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A. MLA Map Gastroenterology Including Liver > Gallstones and biliary colic > Flashcards

Gallstones and biliary colic Flashcards

1
Q

What % of the UK population have gallstones?

1 - 1.5%
2 - 15%
3 - 25%
4 - 50%

A

2 - 15%

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2
Q

Is the incidence of gallstones the same worldwide?

A
  • no
  • American Indians = 70%
  • Iranians = 0.8%
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3
Q

Are gallstones more common in men or women?

A
  • women
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4
Q

Gallstones are more common in females. Which of the following is NOT one of the 5Fs for risk of gallstones in females?

1 - female
2 - >forty
3 - family history
4 - fertile
5 - fat
6 - Fair (skin colour)

A

3 - family history

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5
Q

Does the risk of gallstones increase or decrease with age?

A
  • increases
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6
Q

What % of patients with gallstones develop symptoms over a 20 year period?

1 - 2%
2 - 10%
3 - 20%
4 - 40%

A

3 - 20%

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7
Q

Which ducts drain bile from the liver?

1 - common bile duct
2 - left and right hepatic ducts
3 - cystic duct
4 - common hepatic duct

A

2 - left and right hepatic ducts

  • these then merge to form the common hepatic duct
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8
Q

What is the name of the duct that drain bile to and from the gall bladder?

A

1 - common bile duct
2 - left and right hepatic ducts
3 - cystic duct
4 - common hepatic duct

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9
Q

What is the name of the bile duct that drain bile into the gall bladder?

1 - common bile duct
2 - left and right hepatic ducts
3 - cystic duct
4 - common hepatic duct

A

1 - common bile duct

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10
Q

Which blood vessel supplies the gall bladder?

1 - common hepatic artery
2 - cystic artery
3 - coeliac artery
4 - gastroduodenal artery

A

2 - cystic artery

  • branch of right hepatic artery
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11
Q

What is the name of the duct where the common bile duct and pancreatic duct merge and controls the contents into the duodenum?

1 - ampulla of vatar
2 - major duodenal ampulla
3 - circular fold
4 - sphincter of Oddi

A

4 - sphincter of Oddi

  • drains into ampulla of vatar, but Oddi is a sphincter controlling content entering the duodenum with no reflux
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12
Q

The liver continues to produce and secrete bile that is stored in the gall bladder where it is stored and becomes concentrated due to water reabsorption by the gall bladder. What hormone signals the contraction of the gall bladder and release of bile?

1 - gastrin
2 - somatostatin
3 - lipase
4 - cholecystokinin

A

4 - cholecystokinin

  • secreted by I cells in response to high fat meals
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13
Q

What is the term given to stool when bile cannot be secreted into the duodenum?

1 - steatorrhoea
2 - chyme
3 - chyle
4 - stercobilin

A

1 - steatorrhoea

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14
Q

Which of the following is NOT a large component of bile?

1 - bile salts
2 - cholesterol
3 - phospholipids
4 - Ca2+

A

4 - Ca2+

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15
Q

There are 4 main types of gallstones, with the most common being mixed stones and cholesterol stones. What are the other 2 types of stones?

1 - pigment stones
2 - haematocratic stones
3 - bile stones
4 - calcium carbonate stones

A

1 - pigment stones
4 - calcium carbonate stones

  • pigment = excessive bilirubin
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16
Q

There are 3 main factors that contribute to stone formation. Which of the following is NOT a contributing factor?

1 - change in bile constituent concentrations
2 - temperature changes
3 - biliary stasis
4 - infection

A

2 - temperature changes

  • it is likely that a combination of all 3 contribute to stone formation
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17
Q

What region of the abdomen does biliary pain come from?

1 - epigastric
2 - right hypochondriac
3 - left hypochondriac
4 - right lumbar

A

2 - right hypochondriac

  • can often radiate to the back
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18
Q

When is biliary pain more common?

1 - upon waking
2 - following a fatty meal
3 - following any meal
4 - with an abdominal movement

A

2 - following a fatty meal

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19
Q

What does cholecystitis mean?

A
  • inflammation of the gall bladder
  • normally due to gallstones
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20
Q

If there is an obstruction of the gall bladder that is not removed it can cause the gall bladder to continually secreting and become distended with what?

1 - blood
2 - water
3 - mucus
4 - bile

A

3 - mucus

  • called a mucocoele
  • if the gall bladder then gets infected this can form an abscess called empyema of the gall bladder
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21
Q

In a patient with gallstone, do they always present with raised LFTs and inflammatory markers?

