Hepatobiliary 1 - Paulson Exam 3 Flashcards
Functions of the liver include:
Gluconeogenesis and glycogenesis Detoxification Produces bile Producing clotting factors II, VII, IX, X Produces proteins
Function of bile?
Helps absorb fat
Unconjugated Bilirubin is a product of RBC breakdown. How is it used?
Liver conjugates bilirubin, which is then a component of bile
What is the cause of jaundice?
Increase in either unconjugated or conjugated bilirubin
What other symptoms are related to bilirubin?
Clay colored stools
Dark tea colored urine
Pruritis
What are some causes of increased unconjugated bilirubin?
Increased production of bilirubin (hemolytic anemia)
Decreased uptake of bilirubin by the liver
Decreased conjugation of bilirubin by the liver
What genetic syndromes can cause increased unconjugated bilirubin?
Gilbert syndrome
Crigler-Najjar syndrome
What are some causes of increased conjugated bilirubin?
Liver does not secrete bilirubin into bile ducts
Biliary tree obstruction
What is cholelithiasis?
Gallstones
What can gallstones be made of?
Cholesterol or pigment stones
What type of gallstones are more common?
Cholesterol (90%)
What are the different types of pigment stones?
What do they indicate?
Black stones - formed in sterile bile
Brown stones - from bacterial metabolism in biliary infection.
5 F’s of cholesterol stones
Fat Forty Female Fertile Fair skined
_______ predisposes women to gal stones due to increased levels of estrogen
Pregnancy
What percentage of cholelithiasis’ will be asymptomatic?
80%
What causes symptoms in cholelithiasis?
Intermitent blockage of cystic duct by a stone - this is called a biliary colic
Describe the pain associated with a biliary colic?
Intense, dull discomfort in RUQ that may radiate to the back (R shoulder blade)
What other symptoms can be caused by cholelithiasis?
Nausea, vomiting, diaphoresis
What can trigger symptoms from cholelithiasis?
Eating a large fatty meal
What is the imaging study of choice for cholelithiasis?
US
What US findings indicate a stone?
An acoustic shadow or sludge
What lab abnormalities are present during biliary colic?
No abnormalities
T/F? Emergent cholecystectomy is indicated in patients with biliary colic
False. Can be scheduled on non emergent basis
What is acute cholecystitis?
Inflammation of the gallbladder
What are the two categories of acute cholecystitis? Describe the typical patient for each.
Calculous - women between 40 and 60
Acalculous -critically ill, bedridden elderly patients, patients on TPN, more common in men
Pathophysiology of calculous cholecystitis?
Cystic duct becomes obstructed by stone, leading to inflammation.
Bacterial inflammation present in 50-85% of patients.
Most common organisms of acute bacterial cholecystitis?
E. coli, Klebsiella species, Streptococcus species, and Clostridium species.
Pathophysiology for acalculous cholecystisis?
> 50% have no underlying explanation
Some may have biliary sludge in cystic duct, or other weird causes for obstruction of gallbladder
Classic presentation of acute cholecystitis?
RUQ pain radiating to right shoulder/back.
Nausea/vomiting
Ate a fatty meal before presentation.
Pain lasting 4-6 hours
Physical exam findings for acute cholecystisis?
Tachycardia Fever Guarding Rebound tenderness Positive murphy's sign
Lab abnormalities in acute cholecystitis?
Leukocytosis with left shift
Mild elevation of LFTs
Imaging study of choice for acute cholecystitis?
US
HIDA scan if still uncertain after US
What US findings are indicative of acute cholecystitis?
Gallbladder wall thickening or edema
Sonographic murphy’s sign
Pericholecystic fluid and dilation of the bile duct
How does a HIDA scan work?
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.
T/F? Gallbladder visualization after HIDA administration is a positive test
False
Most common complication of untreated cholecystitis?
Gangrenous cholecystitis
Treatment for acute cholecystitis?
Pain control - NSAIDs or opioids
Antibiotics
Cholecystectomy or cholecystotomy
First line antibiotics for cholecystitis?
Cefazolin, cefuroxime, or ceftriaxone
Cholecystectomy vs cholecystotomy
Cholecystectomy is removal of the gallbladder. Can be done laparoscopic
Cholecystotomy is percutaneous drainage of the gallbladder done by IR
What is a porcelain gallbladder?
Calcification of the gallbladder wall associated with cholelithiasis. Usually diagnosed incidentally.
Porcelain gallbladder increases risk for ______
Gallbladder carcinoma
Treatment for porcelain gallbladder?
Surgical resection
