GI - Biliary Disease; Pancreatic Disease

Question 1

What does ERCP stand for in biliary tree examination?

Answer 1

Endoscopic retrograde cholangiopancreatography

Question 2

__________ refers to impairment of bile flow (and resultant accumulation in hepatic parenchyma).

Answer 2

Cholestasis refers to impairment of bile flow (and resultant accumulation in hepatic parenchyma).

Question 3

__________ refers to biliary tree infection.

Answer 3

Cholangitis refers to biliary tree infection.

Question 4

__________ refers to gallstone formation in the biliary tree.

Answer 4

Choledocholithiasis refers to gallstone formation in the biliary tree.

Question 5

RBC heme is converted to unconjugated bilirubin via what two enzymes?

Answer 5

Heme oxygenase

+

Biliverdin reductase

Question 6

Bilirubin is hydro______ and carried to the liver by _________.

Answer 6

Bilirubin is hydrophobic and carried to the liver by albumin.

Question 7

In the liver, bilirubin is conjugated with ___________ and secreted into bile (to enter the gut).

Answer 7

In the liver, bilirubin is conjugated with glucuronides and secreted into bile (to enter the gut).

Question 8

This slide shows hepatic changes due to what form of cholestasis?

Answer 8

Mechanical obstruction

Question 9

This slide shows hepatic changes due to what form of cholestasis?

Answer 9

Intrahepatic stasis

Question 10

What non-acetominophen drug is especially associated with hepatic injury which potentially leads to intrahepatic cholestasis?

Answer 10

Amoxicillin - clavulinic acid

Question 11

What severe genetic syndrome leads to an increase in serum unconjugated bilirubin?

What mild genetic syndrome leads to an increase in serum unconjugated bilirubin?

Answer 11

Crigler-Najjar syndrome

Gilbert’s syndrome

Question 12

What severe genetic syndrome leads to an increase in serum conjugated bilirubin?

What mild genetic syndrome leads to an increase in serum conjugated bilirubin?

Answer 12

Dubin-Johnson syndrome

Rotor’s syndrome

Question 13

Primary biliary cholangitis is most commonly seen in what demographic?

Answer 13

Middle-aged women

Question 14

Primary biliary cholangitis is a(n) ___________ (etiology) disease most affecting the _______ (size or extent) biliary ducts.

Answer 14

Primary biliary cholangitis is an autoimmune disease most affecting the small biliary ducts.

Question 15

What serum factors are elevated in cases of primary biliary cholangitis?

Answer 15

Anti-mitochondrial antibody

ALP

ANA

Bilirubin

ALT/AST

Cholesterol

Question 16

Which is associated with xanthelasmas, primary biliary cholangitis or primary sclerosing cholangitis?

Answer 16

Primary biliary cholangitis

Question 17

What are the three components of treatment for primary biliary cholangitis?

Answer 17

Ursodeoxycholic acid (a naturally-occurring bile acid),

alendronate (a bisphosphonate),

Ca²⁺

Question 18

The diagnostic criteria for primary biliary cholangitis is 2/3 of the following:

1.

2.

3.

Answer 18

The diagnostic criteria for primary biliary cholangitis is 2/3 of the following:

1. ANA-positive
2. Cholestasis
3. Suggestive liver biopsy

Question 19

Primary biliary cholangitis most affects the ______hepatic ducts.

Answer 19

Primary biliary cholangitis most affects the intrahepatic ducts.

Question 20

Describe the histological appearance of primary biliary cholangitis.

Answer 20

‘Jigsaw’ fibrosis;

granulomas surrounding hepatic portal ducts (extra-hepatic ducts normal)

Question 21

Primary sclerosing cholangitis is most commonly seen in what demographic?

Answer 21

Middle-aged men

(2:1)

Question 22

Primary sclerosing cholangitis is a(n) ___________ (etiology) disease most affecting the _______ (size or extent) biliary ducts.

Answer 22

Primary sclerosing cholangitis is an autoimmune disease most affecting the large biliary ducts.

