GI #1 Flashcards
What is cholelithiasis?
Gallstones in the biliary tract (without inflammation)
MC type of cholelithiasis?
Cholesterol
However, what type of gallstone is MC in ETOH-related cirrhosis and which type is MC in Asian population?
ETOH: black stones
Asian: brown stones
Risk factors for cholelithiasis
- Fat
- Fair skin
- Female
- Forty
- Fertile
- OCPs (increased estrogen)
- Native Americans
- Rapid weight loss
- IBD
- Increased triglycerides
Symptoms of cholelithiasis
-Most asymptomatic
- Biliary colic, abrupt RUQ pain (lasts 30 minutes to hours)
- Nausea precipitated by fatty foods or large meals
What is the initial test of choice for cholelithiasis?
US
If the gallstone is asymptomatic, observation is the management of choice. However, what can also be used to dissolve the stones and how long does it take?
Ursodeoxycholic acid (takes 6-9 months)
Elective cholecystectomy if symptomatic
When the gallstone becomes lodged and obstructs the cystic duct, infection and inflammation occurs, which is called?
Acute cholecystitis
What is the MC infection in acute cholecystitis?
E. coli
Clinical manifestations of acute cholecystitis
- Continuous RUQ or epigastric pain (may be associated with large or fatty meals)
- Nausea, anorexia, guarding
Physical exam findings associated with cholecystitis
- Fever, enlarged palpable gallbladder
- Murphy’s Sign: inspiratory arrest with palpation of gallbladder
- Boas sign: right shoulder pain
Explain the cause of Boas sign with cholecystitis
-Phrenic nerve irritation
The initial test for cholecystitis is ______ whereas the gold standard is _____
US
HIDA scan (cholescintigraphy)
Management for cholecystitis
- NPO
- IVF
- ABX (Ceftriaxone + Metronidazole)
- Followed by cholecystectomy
If the patient is nonoperative, what should be done for cholecystitis?
-Cholecystostomy (percutaneous drainage of the gallbladder)
What is acute acalculous cholecystitis?
-Necroinflammatory disease of the gallbladder not due to gallstones
What is choledocolithiasis?
Gallstones in the common bile duct
Symptoms of choledocolithiasis
- Prolonged biliary colic (more prolonged due to stone blocking bile duct)
- RUQ Pain
- Jaundice
Labs for choledocolithiasis
- Labs: elevated AST and ALT
- Increased Alkaline phosphatase + GGT (cholestasis)
What diagnostics are done for choledocolithiasis?
- US (initial)
- ERCP (diagnostic of choice) because is diagnostic and therapeutic
Treatment for choledocolithiasis
-ERCP stone extraction
Cholangitis is
biliary tract infection secondary to obstruction of the common bile duct
Symptoms of cholangitis
- Charcot’s Triad: fever + RUQ Pain + Jaundice
- Reynold’s Pentad: + Hypotension/Shock + AMS
Diagnostics for cholangitis
- Labs: Leukocytosis, increased alkaline phosphatase + GGT
- US (initial)
- MRCP (Most accurate)
- Cholangiography (gold standard via ERCP)
Treatment for cholangitis
- IV ABX followed by CBD decompression and stone extraction once stable
- ERCP
When should ERCP for cholangitis be done?
Once patient has been afebrile/stable for 48 hours after IV ABX
What population is at increased risk for neonatal jaundice?
Asian population
When does neonatal jaundice present and when should it normalize?
Presents on days 3-5 of life and bilirubin levels fall in about 50% of neonates during the first week of life
Jaundice, yellowing of the skin, is associated with bilirubin levels of
> 5.0 mg/dL
What is kernicterus and what levels of bilirubin is it associated with?
- Cerebral dysfunction and encephalopathy (lethargy, hearing loss, mental developmental delays)
- Bilirubin > 20 mg/dL
What is the initial therapy of choice for neonatal jaundice?
Phototherapy
Phototherapy is initiated based on age. Explain this.
24 hours of age > 12 mg/dL
48 hours of age > 15 mg/dL
72 hours of age > 18 mg/dL
In severe cases of neonatal jaundice, what treatment is done?
Exchange transfusion
What is Dubin-Johnson Syndrome?
Isolated conjugated (direct) hyperbilirubinemia
On liver biopsy, what is seen with Dubin-Johnson Syndrome?
Grossly black liver and dark pigment in hepatocytes
What is Rotor’s Syndrome and how is it different from Dubin-Johnson Syndrome?
Associated with conjugated and unconjugated hyperbilirubinemia
-Not associated with grossly black liver on biopsy
What is Crigler-Najjar Syndrome?
Hereditary unconjugated hyperbilirubinemia
What is the pathophysiology of Crigler-Najjar Syndrome?
-Decreased activity of the UGT enzyme needed to convert indirect bilirubin to direct bilirubin
What are the symptoms of Crigler-Najjar Syndrome?
- Neonatal Jaundice with severe progression in second week leading to kernicterus
- Or asymptomatic
How to diagnose Crigler-Najjar Syndrome?
-Labs: Isolated (indirect) unconjugated hyperbilirubinemia and otherwise normal liver function tests
What is the treatment of choice for Crigler-Najjar Syndrome?
Phototherapy (if no UGT activity) and Phenobarbital (if very little UGT activity)
What is the enzyme responsible for conjugation of bilirubin?
UGT (glucuronosyltransferase)
What is Gilbert’s Syndrome?
-Reduced UGT activity and transient episodes of jaundice during periods of stress, fasting, alcohol, or illness
What findings are on labs for Gilbert’s Syndrome?
-Increase in isolated indirect bilirubin level with otherwise normal LFTs
Is PT or albumin an earlier indicator of severe liver injury/prognosis?
PT
Prolonged PT is seen when _____% of the liver’s protein synthesizing ability is lost
80%
