hepatic part 3

Question 1

Cholelithiasis?

Answer 1

gallstones

Question 2

Cholelithiasis cause

Answer 2

Most are cholesterol stones

Some are Pigment stones

Question 3

what are black and brown pigment stones made of in Cholelithiasis

Answer 3

Black- made of Ca bilirubinate

Brown- made of Ca salts and unconjugated bilirubin

Question 4

Cholelithiasis sx

Answer 4

Most Asx
Biliary colic
Most are sx recurrent but trmt is not an emergency

Question 5

biliary colic?

Answer 5

Intense, steady discomfort in RUQ, epigastric, or substernal that goes to the back, R scapula, or shoulder
Referred pain
Diaphoresis, NV, bloating
Lasts 30 min and plateaus in 1hr but goes away within 5-6 hrs
Occurs after eating

Question 6

Cholelithiasis pe

Answer 6

No fever, uncomfortable, NV, sweating, RUQ ttp
- murphy sign: stop in breathing with inspiration
No peritoneal signs

Question 7

dx Cholelithiasis

Answer 7

RUQ US is modality of choice

CT is less sensitive but can pick up other things

Question 8

trmt Cholelithiasis

Answer 8

Ultimate trmt for symptomatic choleithiasis is lap cholecystectomy
Don’t treat if Asx but tell pt to come back if sx worsen, nv, jaundice
Ursodeoxycholic acids- meds that dissolve stones if refuses surgery

Question 9

Mirizzi syndrome-?

Answer 9

stone putting pressure on CBD

Question 10

Cholecystitis?

Answer 10

Inflammation of the GB usually dt a stone in the cystic duct→ obstruction and inflammation in the GB
GB is trying to contract but it inflames cause nothing can get out of it

Question 11

Cholecystitis cause

Answer 11

Cholelithiasis

Acute cholecystitis- d/t impacted stone in cystic duct leads to obstruction and inflammation

Question 12

Cholecystitis sx

Answer 12

Similar to stone
RUQ or epigastric pain, constant severe pain that radiates to the shoulder/scapula/back
NV,* fever, anorexia
Postprandial- over 1 hr after eating
Pain for over 6 hrs*

Question 13

Cholecystitis pe

Answer 13

Ill, febrile, may be lying still bc moving hurts
RUQ ttp with + murphy sign
Guarding

Question 14

Cholecystitis dx

Answer 14

CBC→ leukocytosis with left shift (inc immature wbc)
RUQ US is 1st line→ will see GB wall thickening, pericholecystic fluid, and + sonographic murphy sign
HIDA if US is normal and you have high suspicion

Question 15

trmt Cholecystitis

Answer 15

IV atb
Mild to moderate- 2nd or 3rd gen cephalosporin, cefazolin, cefuroxime, ceftriaxone
2nd or 3rd gen cephalosporin, ciprofloxacin, levofloxacin AND metronidazole
Lap chole is definitive

Question 16

Acalculous cholecystitis?

Answer 16

In pts who are ill with no oral intake for long periods of time

Question 17

Acalculous cholecystitis

trmt?

Answer 17

Immediate referral and admission
IV atb and cholecystectomy
Percutaneous cholecystostomy if too critical for surgery

Question 18

Choledocolithiasis?

Answer 18

Stone in common bile duct

Question 19

Choledocolithiasis sx

Answer 19

Biliary type pain
RUQ pain
NV
May be Intermittent 
Jaundice*

Question 20

Choledocolithiasis dx

Answer 20

US shows dilated CBD over 6 mm
CT shows dilated CBD
MR cholangiopancreatography- diagnostic, not as expensive
ERCP- diagnostic and therapeutic
Can cause iatrogenic pancreatitis
High AST, ALT, ALP, GGT and bili
Lipase is high if obstruction is in the pancreatic duct too

Question 21

Choledocolithiasis trmt

Answer 21

ERCP with sphincterotomy to remove stone
Lap chole to remove GB
ATB if cholangitis present too

Question 22

Cholangitis?

