GI: Biliary Diseases Flashcards
The Four Fs of cholelithiasis…
female
fluffy
forty
fertile
MC presentation of cholelithiasis…
asymptomatic
Initial test of choice for cholelithiasis
US
What causes the pain in biliary colic?
pressure forcing stone against gallbladder
what disorder?
Intense RUQ, Epigastric Pain
+/- Radiation to Right Shoulder Blade
Constant and steady, lasts < 5-6 hours
Postprandial
N/V
Diaphoresis
Nocturnal pain
biliary colic
does movement make biliary colic worse?
no
is there jaundice, peritoneal signs, or murphy’s sign with biliary colic?
no
For biliary colic, US should show…
gallstones/sludge
When should tx be considered with asymptomatic gallstones?
when sxs develop, cholecystectomy
patient p/w…
Biliary colic
Normal PE
Normal CBC, LFTs, Amylase, Lipase
uncomplicated gallstone disease
gallbladder dysmotility…
functional gallbladder d/o
how is functional gallbladder d/o diagnosed?
exclusion + Rome IV criteria
What diagnostic should be ordered for suspected functional gallbladder d/o if no other causes can be considered…
CCK + HIDA scan
GBEF < 35%
Rome IV Criteria for functional gallbladder d/o…
Biliary pain
No stones
Low EF
Normal Labs
the below describes…
Lasts 30+ min
Not relieved w. BM, posture, antacids
Variable occurrence
Severe, interrupts daily life
biliary pain
When is cholecystectomy indicated in functional gallbladder d/o?
Biliary pain + GBEF < 40%
This is an acute inflammation of the GB +/- cystic duct obstruction
acute cholecystitis
Hx of:
Attack of worsening biliary pain ( > 4-6 hours steady, severe, RUQ/epigastric pain)
Fever
N/V, anorexia
Hx of fatty food
Acute cholecystitis
On PE…
laying still
(+) Murphy’s
(+) guarding
(+) RUQ TTP
acute cholecystitis
Labs should show ______ in acute cholecystitis
leukocytosis w/ left shift
+/- elevated AST/ALT
US shows + hx of biliary pain
Gallstones
Wall thickening
Pericholecystic fluid
Sonographic murphy’s sign
acute cholecystitis
When to order HIDA w. suspected acute cholecystitis
if dx uncertain
what is a POS for acute cholecystitis on HIDA scan?
failed gallbladder visualization
MC complication of acute cholecystitis (20%)
gangrene
What is a serious, but rare, complication of acute cholecystitis that can cause jaundice?
Mirizzi Syndrome (impaction)
Management of acute cholecystitis
admission for cholecystectomy + NPO, IV Fluids, IV pain meds (opioids), IV abx
What disorder?
A/w gallstones
Minimal sxs
chronic cholecystitis
What biliary disorder?
Acute inflammation w/o stones
High morbidity/mortality
Common w. Critically ill patients
acute acalculous cholecystitis
Patient p/w
critically ill
sepsis w/o clear source
biliary pain
jaundice
Acute acalculous cholecystitis
workup for biliary pain
US LFTs CBC CMP Amylase Lipase UA Urine Preg
tx for acute acalculous cholecystitis
prompt Abx + blood Cx
Patient p/w…
Prolonged Biliary Pain
Jaundice
Courvoisier Sign
normal vitals
choledocolithiasis
What elevated LFTs indicate cholestasis?
serum bili
alk phos
GGt
Labs in choledocolithiasis
cholestasis LFTs
Management of choledocolithiasis
ERCP (therapeutic & Dx)
ID/tx of complications (acute cholangitis)
what biliary d/o?
Bacterial infection in pt w. biliary obstruction
Ascent of bacteria from duodenum
“Pus under pressure” = surgical emergency
acute cholangitis
Lab results suggesting acute cholangitis… (4)
leukocytosis w. left shift
elevated CRP/ESR
cholestatic LFTs
3x normal pancreatic enzymes
What 2 things can be seen on MRCP/EUS in acute cholangitis?
CBD dilation, stone
Charcot’s Triad for acute cholangitis…
fever
abd. pain
jaundice
Reynolds pentad for acute cholangitis
fever abd. pain jaundice AMS hypotension
Tx for acute cholangitis
911 admit/surg consult
biliary drainage via ERCP
which biliary d/o?
Women 30-65 yo
Autoimmune destruction of intrahepatic bile ducts → cholestasis
Can lead to liver failure/cirrhosis
primary biliary cholangitis
Patient presents with…
Fatigue + Pruritus Jaundice RUQ discomfort Xanthomas Hepatomegaly Hx of autoimmune conditions
PBC
Labs for PBC
(+) AMA (hallmark)
cholestatic LFTs
(+) ANA
Hyperlipidemia
To Dx PBC…
No extrahepatic biliary obstruction \+ no liver comorbidities \+ 2 of... (3)
elevated Alk Phos
(+) AMA
Histologic evidence
Which biliary d/o?
MC in men
Assoc. w. UC
Leads to cholestasis, end-stage liver disease
PSC
Male patient presents with…
Fatigue
Pruritus
Jaundice
Hepatomegaly
PSC
Lab results for PSC
AMA NEG
cholestatic LFTs
2 diagnostics helpful for PSC
cholangiography/MRCP/ERCP/PTC
Liver Bx
3 complications of PSC…
End-stage liver disease
Hepatobiliary CA
Colon CA
Which biliary d/o?
Inherited deficiency in biliary glucuronidation enzymes more common in men
Elevated UCB w/o hemolysis
Gilbert Syndrome
Does Gilbert Syndrome require Tx?
no
Male patient p/w:
mild intermittent jaundice triggered by dehydration, fasting
Gilbert Syndrome
Which biliary neoplasm?
MC CA of biliary tract
Uncommon but fatal
Incidental finding
gallbladder CA
RF for gallbladder CA?
procelain gallbladder
Which biliary neoplasm?
Arise from epithelial bile duct cells
Rare, but more common in men
Associated with PSC and choledochal cysts
cholangiocarcinoma
Patient p/w…
Jaundice Pruritus Abd. pain Wt. loss Fever (+) Courvoisier sign cholestatic LFTs
cholangiocarcinoma
which biliary neoplasm?
Near ampulla of vater
Associated with FAP and HNPCC
ampullary carcinoma
Patient p/w
Obstructive Jaundice
Occult GI bleed + microcytic anemia
Abd. pain
hx FAP or HNPCC
ampullary carcinoma
