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GI Week 6 > Gallbladder Disease and Jaundice > Flashcards

Gallbladder Disease and Jaundice Flashcards

1
Q

WHat are the four main liver tests?

A

AST
ALT
bilirubin
alkaline phosphatase

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2
Q

If AST and ALT are elevated, but bilirubin and alkaline phosphatase are not, where is the issue?

A

hepatocellular

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3
Q

If bilirubin and alkaline phosphatase are higher than the AST/ALT, where is the issue?

A

cholestatic

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4
Q

What is hte main etiology of jaundice in an infant?

A

physiologic jaundice of the newborn

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5
Q

What are the two main etiologies of jaundice in adolescents?

A
  1. Gilbert’s syndrome

2. Viral hepatitis

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6
Q

What are the main etiologies of jaundice in young adults?

A
  1. Viral hepatitis
  2. Biliatry tract obstructions
  3. Autoimmune hepatitis
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7
Q

What are the main etiologies of jaundice in the elderly?

A
  1. malignancy
  2. toxins or drugs
  3. stones
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8
Q

What disorder causes a benign unconjugated (indirect_)bilirubinemia?

A

Gilbert’s Syndrome

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9
Q

What are some examples of physical evidence of chronic liver disease?

A 
spider hemantiomas
ascites
edema
caput medusa
palmar erythema
asterixis
xanthelasma
proximal muscle wasting
testicular atrophy
partotid enlargement
Dupuytren's contractures
gynecomastia
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10
Q

What level does the bilirubin typically have to reach before jaundice becomes visible?

A

2-3 mg/dl

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11
Q

WHat is the likely cause of the pruritis that typically occurs with jaundice?

A

thought to be retained bile acids in the skin

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12
Q

What is the cause of the spider hemangiomas and palmar erythema in liver disease?

A

reduced estrogen breakdown leading to increased estrogen levels

(also causes the testicular atrophy and gynecomastia)

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13
Q

What are some causes of unconjugated bilirubinemia (more in depth than just hemolysis please)….

A 
Gilbert's
hemolysis
ineffecive erythropoiesis
drugs
thyroid disease
pulmonary infarct
Crigler-Najjar syndrome
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14
Q

What are potential causes of conjugated bilirubinemia?

A
  1. obstruction of biliary tract
  2. Cholestatic liver disease
  3. Hepatocellular disease
  4. Drugs
  5. Septis
  6. Infiltrative disorders like amyloidosis
  7. post-op complications
  8. benign recurrent intrahepatic cholestasis (the oconjugated version of Gilbert’s)
  9. renal disease
  10. congenital causes
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15
Q

90% of gallstones in america are composed of what?

A

cholesterol (with somebilirubinate mixed in)

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16
Q

When are pigmented stones more common?

A

black - cirrhosis or hemolytic anemia

brown - commin in asian immigrants and associated with biliary tract infections

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17
Q

What imaging study is the gold standard for first look at gallstones or cholecystitis?

A

transabdominal ultrasound
sensitivey 95% and specificity 98% unless you have a really fat person

pretty bad for CBD stones though because they’re further down.
Can detect CBD dilation (over 6 mm is dilated) though. and GB wall thickenss (over 4 mm thickened)

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18
Q

What are the risk factors for cholesterol stones?

A
  1. increasing age
  2. female (fat, female, forty, fertile)
  3. rapid weight loss
  4. native american
  5. hyperalimentation
  6. elevated triglycerides
  7. taking fibric acid derivatives, estrogens or octreotide
  8. ileal disease (resection or bypass)
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19
Q

What are the risk factors for pigement stones?

A
  1. increasing age.
  2. chronic hemodialysis
  3. alcoholic liver disease
  4. biliary infection
  5. asian heritage
  6. hyperalimentation (GB stasis)
  7. duodenum diverticulum
  8. truncal vagotomy primary biliary cirrhosis
20
Q

True or false: most gall stones are asymptomatic.

A

true - rate of biliary pain seen in people with incidental asymptomatic gall stones was 2% per year for 5 years and decreased after that

21
Q

What are the main complications of gall stones?