A
  • no
  • depends on where the stones are blocking and if there is presence of infection
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22
Q

If a patient has suspected gallstones, they should be screened for what sort of hereditary disorder?

1 - celiac
2 - spherocytosis (blood disorder)
3 - UC
4 - liver malignancy

A

2 - spherocytosis (blood disorder)

  • thalassaemia, sickle cell
  • increase risk of pigment stones due to high bilirubin
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23
Q

What is typically the first line imaging used for gall stones?

1 - X-ray
2 - CT with contrast
3 - ultrasound
4 - MRI scan

A

3 - ultrasound

  • can confirm dilation of common bile duct
  • cannot identify presence of cholecystitis
  • gas can also obscure the stones
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24
Q

In a non-jaundiced patient, cholangiography, where a dye is inserted into the cystic duct and common bile duct that can be detected on X-ray. Which of the following is NOT provided by this imaging technique?

1 - gall bladder morphology
2 - duct dilation
3 - obstruction
4 - gall bladder wall thickness

A

4 - gall bladder wall thickness

  • this is only investigatory and cannot remove biles stones
25
Q

If a patient has obstructed jaundice, which may be due to stricture, gallstones or a tumour, ultrasound is the 1st line imaging used. If we need extensive imaging and morphological biliary tree information which imaging techniques are used?

1 - CT with cintrast
2 - MRI with contrast
3 - magnetic resonance cholangiopancreatography
4 - endoscopic retrograde cholangiopancreatography

A

3 - magnetic resonance cholangiopancreatography
4 - endoscopic retrograde cholangiopancreatography

26
Q

If a patient has obstructed jaundice, which may be due to stricture, gallstones or a tumour, ultrasound is the 1st line imaging used. If we need extensive imaging and morphological biliary tree information magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) can be performed. What is the advantage of ERCP?

A
  • diagnostic and therapeutic
  • can perform a sphincterotomy, cutting the ampulla of vatar and allowing the stone to pass
27
Q

If a patient has a blocked bile duct and the clinical decision is made to perform a cholecystectomy, how soon must it be performed?

1 - <12 hours
2 - <24 hours
3 - <48 hours
4 - <72 hours

A

4 - <72 hours

28
Q

A laparoscopic cholecystectomy is the most common operation in the UK and is usually a day case. When performing the operation the surgeon needs to identify calots triangle. Which of the following is NOT part of calots triangle?

1 - inferior border of the liver
2 - cystic duct
3 - common hepatic duct
4 - right hepatic artery

A

4 - right hepatic artery

Medial – common hepatic duct.
Inferior – cystic duct.
Superior – inferior surface of the liver.

29
Q

What one of the following is NOT a top 3 most common differentials for a patient with right hypochondriac pain that radiates to the back, nausea and vomiting with pain worse following a fatty meal?

1 - peptic ulcer
2 - UTI
3 - IBS
4 - chronic constipation

A

3 - IBS

30
Q

Courvoisier syndrome, also called Courvoisier’s law relating to the gall bladder states that 2 things must be present for there to be malignancy causing obstruction in the common hepatic duct. Which of the following are the 2 signs?

1 - painless jaundice
2 - pain relieved when eating
3 - palpable gall bladder
4 - raised inflammatory markers

A

1 - painless jaundice

3 - palpable gall bladder

31
Q

A porcelain gallbladder is given the name due to its appearance on imaging and is due to chronic cholelithiasis (gall stones) and cholecystitis (inflamed gall bladder) causing calcified scarring. What imaging can be used to detect porcelain gallbladder?

1 - X-ray
2 - CT scan
3 - ultrasound
4 - MRI
5 - all of the above

A

5 - all of the above

32
Q

If a patient presents one episode of biliary colic, what is the conservative form of management used?

1 - analgesics
2 - steroids
3 - ERCP with steroids
4 - analgesics with ERCP

A

1 - analgesics

33
Q

If a patient presents with multiple episode of biliary colic or suspected acute acute gallstone disease what is the management of choice?

1 - analgesics
2 - cholecystectomy
3 - ERCP with steroids
4 - analgesics with MRCP

A

2 - cholecystectomy

  • also case if patient has a mucocoele as this can lead to empyema
  • operating early reduces the complications of gall stones
34
Q

Common complications and locations for the gall bladder and biliary tree

A
35
Q

In a patient with no history of biliary disease, what is the likely cause of jaundice?