Answer 22

Bacterial infection in biliary tree in pts with obstruction (usually choledocholitiasis)

Question 23

Cholangitis cause

Answer 23

Ascending infection from duodenum

MC E coli→ get UA

Question 24

Cholangitis sx

Answer 24

Charcot’s triad= fever/chills + RUQ pain + jaundice
Reynold’s pentad= charcot’s triad + confusion + hypotension→ indicates shock
Mild to life threatening

Question 25

Cholangitis dx

Answer 25

``` Leukocytosis Aminotransferases in 1000 High bilirubin High ALP High GGT ```

Question 26

Cholangitis trmt

Answer 26

Remove stone IV atb ERCP for dx and therapeutics

Question 27

Most pts survive 9-17 yrs

Answer 27

Primary sclerosing cholangitis

Question 28

Primary sclerosing cholangitiscause

Answer 28

Inc immune response from intestinal endotoxins Inflammation of biliary tract → fibrosis and strictures of biliary system Assoc. With IBD and UC

Question 29

Primary sclerosing cholangitis sx

Answer 29

Progressive obstructive jaundice Fatigue, pruritus (bilirubin in skin), anorexia, indigestion May be seen during asx period after elevated ALP on lab

Question 30

Primary sclerosing cholangitis dx

Answer 30

MRCP- magnetic resonance cholangiopancreatography Segmental fibrosis of bile ducts with saccular dilation between strictures High ALP (liver enzyme)

Question 31

Primary sclerosing cholangitis trmt

Answer 31

Ursodeoxycholic acid orally to improve liver tests | Balloon dilation or stent for strictures

Question 32

3rd MC inpatient GI dx in US

Answer 32

Acute pancreatitis

Question 33

Acute pancreatitis | cause

Answer 33

MCC gallstones and alcohol abuse- more common if smaller stones Iatrogenic, scorpion sting, meds Mechanism unknown Autodigestion of the pancreas bc pancreatic zymogens (trypsinogen) are activated and injure acinar cells (lipase release)

Question 34

Acute pancreatitis | sx

Answer 34

Acute onset, epigastric pain may be worse with walking, lying flat, better sitting up and leaning forward Radiation to the back NV, sweating h/o ETOH, heavy meal, or GB disease

Question 35

Acute pancreatitis | pe

Answer 35

Vomiting, fever, tachycardic, pallor, sweating + tenderness in upper abdomen without peritoneal signs Dec BS from ileus Abdominal ecchymosis suggest hemorrhagic pancreatitis Grey turner sign- ecchymosis around kidneys Cullen sign- around belly button

Question 36

Acute pancreatitis | dx criteria: 2/3 must be met

Answer 36

Hx consistent with dx Lipase 3 times normal limit CT findings of pancreatitis- fat stranding→ suggest inflammation

Question 37

Acute pancreatitis | dx

Answer 37

``` High lipase Leukocytosis Hyperglycemia if chronic US if GB cause but wont help you see pancreas Imaging not routinely indicated CT if you don't know what it is ```

Question 38

Revised Atlanta Classification | for Acute pancreatitis

Answer 38

Mild- no organ failure or systemic complications Moderate- organ failure or systemic complications under 48 hrs Severe- organ failure over 48 hrs

Question 39

Ranson criteria for assessing severity | for Acute pancreatitis

Answer 39

``` No rebound abd tenderness/guarding, normal hematocrit, normal serum Cr? Nonsevere Looks at age, WBC count, glucose, LDH, AST, hematocrit, BUN, serum Ca, pO2, base deficit, fluid sequestration 1 to 3→ Mild pancreatitis Over 3→ severe pancreatitis Predicted mortality 0-2→ 0-3% 3-5→ 11-15% 6→ 40% ```

Question 40

Acute pancreatitis | trmt

Answer 40

``` NPO if severe IVF with normal saline Analgesics- morphine, hydromorphone Antiemetics- zofran If severe give LOTS of IV fluids IV ATB if necrosis Admit to hospital ```

Question 41

Grey turner sign-

Answer 41

ecchymosis around kidneys

Question 42

Cullen sign-

Answer 42

around belly button

Question 43

Chronic pancreatitis cause

Answer 43

MC in chronic alcoholics Tumor, obstruction, autoimmune, idiopathic Acute pancreatitis→ necrosis→ chronic pancreatitis

Question 44

Chronic pancreatitis | sx

Answer 44

Recurrent epigastric or LUQ pain Anorexia, NV, weight loss, constipation, steatorrhea* Episodes last few hrs to wks

Question 45

Chronic pancreatitis | pe

Answer 45

``` Varying presentations Epigastric abd ttp Guarding Ileus Similar to acute but gradual onset ```

Question 46

Chronic pancreatitis | dx

Answer 46

Lipase normal* Typical labs for pancreatitis Fatty stools No imaging routinely indicated

Question 47

Chronic pancreatitis | trmt

Answer 47

``` Stop drinking IV fluids and pain control (no opioids bc they're addictive) Low fat diet Pancreatic enzyme supplements with meals Antacids Steroids if autoimmune Surgery if underlying GB disease ERCP for an obstruction Admit if severe pain, new jaundice, new fever ```