Question 23

What serum factors are elevated in cases of primary sclerosing cholangitis?

Answer 23

ALP

Bilirubin

(ANA-negative!)

Question 24

Which is ANA-negative, primary biliary cholangitis or primary sclerosing cholangitis?

Answer 24

Primary sclerosing cholangitis

Question 25

Which affects the intrahepatic ducts only, primary biliary cholangitis or primary sclerosing cholangitis?

Answer 25

Primary biliary cholangitis

Question 26

Which can affect both the extrahepatic and intrahepatic ducts, primary biliary cholangitis or primary sclerosing cholangitis?

Answer 26

Primary sclerosing cholangitis

Question 27

What are the S/Sy and features of primary sclerosing cholangitis?

Answer 27

Pruritus, fatigue, episodic jaundice, abdominal pain; concomitant ulcerative colitis

Question 28

Which is associated with ulcerative colitis, primary biliary cholangitis or primary sclerosing cholangitis?

Answer 28

Primary sclerosing cholangitis

Question 29

How is primary sclerosing cholangitis diagnosed?

Answer 29

**Liver biopsy** + **ERCP** (endoscopic retrograde cholangiopancreatography)

Question 30

How will the biliary tree appear on ERCP in patients with primary sclerosing cholangitis?

Answer 30

‘Pearl necklace’ strictures; onion skinning possible

Question 31

What is the prognosis for primary sclerosing cholangitis?

Answer 31

It is progressive and incurable

Question 32

Primary sclerosing cholangitis is associated with c\_\_\_\_\_\_\_\_\_\_\_, recurrent b\_\_\_\_\_\_\_\_\_, and g\_\_\_\_\_\_\_\_\_\_.

Answer 32

Primary sclerosing cholangitis is associated with c**_holangiocarcinoma_**, recurrent b**_acteremia_**, and g**_allstones_**.

Question 33

What is the name for any biliary fibrosis / cirrhosis due to large duct trauma or extrahepatic obstruction by causes other than primary biliary sclerosis?

Answer 33

Secondary biliary sclerosis/cirrhosis

Question 34

What is the term used to describe cysts of the biliary tree?

Answer 34

**Choledochoceles** | (choledochal cysts)

Question 35

What is the term used to describe stone deposition in the gallbladder?

Answer 35

Cholelithiasis

Question 36

A type ____ choledocholcele (a congeital biliary tree dilatation) protrudes into the duodenum.

Answer 36

A type **_III_** choledocholcele (a congeital biliary tree dilatation) protrudes into the duodenum.

Question 37

What are some of the possible S/Sy of a choledochal cyst (choledocholcele)?

Answer 37

Abdominal pain, jaundice, palpable mass

Question 38

Name the three most common infectious causes of cholangitis in descending order of occurrence.

Answer 38

***Enterococci spp.*** \> ***E. coli*** \> ***Klebsiella spp.***

Question 39

Name a few etiologies of bile stasis that might lead to cholangitis.

Answer 39

Choledocholithiasis; benign strictures; malignancy; choledochoceles

Question 40

What are the three points of Charcot’s triad of cholangitis?

Answer 40

Fever, pain, jaundice

Question 41

Reynaud's pentad of cholangitis includes what two factors besides Charcot's (fever, jaundice, and pain)?

Answer 41

Confusion, hypotension

Question 42

Describe the elevated serological features of cholangitis.

Answer 42

**AST** and **ALT**, **ALP**, **bilirubin**

Question 43

How is cholangitis treated?

Answer 43

**Ciprofloxacin** | (or another fluoroquinolone)

Question 44

Choledocholithiasis is more common in which gender?

Answer 44

Females | (2:1)

Question 45

What are the four 'F's of choledocholithiasis?

Answer 45

**F**at, **f**ertile **f**emales over **f**orty

Question 46

Describe the gross appearance and character of cholesterol gallstones.

Answer 46

White, tough

Question 47

Describe the gross appearance and character of pigment gallstones.

Answer 47

Black, crushable

Question 48

How does choledocholithiasis typically present?