A
  1. biliary pain
  2. acute cholecystitic
  3. chronic choleycstitis
  4. choledocholithiasis (when the stone exits the GB and lodges somewhere else)
  5. ascending cholangitis
  6. gallstone pancreatitis
22
Q

Why is the pain you get with gallstones so colicky?

A

It’s caused by the GB muscle wall spasming around the obstruction

23
Q

Where is the biliary pain usually located?

A

RUQ and epigastrium

can radiate around to the interscapular region or right shoulder

24
Q

Pain over 6 hours with fever suggests either what two things?

A

cholceystitis or cholangitis

25
Q

If you were sure there was a gallstone causing someone’s pain, but but you didn’t see it on transabdominal ultrasound, what are your options?

A
  1. do an esophageal ulstrasound to get a better look for the missed stones
  2. might be microlithiasis (sludge) that was missed by TAUS - try EUS
  3. HIDA scan with CCK to look for ejection fraction. If the ejection fraction is less than 35%, probably has chronic choleyctitis
26
Q

What symthptoms would you expect to see in acute cholecystitis?

A

abdominal pain
fever
leukocytosis

27
Q

90-95% of acute cholecystitis is caused by….

A

gallstones

28
Q

The 5% of acute cholcystitis cases not cause by gallstones are caused by what?

A

caclculous cholecystitis in critically ill patients - no obstruction is present but the gall bladder is dysfunctioning and you still have stasis

29
Q

Describe a Murphy sign

A

push on RUQ, tenderness on inspiration with inspiratory arrest

30
Q

WHat are the typical US findings in acute cholecystitis?

A

gallstones
gallbladder wall thickening over 4 mm
pericholecystic fluid

31
Q

What is the general management for most acute cholecystitis?

A

broad spectrum antibiotics
pain management
cholecystectomy within 96 hours of onset of symptoms

32
Q

WHat is the differnce between primary choledocholithiasis and secondary choledocholithiasis?

A

primary = stones that actually form in the CBD

secondary stones that migrate to the CBD from the GB

33
Q

Sometimes you’ll get a patient who is clearly having a gallbladder or biliary tree issue. WHat are some predictors that the issue includes choledococholithiasis?

A
  1. CBD stone seen on US (duh)
  2. clinical ascending cholangitis
  3. bilirubin over 4 mg/dl

less strong: dilated CBD, minimal bilirubin elevation, abnromal LFT other than bili, age over 55, clinical gallstone pancreatitis

34
Q

Although some cases of choledocholithiasis are asymptomatic, many have charcot’s triad, which is…

A

fever
abdominal pain
jaundice

35
Q

What is the treatment for choledocholithiasis?

A

ERCP with stone removal

36
Q

80% of cholangitis cases are from gallstones, but what are some other causes?

A

neoplasm
strictures from primary sclerosin cholangitis
parasitic infections
congenital bile duct abnormalities that lead to bile stasis

37
Q

What is the treatment for cholangitis?

A

broad spectrum antibiotics to cover biliary pathogens

ERCP for bile duct decompression

38
Q

Gallstones cause what percentage of acute pancreatitis in the US?

A

30%

39
Q

What are the complications of necrotixing pancreatitis?

A 
organ failure
pseudocyt formation
walled off pancreatic necrosis
infected pancreatic necrosis
disconnected tail
diabetes
exocrine dusfunction
40
Q

What type of cancer is all gallbladder cancer?

A

adenomcarcinoma

often proximal obstructions of bifurcation obstructions, poor prognosis

41
Q

What tumor marker is often positive in cholangiocarcinoma?

A

CA19-9 (but not at all specific)

42
Q

What UC complication confers a 15% lifetime risk for cholangiocarcinoma?

A

primary sclerosis cholangitis

43
Q

What is the only potential for cure in cholangiocarcinoma?

A

surgical resection

but still dismal

44
Q

What is the most sensitive imaging method to detect ascites?

A

transabomdinal ultrasound

45
Q

What is the most sensitive imaging method to detect sontes/micrliths?

A

endoscopic ultrasound

46
Q

How does a HIDA scan work?

A

give IV technetium

this is taken up and excreted by hepatocytes into bile

take imagines for about an horur and watch as it moves into the common bile duct, gallbladder and small bowel

non-visualization of the gallbladder is a positive test

GI Week 6 (14 decks)

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