1 - cardiac failure
2 - bone marrow suppression
3 - GI malignancy
4 - pre-hepatic or hepatic disorder

A

4 - pre-hepatic or hepatic disorder

36
Q

Jaundice is the defined as a yellow colouration of the skin and sclerae caused by what?

1 - RBCs
2 - iron deficiency
3 - Bilirubin
4 - anaemia

A

3 - Bilirubin

37
Q

Where does bilirubin come from?

1 - spleen produces this
2 - product of RBC breakdown in spleen
3 - liver produces this
4 - product of WBC breakdown in bone marrow

A

2 - product of RBC breakdown in spleen

  • RBCs broken down by macrophages (mainly in spleen) into globin (amino acids) and heme
  • heme then separated into iron (Fe) and protoporphyrin
  • protoporphyrin is then converted into unconjugated biliruben
38
Q

Which cells are responsible for breaking down old RBCs in the spleen and thus creating bilirubin?

1 - dendritic cells
2 - monocytes
3 - macrophages
4 - neutrophils

A

3 - macrophages

39
Q

Once RBCs have been broken down, creating globin (amino acids) and heme (iron and protoporphyrin, subsequently unconjugated bilirubin) the biliruben needs to be transported to the liver. But it must bind with what to do this as it is unconjugated, meaning it is insoluble in the blood?

1 - albumin
2 - bilirubin binding proteins
3 - conjugation proteins
4 - CRP

A

1 - albumin

40
Q

When a RBCs is nearing the end of its 120 day life cycles it travels to the spleen where macrophages recycle it. Doing this they produce 2 primary compounds, what are they?

1 - bilirubin and globin
2 - bilirubin and heme
3 - heme and amino acids
4 - heme and globin

A

4 - heme and globin

  • globin then becomes amino acids for recycling
  • heme is converted into iron and protoporphyrin
41
Q

Once unconjugated bilirubin (lipid soluble) has bound to albumin and travels to the liver, what do hepatocytes do with it?

1 - convert it into conjugated bilirubin
2 - store it for release into bile ducts
3 - break it down and release as bile salts

A

1 - convert it into conjugated bilirubin

  • pumped into canaliculi and to the gall bladder as bile
42
Q

What enzyme is responsible for the conjugation of unconjugated bilirubin in the liver?

1 - Alkaline phosphatase
2 - uridine 5 diphospho glucuronosyltransferase (UGT)
3 - Aspartate transaminase (
4 - 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase

A

2 - uridine 5 diphospho glucuronosyltransferase (UGT)

43
Q

Once conjugated bilirubin is released from the gall bladder into the GIT as bile. Here it is then converted into what by the microbes of the GIT?

1 - urobilinogen
2 - stercobilin
3 - urobilin
4 - faecal calprotectin

A

1 - urobilinogen

44
Q

Once bile is released into the GIT it is converted into urobilinogen by microbes. What is it then converted into, which also creates the brown colour of the stool?

1 - SCFA
2 - stercobilin
3 - urobilin
4 - faecal calprotectin

A

2 - stercobilin

45
Q

Once bile has been converted into urobilinogen and then stercobilin, some urobilinogen can be reabsorbed via the enterohepatic circulation and is oxidised into what?

1 - SCFA
2 - taurocholic acid
3 - urobilin
4 - glycocholic acid

A

3 - urobilin

  • most urobilin is transferred to the liver for recycling
  • some urobilin goes to the kidney and give the yellow colour of urine
46
Q

Is jaundice caused by:

1 - conjugated bilirubin
2 - unconjugated bilirubin
3 - can be both

A

3 - can be both

47
Q

The causes ofjaundice can be divided into 3 areas which help identify they cause. These are pre-hepatic, intrahepatic and post-hepatic. Which of the following is NOT a common cause of pre-hepatic jaundice?

1 - sickle cell disease
2 - cholecystitis
3 - extravascular hemolytic anemias
4 - ineffective hematopoiesis

A

2 - cholecystitis

  • all others are blood disorders
  • all cause dysfunctional RBCs, meaning they are killed off earlier
  • more RBC death = more bilirubin that the liver is unable to process
48
Q

If a patient has gilberts syndrome or a blood disorder, this can increase the amount of conjugation of bilirubin being transferred to the gall bladder to increase excessively. What can this then increase the risk of?

