Hepatobiliary 1 - Paulson Exam 3

Question 1

Functions of the liver include:

Answer 1

Gluconeogenesis and glycogenesis
Detoxification
Produces bile
Producing clotting factors II, VII, IX, X
Produces proteins

Question 2

Function of bile?

Answer 2

Helps absorb fat

Question 3

Unconjugated Bilirubin is a product of RBC breakdown. How is it used?

Answer 3

Liver conjugates bilirubin, which is then a component of bile

Question 4

What is the cause of jaundice?

Answer 4

Increase in either unconjugated or conjugated bilirubin

Question 5

What other symptoms are related to bilirubin?

Answer 5

Clay colored stools
Dark tea colored urine
Pruritis

Question 6

What are some causes of increased unconjugated bilirubin?

Answer 6

Increased production of bilirubin (hemolytic anemia)
Decreased uptake of bilirubin by the liver
Decreased conjugation of bilirubin by the liver

Question 7

What genetic syndromes can cause increased unconjugated bilirubin?

Answer 7

Gilbert syndrome

Crigler-Najjar syndrome

Question 8

What are some causes of increased conjugated bilirubin?

Answer 8

Liver does not secrete bilirubin into bile ducts

Biliary tree obstruction

Question 9

What is cholelithiasis?

Answer 9

Gallstones

Question 10

What can gallstones be made of?

Answer 10

Cholesterol or pigment stones

Question 11

What type of gallstones are more common?

Answer 11

Cholesterol (90%)

Question 12

What are the different types of pigment stones?

What do they indicate?

Answer 12

Black stones - formed in sterile bile

Brown stones - from bacterial metabolism in biliary infection.

Question 13

5 F’s of cholesterol stones

Answer 13

Fat
Forty
Female
Fertile
Fair skined

Question 14

_______ predisposes women to gal stones due to increased levels of estrogen

Answer 14

Pregnancy

Question 15

What percentage of cholelithiasis’ will be asymptomatic?

Answer 15

80%

Question 16

What causes symptoms in cholelithiasis?

Answer 16

Intermitent blockage of cystic duct by a stone - this is called a biliary colic

Question 17

Describe the pain associated with a biliary colic?

Answer 17

Intense, dull discomfort in RUQ that may radiate to the back (R shoulder blade)

Question 18

What other symptoms can be caused by cholelithiasis?

Answer 18

Nausea, vomiting, diaphoresis

Question 19

What can trigger symptoms from cholelithiasis?

Answer 19

Eating a large fatty meal

Question 20

What is the imaging study of choice for cholelithiasis?

Answer 20

US

Question 21

What US findings indicate a stone?

Answer 21

An acoustic shadow or sludge

Question 22

What lab abnormalities are present during biliary colic?

Answer 22

No abnormalities

Question 23

T/F? Emergent cholecystectomy is indicated in patients with biliary colic

Answer 23

False. Can be scheduled on non emergent basis

Question 24

What is acute cholecystitis?

Answer 24

Inflammation of the gallbladder

Question 25

What are the two categories of acute cholecystitis? Describe the typical patient for each.

Answer 25

Calculous - women between 40 and 60

Acalculous -critically ill, bedridden elderly patients, patients on TPN, more common in men

Question 26

Pathophysiology of calculous cholecystitis?

Answer 26

Cystic duct becomes obstructed by stone, leading to inflammation.
Bacterial inflammation present in 50-85% of patients.

Question 27

Most common organisms of acute bacterial cholecystitis?

Answer 27

E. coli, Klebsiella species, Streptococcus species, and Clostridium species.

Question 28

Pathophysiology for acalculous cholecystisis?

Answer 28

> 50% have no underlying explanation

Some may have biliary sludge in cystic duct, or other weird causes for obstruction of gallbladder

Question 29

Classic presentation of acute cholecystitis?

Answer 29

RUQ pain radiating to right shoulder/back.
Nausea/vomiting
Ate a fatty meal before presentation.
Pain lasting 4-6 hours

Question 30

Physical exam findings for acute cholecystisis?

Answer 30

Tachycardia
Fever
Guarding
Rebound tenderness
Positive murphy's sign

Question 31

Lab abnormalities in acute cholecystitis?

Answer 31

Leukocytosis with left shift

Mild elevation of LFTs

Question 32

Imaging study of choice for acute cholecystitis?

Answer 32

US

HIDA scan if still uncertain after US

Question 33

What US findings are indicative of acute cholecystitis?

Answer 33

Gallbladder wall thickening or edema
Sonographic murphy’s sign
Pericholecystic fluid and dilation of the bile duct

Question 34

How does a HIDA scan work?

Answer 34

Technetium labeled HIDA injected IV
Taken up by hepatocytes and excreted into bile
If cystic duct is patent, tracer enters gallbladder which can be visualized.

Question 35

T/F? Gallbladder visualization after HIDA administration is a positive test

Answer 35

False

Question 36

Most common complication of untreated cholecystitis?

Answer 36

Gangrenous cholecystitis

Question 37

Treatment for acute cholecystitis?

Answer 37

Pain control - NSAIDs or opioids
Antibiotics
Cholecystectomy or cholecystotomy

Question 38

First line antibiotics for cholecystitis?

Answer 38

Cefazolin, cefuroxime, or ceftriaxone

Question 39

Cholecystectomy vs cholecystotomy

Answer 39

Cholecystectomy is removal of the gallbladder. Can be done laparoscopic
Cholecystotomy is percutaneous drainage of the gallbladder done by IR

Question 40

What is a porcelain gallbladder?

Answer 40

Calcification of the gallbladder wall associated with cholelithiasis. Usually diagnosed incidentally.

Question 41

Porcelain gallbladder increases risk for ______

Answer 41

Gallbladder carcinoma

Question 42

Treatment for porcelain gallbladder?

Answer 42

Surgical resection