GI problems II - Ow

Question 1

What colour is jaundiced urine?

Answer 1

Tea without milk (dark)

Question 2

What colour are jaundiced stools?

Answer 2

Clay like and yellow

Question 3

can you still get stones if you’ve had your gall bladder removed?

Answer 3

yes because they can still form in the duct

Question 4

What can happen if the stone gets stuck for too long?

Answer 4

Can get infected

Question 5

What is cholydocolithiasis?

Answer 5

Stone stuck in the duct

Question 6

What is cholangitis?

Answer 6

when you have choledocolithiasis and infection (fever and chills etc)

Question 7

What does colic pain mean?

Answer 7

Pain that comes and goes

Question 8

What is Murphy’s sign?

Answer 8

Patient takes a deep breath with an examining hand just below the right costal margin. Sign for cholycistitis

Question 9

Guarding?

Answer 9

not always involuntary
e.g. if you have cold hands and you touch someones abdomen or if patient ticklish = voluntary
When in pain, specifically peritonisim (localised) Peritonitis is generalised = voluntary

Question 10

Why is cholycistitis painful?

Answer 10

because of inflammation. distention, swelling of visceral organs
This is inflammation of the gall bladder

Question 11

Cholycistitis - what could be the imitating event

Answer 11

impaired bile flow or abnormal gall bladder contraction, build up of bile and because of stasis can cause infection in the gall bladder.

Question 12

What are the commonest gallstones? Why do they form in the gall bladder?

Answer 12

Cholesterol stones (80% of stones in the gall bladder) because cholesterol is stored in the GB, so when outflow of bile impeded, you get stasis and concentration of cholesterol --> stones. 
Other stones are generally made from bilirubin and other combos (pigmented stones) Bile duct tends to from pigment stones

Question 13

What initiates emptying of the gall bladder?

Answer 13

Cholecystokinin (hormone)

Question 14

What is biliary colic?

Answer 14

The description of the right upper quadrant pain (descriptive term, not a diagnosis)

Question 15

Cholelithiasis?

Answer 15

Someone has uncomplicated stones in their gall bladder

Question 16

Choledocolithiasos

Answer 16

When you have a gall stone in the bile duct

Question 17

what is the cystic duct?

Answer 17

It joins the gall bladder to the common duct

Question 18

What do elevated GGT, ALP and bilirubin indicate?

Answer 18

Cholestasis - there is a reduction of bile flow out of the liver.
elevated bilirubin means jaundice (just because someone doesn’t report jaundice doesn’t mean they don’t have biochemical jaundice, need quite high levels to look yellow)

Question 19

What is a potential consequence of cholangitis?

Answer 19

If you have a stone that is stuck in the distal common bile duct, if the stone is not relived. can get pancreatitis, because this organ also cannot secrete its enzymes.

Question 20

Other rarer causes of cholestasis?

Answer 20

Autoimmune disorders that cause inflammation in the bile ducts 
- primary biliary cirrhosis 
- Primary sclerosing cholangitis 
Drugs can also cause cholestasis 
and tumors

Question 21

Sinful verses painless jaundice

Answer 21

Painful most commonly caused by gall stones, whereas painless has a long list of differentials

Question 22

The difference between primary and secondary stones in the common duct

Answer 22

Primary stones form in the duct whereas secondary stones fall out of the gall bladder into the bile duct.
so people can get continuous problems even after they’ve had their gall bladder removed

Question 23

Charcot’s Triad

Answer 23

Fever
Jaundice
RUQ pain

If you have these three you are very likely to have cholangitis. But there will also be many people with cholangitis who don’t fill the triad.

Question 24

How would a history and examination suggest the duct obstruction was cause by cancer

Answer 24

acute presentation
weight loss
He had positive murphy sign and guarding which are signs of inflammation which you don’t typically get with cancer
would normally feel a mass in the area, or the patient could be wasted or cachexic

Question 25

Why would the patient have an elevated prothrombin time but this is restored to normal after an injection of vitamin K

Answer 25

Fat malabsorption and therefore malabsorption of vitamin K which is fat soluble

Question 26

What about a dilated common bile duct

Answer 26

Could still have stones in it, but might not be able to see under US

Question 27

Better imaging than US?

