Gut Problems 3 (Clinical) (Ow) Flashcards
56 yo man presents with right upper quadrant (RUQ) pain for 24hr
- If RUQ pain is colicky (comes and goes, with periods of quite severe pain that subsides), typically indicates that there is a blockage to a lumen (e.g. biliary colic, renal colic))
On examination:
- Tender in RUQ with guarding
- Pain is particularly prominent when he is asked to take a deep breath with an examining hand just below the right costal margin (Murphy’s sign is hypersensitivity to deep palpation in subcostal area when a patient with gallbladder inflammation takes a deep breath)
His temperature is 38.2 C, white blood cell count elevated
Abdominal ultrasound showed gallstones, thickening of gallbladder wall, and fluid around the gallbladder
What Is Meant By The Term Guarding?
- Tensing of abdominal wall due to pain (can be voluntary or involuntary)
- Involuntary guarding indicates _peritonism (_percussion tenderness etc.)
- Voluntary guarding is usually due to anticipation of pain, cold hands etc.
Where does pain radiate for gallbladder pain?
Right back and/or shoulder blade
Describe the symptoms of gallstones
1) Strong pain
2) Comes and goes
- Sudden and rapidly intensifying pain in the upper right portion of your abdomen
- Sudden and rapidly intensifying pain in the center of your abdomen, just below your breastbone
- Back pain between your shoulder blades
- Pain in your right shoulder
- Nausea or vomiting
Involuntary guarding indicates ______
Involuntary guarding indicates peritonism
56 yo man presents with right upper quadrant (RUQ) pain for 24hr
- If RUQ pain is colicky (comes and goes, with periods of quite severe pain that subsides), typically indicates that there is a blockage to a lumen (e.g. biliary colic, renal colic))
On examination:
- Tender in RUQ with guarding
- Pain is particularly prominent when he is asked to take a deep breath with an examining hand just below the right costal margin (Murphy’s sign is hypersensitivity to deep palpation in subcostal area when a patient with gallbladder inflammation takes a deep breath)
His temperature is 38.2 C, white blood cell count elevated
Abdominal ultrasound showed gallstones, thickening of gallbladder wall, and fluid around the gallbladder
What Is Cause Of The Pain?
Because of inflammation -> distension, swelling, stretching of visceral organs
56 yo man presents with right upper quadrant (RUQ) pain for 24hr
- If RUQ pain is colicky (comes and goes, with periods of quite severe pain that subsides), typically indicates that there is a blockage to a lumen (e.g. biliary colic, renal colic))
On examination:
- Tender in RUQ with guarding
- Pain is particularly prominent when he is asked to take a deep breath with an examining hand just below the right costal margin (Murphy’s sign is hypersensitivity to deep palpation in subcostal area when a patient with gallbladder inflammation takes a deep breath)
His temperature is 38.2 C, white blood cell count elevated
Abdominal ultrasound showed gallstones, thickening of gallbladder wall, and fluid around the gallbladder
Diagnose
What would be the initiating event?
Cholecystitis
What Would Be Initiating Event?
Impaired bile flow or abnormal gallbladder contraction leading to a build-up of bile and bacteria due to stasis à infection à cholecystitis
Cholesterol Gallstones Form In The Gallbladder Not In The Bile Duct. Why?
- Cholesterol gallstones are the most common (80%) form of gallstone
- Cholesterol is part of the component of bile. When there is abnormal emptying or obstruction to flow, you get a _stasis of bil_e which causes the concentration of cholesterol -> formation of stones
- Other type called pigmented stone (bilirubin), tend to form in the bile duct
What Initiates Emptying Of Gallbladder? (hormone)
Cholecystokinin
What are the terms for gallstones in different areas of the Biliary tract?
- Biliary colic (not a diagnosis, just a descriptive term for pain people experience with gallstones (RUQ pain))
- Cholelithiasis (gallstones)
- Cholecystitis (inflammation of gallbladder)
- Choledocholithiasis (stone in bile duct)
- Cholangitis (infection in biliary tree; infected, blocked duct)
- Cholesterol stone (80%)
- Pigment stones
(stone in bile duct)
Choledocholithiasis
(inflammation of gallbladder)
Cholecystitis
(gallstones)
Cholelithiasis
(infection in biliary tree; infected, blocked duct)
Cholangitis
He is found to have an elevated GGT and ALP and bilirubin . Common bile duct is dilated on ultrasound. He develops a high fever and rigors.
What is the diagnosis now?
elevated GGT and ALP (cholestasis) and bilirubin (jaundice).