1 - cholecystitis
2 - cholangitis
3 - cholesterol gallstones
4 - pigmented gallstones

A

4 - pigmented gallstones

  • can also cause darker urine due to excessive urobilin being re-absorbed
49
Q

The causes ofjaundice can be divided into 3 areas which help identify they cause. These are pre-hepatic, intrahepatic and post-hepatic. Intra-hepatic causes of jaundice are essentially when the hepatocytes are unable to conjugate the bilirubin. Which of the following is not a cause of this:

1 - Gilberts syndrome
2 - Physiological jaundice of newborns
3 - chronic liver disease
4 - cholangitis

A

4 - cholangitis

  • newborns typically have lower levels of uridine 5 diphospho glucuronosyltransferase (UGT)
  • newborns also have old foetal blood cells that will be killed off
50
Q

The causes ofjaundice can be divided into 3 areas which help identify they cause. These are pre-hepatic, intrahepatic and post-hepatic. A rare but possible cause of intra-hepatic jaundice is a genetic condition called Gilberts syndrome. How does this cause jaundice?

1 - hepatic bile ducts become blocked
2 - common bile duct becomes blocked
3 - decreased expression of uridine 5 diphospho glucuronosyltransferase (UGT)
4 - high levels of urobilin reabsorbed from GIT

A

3 - decreased expression of uridine 5 diphospho glucuronosyltransferase (UGT)

  • enzyme is normal but less bilirubin is conjugated
  • excessive bilirubin builds up in the blood
  • times of stress excessive (infection, stress, starvation) bilirubin can be generated (asians as well)
51
Q

Which of the following is NOT a common cause of post-hepatic jaundice?

1 - Gilberts syndrome
2 - Mirizzi syndrome
3 - Dublin-Johnson syndrome
4 - Cholangitis

A

1 - Gilberts syndrome

  • Dublin-Johnson syndrome is a genetic defect of hepatocytes to transport conjugated bilirubin out of hepatocytes
  • Mirizzi syndrome (obstructed jaundice) is common hepatic bile duct obstruction due to stone compression at cystic duct or Hartmanns pouch
52
Q

Patients with jaundice will generally get a blood film, why is this?

1 - incase they need a blood transfusion
2 - incase they have infection
3 - diagnose blood disorders
4 - identify liver damage

A

3 - diagnose blood disorders

  • these cause excessive RBC death, thus increased bilirubin
53
Q

When trying to identify the cause of a patients jaundice we can run some blood tests. Which of the following is best for identifying an obstruction or a pre-hepatic problem?

1 - AST
2 - ALT
3 - Bilirubin
4 - ALP

ALP = alkaline phosphatase ALT = alanine transaminase AST = aspartate aminotransferase

A

3 - Bilirubin

54
Q

When trying to identify the cause of a patients jaundice we can run some blood tests. Which of the following is best for identifying a bile duct obstruction?

1 - AST
2 - ALT
3 - Bilirubin
4 - ALP

ALP = alkaline phosphatase ALT = alanine transaminase AST = aspartate aminotransferase

A

4 - ALP

55
Q

When trying to identify the cause of a patients jaundice we can run some blood tests. Which 2 of the following is best for identifying a bile duct obstruction?

1 - AST
2 - ALT
3 - Bilirubin
4 - ALP

ALP = alkaline phosphatase ALT = alanine transaminase AST = aspartate aminotransferase

A

1 - AST
2 - ALT

56
Q

Patients with jaundice will generally get a virus screen, why is this?

1 - incase they need a blood transfusion
2 - infection can damage hepatocytes
3 - diagnose blood disorders
4 - liver hepatomegaly

A

2 - infection can damage hepatocytes

  • specifically viral hepatitis
57
Q

Why is it useful to identify if bilirubin is conjugated or unconjugated in a patient with jaundice?

A
  • identifies where the problem is
58
Q

Which of the following imaging modalities is NOT typically used to help diagnose a patient with jaundice?

1 - ERCP
2 - ultrasound
3 - MRCP
4 - CT

A

1 - ERCP

59
Q

In patients who have undergone an ERCP, there is a risk of developing a bacterial infection. Which of the following organisms is most likely to cause an infection following the ERCP?

1 - pseudomonas aeruginosa
2 - escherichia coli
3 - enterobacter
4 - staphylococcus

A

2 - escherichia coli

A. MLA Map Gastroenterology Including Liver (20 decks)

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