Early <1 week
Late phase after 1 week
Severity:
Mild=no organ dysfunction (Hypotension not responding to fluid, AKI, Respiratory Failure)
Moderate=Transient organ failure that resolves in <48 hours
Severe= Organ failure >48 hours
What are the local complications of acute pancreatitis?
- Interstitial edematous pancreatitis:
<4 weeks=Acute peripancreatic collection
>4 weeks=Pseudocyst - Necrotizing pancreatitis
<4 weeks=Acute necrotic collection
>4 weeks=Walled of necrosis
Which scoring system is used to predict mortality in acute pancreatitis?
BISAP score
BUN >24 Impaired mental ion SIRS Age >60 Pleural effusion
Patients with Gallstone pancreatitis undergoing cholecystectomy should also undergo what additional test and why?
They should undergo Lap chole with Intraoperative cholangiogram
The cholangiogram is done to see if there is any filling defects in the CBD for retained stone; if + then the patient will also need to undergo ERCP with stone extraction
Causes of death in pancreatitis?
First Week= Organ failure (ARDS, Shock)
After First Week=Pancreatic or systemic infections
How do we diagnose Pancreatic necrosis?
If symptoms do not resolve after 72 hours order CT with contrast
Necrosis is usually sterile (chemical necrosis) but if infection is suspected (ie fever) FNA under CT guidance is performed
What are other complications of acute pancreatitis?
- Asymptomatic pancreatic or extra-pancreatic necrosis and pseudocyst need no intervention regardless of size, location, or extent
- Symptomatic mature pseudocysts are drained
- Pseudoaneurysm formation with bleeding into the retroperitoneum and bowel treatment is with embolization
- Can lead to fistula formation
- Splenic vein thrombosis-leads to isolated gastric varies
- Alcoholic pancreatitis can lead to diabetes
What test are ordered for chronic pancreatitis?
First test Fecal elastase/ chymotrypsin (low in chronic pancreatitis)
Serum trypsinogen
If all negative can do Secretin-CCK test
what is the best initial imaging for chronic pancreatitis?
CT abdomen
which immunoglobulin is elevated in Autoimmune pancreatitis?
IgG4
What constitutes the majority of pancreatic cancers?
Adenocarcinoma makes 90%
Neuroendocrine tumors make 5% (Gastrinoma, Insulinoma, Glucagonoma, VIPoma, Somatostatinoma)
Presentation of pancreatic cancer?
What is the workup?
Abdominal or back pain Weight loss Jaundice New onset DM Worsening of previously controlled DM
Order CT scan with thin cuts this is followed by EUS with FNA
How should a asymptomatic pancreatic cyst be be managed?
If cyst has more than 2 high risk features then EUS with FNA
No high risk features then MRI in 1 year, if unchanged, repeat MRI every 2 years for a total of 5 years.
chronic non-healing anal fissure can be treated with?
Lateral internal sphincterotomy or Botox injections
What are the types of constipation?
- Slow transit (MC type)
- the normal colonic transit time of <72 hours is increased up to 120 hours
- Rx fiber, laxatives - Dyssynergic defecation or evaluation disorders (AKA Pelvic floor dysfunction)
-when the patient is ready to poop instead of the pelvic floor relaxing it instead contracts and patient often strains
-Dx with Anorectal Manometry
Rx: Biofeedback - constipation predominant IBS
- Pain is predominant, transit time and pelvic function normal.
When do we perform colonic transit and pelvic floor dysfunction testing for constipation?
when there’s no response to standard therapy
How is continuation treated?
Fiber and Fluid
If no relief start with a bulking agent (psyllium) then osmotic (lactulose, polyethylene glycol, sorbitol) then stimulants (bisacodyl, senna)
What medications a re approved for chronic idiopathic constipation And constipation predominant IBS
Lubiprostone
Linaclotide
What medication is approved for opioid induce constipation?
what medication is proved for post-op ileus due to bowel surgery?
Methylnaltrexone
Alvimopan
What do we use to screen for Malnutrition inpatient?
MUST screening tool or Nutritional risk screening tool
Does PEG tube placement improve outcome in advance dementia patients?
No, it does not recent ulcers and it increase risk of aspiration PNA
they are only placed if enteral feeding needs are greater than 4 weeks
Patients with PEG tube how should residuals be managed?
Check residuals q 4hours for first 48 hours
If Residual > 250 add promotility
If Residual >500 hold tube feeding and reassess
Also elevate head of bed for all patients on Peg feeding
What electrolyte abnormalities do we see with reseeding syndrome?
Hypophosphatemia Hypokalemia Hypomagnesemia Hypocalcemia hyponatremia