Cholangitis
What Is Another Potential Consequence Of Cholangitis?
- Cholangitis (infection in biliary tree; infected, blocked duct)
What Is Another Potential Consequence Of This Problem?
Risk of development into pancreatitis (commonest cause of pancreatitis is gallstone and pancreatitis)
- Therefore check for lipase and amylase too (pancreatic enzymes)
Describe Cholestasis
- lab tests
- causes
Cholestasis presents with elevated GGT and ALP. Common causes include:
- Stones
- Biliary disease (these conditions are autoimmune disease that cause inflammation of bile duct -> stricture -> restrict bile flow)
- Primary biliary cirrhosis (PBC)
- Primary sclerosing cholangitis (PSC)
- Drugs (important to take a medication history)
- Tumors
What are the common presenations of cholangitis?
Cholangitis is _complication of choledocholithiasi_s.
It presents with Charcot’s triad:
- Fever (infection)
- Jaundice (indicate obstructed bile duct)
- RUQ pain (biliary colic)
Not all cases of cholangitis will have the full triad!
What is the therapeutic procedure for choledocholithiasis?
ERCP (Endoscopic Retrograde Cholangiopancreatography)
ERCP involves cannulation of the bile duct
- Advantage: diagnostic and therapeutic
- Disadvantage: risk of complication
ERCP Is Not Final Step…
In people who have had an ERCP for choledocholithiasis, an elective cholecystectomy needs to be performed at a future date to remove source of gallstones i.e. gallbladder
- >85% of common duct stones are secondary (i.e. migrated from the gallbladder).
- This means that remaining percentage is due to primary common duct stones (i.e. stones that form in the common bile duct). In this small amount of people, they may get future episodes of biliary obstruction even after cholecystectomy.
- So even if a patient has had cholecystectomy, they may still present in future with choledocholithiasis!
Describe Primary Biliary Cirrhosis (PBC)
-Cause
-Diagnosis
-Where it affects
She had positive mitochondrial antibodies, which suggested a diagnosis of primary biliary cirrhosis.
Primary biliary cirrhosis is autoimmune chronic cholestatic liver disease that affects small intra-hepatic bile ducts.
- Bile duct abnormality in PBC is not detectable on imaging.
- Detected by liver biopsy (showed destruction of bile ductules by an autoimmune process)
- Diagnosed by positive anti-mitochondrial antibody (AMA)
Diagnosis requires 2 out of the following 3 criteria
- high ALP,
- positive AMA,
- liver biopsy
What are the difference between PBC and PSC? **
8:42
Describe PBC presentation
In PBC, ~50-60% are asymptomatic
- Usually diagnosed when patient has LFTs done for something else
- ALP tends to go up first
Early symptoms include:
- Fatigue
- Pruritus (severe itching) (even without jaundice) (due to the accumulation of bile salts in the skin)
- May have steatorrhea (pale, floating, bulky, oily, sticky)
- Fat malabsorption
- Fat-soluble vitamin deficiencies as well (e.g. Vitamin D and K)
It is progressive disease:
- Jaundice
-
Liver cirrhosis and related complications (including hepatocellular carcinoma)
- Bile duct is damaged by the antibodies, but the bile leaks into the adjacent liver cells and damage the liver.
Describe PSC
Primary sclerosing cholangitis is _chronic cholestatic liver disease t_hat affects both intra and extrahepatic bile ducts
- It causes distinctive stricturing of bile ducts (typical abnormality on imaging)
-
Immune mediated but antigen unknown
- Autoimmune
- May be triggered by chronic or recurrent bacteria
- Ischemic damage
- No good autoantibody tests for this condition (usually diagnosed with imaging, sometimes liver biopsy)
Diagnosis is usually radiological, occasionally requires liver biopsy
What are the PSC presentations?
Often associated with ulcerative colitis (IBD)
- If you have PSC, you most likely will have UC
- But people with UC don’t normally have PSC
Asymptomatic ~50%
- Diagnosed when patients have LFTs done for something else
- Cholestatic with predominant ALP elevation
Symptomatic (~50%) include:
- Pruritus
- Fatigue
- May have steatorrhea (advanced disease) (fat malabsorption + fat-soluble vitamin deficiencies)
Progressive disease:
- Jaundice
- Cholangitis (not seen in PBC) (because PSC also affects extrahepatic ducts which can lead to recurrent infections when they become strictured)
- Liver cirrhosis and related complications (including hepatocellular carcinoma)
Compare and contrast the diff between PBC and PSC
1) Affects where?
2) Causes
3) Presentation
4) Ass. Conditions
5) Treatment