Answer 27

MRCP = magnetic resonance cholangiopancreatography

Useful for accurate visualisation of biliary tree
Advantage: non-invasive
Disadvantage: non-therapeutic

Question 28

ERCP

Answer 28

Endoscopic retrograde cholangiopancreatography
Diagnostic and therapeutic
Advantage: therapeutic
Disadvantage: risk of complications
They go in there with a wire basket and draw it out

Question 29

ERCP not the final step?

Answer 29

for people who have had an ERCP for choledocholithiasos and elective cholecystectomy needs to be performed at a future date to remove source of the gallstones i.e. the gall bladder.

Question 30

What feature on the ultrasound would have suggested that obstruction to the common bile duct was the diagnosis?
Given the absence of this finding where is the obstruction to bile flow?

Answer 30

Dilated bile duct

Obstruction to the biliary system either intrahepatic or extra hepatic.
One biliary condition only affects the ducts inside the liver, the other affects both intra and extra hepatic bile ducts

Question 31

primary biliary cirrhosis (PBC)

Answer 31

affects the intrahepatic bile ducts, on scan probably wont see any abnormalities because it affects the small bile ducts. Not even visible on MRI.
Only diagnose through liver biopsy.
Strongly associated with particular antibody: anti-mitochondrial antibody. so for diagnosis is just blood test

Diagnosis requires 2 out of 3 of:

• High ALP
• Positive AMA
• Liver biopsy

You can have cirrhosis as a complication but the term itself doesn’t mean you need to have cirrhosis.

Question 32

PSC: primary sclerosing cholangitis

Answer 32

on MRI or US see diffuse stricturing in the intra and extra hepatic bile ducts, often associated with inflammatory bowel disease. No good autoantibody tests for the condition, so sometimes diagnosed with imaging or liver biopsy
Immune mediated but antigen unknown
- Autoimmune
- May be triggered by chronic or recurrent bacteria
- Ischaemic damage

Question 33

PBC: presentation

Answer 33

Approximately 50-60% are asymptomatic
Progressive disease
- Jaundice
- Liver cirrhosis and related complications

Early symptoms

• fatigue
• pruritius
• May have steatorrhoea (fat malabsorption and fat soluble vitamin deficiencies)

Question 34

What is the description of fatty diarrhoea

Answer 34

Bulky, sticky, hard to flush, oil droplets in the pan as well.

Question 35

Why does cholestasis cause fibrosis

Answer 35

Instead of being in the canaliculi there is back flow of bile into the hepatocytes, it is an irritant
First get fibrosis then cirrhosis and while this is going on have associated symptoms

Question 36

PBC associated conditions

Answer 36

striking dyslipidaemia
- different from other lipid disorders: lipoprotein X elevated, HDL elevated
- no obvious risk of atherosclerotic complications: Unless risk factors for coronary artery disease
Associated with osteopenia/osteoporosis
- Not due to vit D malabsorption (from fat malabsorption)
- Mechanism not well understood
- Low bone formation
Hypothyroidism
- Autoimmune

Question 37

PSC: presentation

Answer 37

Often associated with ulcerative colitis (if you have PSC very likely to have USC, but many people with UC don’t have PSC)
50% asymptomatic
if symptomatic
- pruritius
- Fatigue
- May have steatorrhea (advanced disease), Fat malabsorption, fat soluble vitamin deficiencies
progressive disease
- Jaundice
- Cholangitis
- Liver cirrhosis and related complications (including hepatocellular carcinoma)

Can get recurrent infections with PSC (because affects the large and small ducts) whereas with PBC, you don’t get.

Progresses far more rapidly than PBC

Question 38

PSC: associated conditions

Answer 38

Associated with osteopenia / osteoporosis

• Not due to vit D malabsorption
• MOA unknown
• Low bone formation

Question 39

PSC treatment

Answer 39

No medication to slow progression
If develops jaundice/ cholangitis and due to a dominant structure in a large bile duct could treat with ERCP and dilation/ stenting.

Question 40

Tumors causing obstructive jaundice

Answer 40

Pancreatic cancer - Head of pancreas
Cholangiocarcinoma (cancer of the bile duct) (when found at the hilum known as a Klatskin tumour, see dilation of the right and left hepatic bile ducts but not the extra hepatic bile ducts)
Cancer of the duodenum in the ampulla

Question 41

Symptoms and signs of tumours causing obstructive jaundice

Answer 41

Painless jaundice
Palpable epigastric mass
Palpable gal bladder - courvoisiers sign
- As obstruction occurs slowly, pressure also increases slowly an the gall bladder distends to compensate for this and reduce pressure in biliary system