Answer 48

Asymptomatically

Question 49

If asymptomatic, how does choledocholithiasis typically present?

Answer 49

Typically a sharp, colicky pain in RUQ or epigastric regions (sometimes associated with fatty food intake)

Question 50

A patient with cholecystitis presents with a positive Murphy's sign. What happened when you compressed her gallbladder?

Answer 50

She stopped breathing

Question 51

Name two fairly intense complications of choledocholithiasis.

Answer 51

Pancreatitis; cholangitis

Question 52

Do serum liver enzymes change with choledocholithiasis?

Answer 52

They can | (may be normal or abnormal)

Question 53

How are gallstones typically diagnosed?

Answer 53

Ultrasound or ERCP

Question 54

Gallbladder malignancies are ______ (frequency) and almost always ___________ (type).

Answer 54

Gallbladder malignancies are **_very rare_** and almost always **_adenocarcinomas_**.

Question 55

Gallbladder malignancies are associated with chronic __________ and/or \_\_\_\_\_\_\_\_\_\_.

Answer 55

Gallbladder malignancies are associated with chronic **_inflammation_** and/or **_infection_**.

Question 56

What infections are associated with development of gallstone malignancies?

Answer 56

* Helicobacter pylori* * Salmonella typhi*

Question 57

Which is more common, gallbladder malignancies or cholangiocarcinomas? (I.e. which is more common, malignancies of the gallbladder or the biliary tree?)

Answer 57

Gallbladder malignancies

Question 58

What is the term for an abberrant portion of pancreatic tissue found somewhere in the GI tract?

Answer 58

A pancreatic rest

Question 59

**True/False**. Pancreatic divisum (split pancreas) is fairly common and fairly benign.

Answer 59

True.

Question 60

An annular pancreas can form via what process?

Answer 60

The natural rotation of the duodenum during development

Question 61

Name two complications that an annular pancreas can cause.

Answer 61

Duodenal strictures; pancreatitis

Question 62

Name the two most common causes of pancreatitis and give the percentage of cases for which each is responsible.

Answer 62

**Gallstones** (40%); **alcohol** (40%)

Question 63

Autoimmune pancreatitis is associated with increased levels of serum \_\_\_\_\_\_\_.

Answer 63

Autoimmune pancreatitis is associated with increased levels of serum **_IgG4_**.

Question 64

Pancreatitis is associated with \_\_\_\_\_calcemia.

Answer 64

Pancreatitis is associated with **_hyper_**calcemia (due to errant in-pancreas activation of pancreatic enzymes by calcium).

Question 65

What is the main cause of 'hereditary pancreatitis?'

Answer 65

Cystic fibrosis

Question 66

What is the typical clinical presentation of pancreatitis?

Answer 66

Mid-epigastric pain through the back; umbilical or back bruising may be present

Question 67

What lab values are indicative of pancreatitis?

Answer 67

Elevated serum amylase and lipase

Question 68

Name some of the many possible complications of pancreatitis.

Answer 68

Duodenal obstruction; bile duct stricture; gastric varices; pseudoaneurysms splenic rupture

Question 69

What are the components of treating pancreatitis?

Answer 69

**Rest** the pancreas; **antacids** + oral pill of **pancreatic enzymes**; **pain** management

Question 70

Why is it useful to treat pancreatitis with oral pills of pancreatic enzymes?

Answer 70

Subsequent downregulation of secretin and pancreatic enzyme secretion

Question 71

Pancreatic cysts may be congenital. Pancreatic pseudocysts are more associated with what processes?

Answer 71

**Inflammation** (pancreatitis) or **neoplasia** (e.g. serous or mucinous cystadenomas)

Question 72

What is the most common sign of pancreatic malignancy?

Answer 72

Painless jaundice

Question 73

Pancreatic malignancies are typically __________ (type) and present at a(n) \_\_\_\_\_\_\_-stage (early/mid/late).

Answer 73

Pancreatic malignancies are typically **_adenocarcinomas_** and present at a **_late_**-stage.