Hepatobiliary part 1- Paulson-exam 3 Flashcards
1
Q
Acute cholecystitis: Clinical presentation?
A
- RUQ pain (or epigastric)
- (+/-) associated NVD or fever
- (+/-) often have a Hx of fatty food ingestion prior to presentation
- Episode has typically lasted several hours (>4-6 hours)
2
Q
Acute cholecystitis: Common radiation site of RUQ pain?
A
- Right shoulder
3
Q
Acute cholecystitis= acute inflammation of the _______
-usually characterized by?
A
gallbladder usually characterized by RUQ pain, fever, and leukocytosis with left shift (increase in bands)
4
Q
Acute cholecystitis: Describe a positive Murphy’s sign.
A
- PT asked to inspire deeply while examiner palpates RUQ subcostal area
- –> inspiratory arrest and increased discomfort
5
Q
Acute cholecystitis: Describe if providing the patients with antibiotics is a common part of the treatment plan or not.
A
- It is often given to all patients with acute cholecystitis until clinical resolution or cholecystectomy (gallbladder removal)
6
Q
Acute cholecystitis: Dx based on U/S findings?
A
- Gallbladder wall thickening or edema
- Sonographic Murphy’s sign
- (+/-) pericholecystic fluid & dilation of the bile duct.
7
Q
Acute cholecystitis: Empiric antibiotic treatment for community acquired acute cholecystitis of mild-to-moderate severity?
A
- Cefazolin
- Cefuroxime
- (or) Ceftriaxone
8
Q
Acute cholecystitis: Epidemiology of a calculous condition?
A
- MC in women 40-60
9
Q
Acute cholecystitis: Epidemiology of an acalculous condition?
A
- MC in critically ill patients, bedridden elderly patients, and those on TPN (total parenteral nutrition)
- 5-10% of all patients with cholecystitis
- More prevalent in men
10
Q
Acute cholecystitis: How long does it take for the tracer to be picked up in cholescintigraphy after injection?
A
- Takes 30-60 minutes
11
Q
Acute cholecystitis: How many patients present with a Hx of previous similar attacks that have resolved spontaneously?
A
- 60-70%
12
Q
Acute cholecystitis: How often is bacterial inflammation associated with a calculous condition?
-MC organisms?
A
- 50-85% of PTs
- MC organisms= E. coli, Klebsiella spp, Streptococcus spp, and Clostridium spp
13
Q
Acute cholecystitis: is an IV required for a HIDA Scan?
A
- Yes
- Technetium labeled HIDA injected IV–> Taken up by hepatocytes–> excreted into bile
If cystic duct is patent, tracer enters gallbladder, which can then be visualized (takes 30-60 minutes)
**Test is positive if gallbladder is not visualized
Note: hepatobiliary iminodiacetic acid (HIDA) scan is an imaging procedure used to diagnose problems of the liver, gallbladder and bile ducts.
14
Q
Acute cholecystitis: Labs?
A
CBC:
- Leukocytosis with left shift (increased bands)
LFTs:
- May have mild elevation of LFTs
15
Q
Acute cholecystitis: MC bacterial organisms associated with a bacterial inflammation in a calculous acute cholecystitis?
A
- E. coli
- Klbesiella spp
- Streptococcus spp
- Clostridium spp
16
Q
Acute cholecystitis: On U/S, does the presence of cholelithiasis support the diagnosis of cholecystitis?
A
- It supports the diagnosis, but it doesn’t make the diagnosis.
17
Q
Acute cholecystitis: Other than gangrenous cholecystits, what are other complications of untreated acute cholecystitis?
A
- Perforation
- Cholecystoenteric fistula
- Gallstone ileus
- Emphasematous cholecystitis.
18
Q
Acute cholecystitis: Other than U/S, what is another imaging modality that could be used?
A
- HIDA Scan (Cholescintigraphy)
19
Q
Acute cholecystitis: Pathophysiology of acalculous cholecystitis?
A
- > 50%: no underlying explanation found.
- (+/-) biliary sludge in the cystic duct, vasculitis, obstructing adenocarcinoma of the gallbladder, unusual infections, or systemic disease processes such as sarcoidosis, TB, syphilis.
20
Q
Acute cholecystitis: Pathophysiology of a calculous condition?
A
- Usuall cystic duct becomes obstructed by a stone.
- -> Leads to inflammation.
- Bacterial inflammation may have a role in 50-85% of patients
- MC organisms: E. coli, Klebsiella spp, Streptococcus spp, and Clostridium spp
21
Q
Acute cholecystitis: Physical exam findings?
A
- Usually ill-appearing
- Fever
- (+/-) tachycardic
- (+/-) voluntary and involuntary guarding or rebound tenderness
- RUQ likely TTP
- POSITIVE Murphy’s sign
- (+/-) enlarged, tender gallbladder
22
Q
Acute cholecystitis: Patients with acalculous cholecystitis usually have **underlying severe illnesses. What are some of these conditions?
A
- Serious trauma or burns
- Postpartum period after prolonged labor
- Post-op after major surgery
- Patients on TPN
23
Q
Acute cholecystitis: (T/F) If PT is untreated, symptoms will not resolve.
A
- False
- Symptoms MAY subside within 7-10 days
24
Q
Acute cholecystitis: Tx?
A
- Hospital admission
- Pain management (NSAIDs or opioids)
- Abx
- Cholecystectomy or cholecystotomy
25
Acute cholecystitis: What is a positive finding associated with a HIDA scan (Cholescintigraphy)?
- Test is positive if gallbladder is not visualized.
26
Acute cholecystitis: What is the most common complication if the patient is not treated?
- Gangrenous cholecystitis (~20%)= MC complication**
Other complications if left untreated:
- Perforation--> Can lead to abscess or generalized peritonitis
- Cholecystoenteric fistula
- Gallstone ileus
- Emphasematous cholecystitis
27
Acute cholecystitis: What specifier is typically added to this condition?
- Calculous
| - Acalculous
28
Acute cholecystitis: When is a HIDA scan indicated?
- If Dx is still uncertain after an ultrasound.
29
Acute cholecystitis: Why is technetium labeled HIDA utlized in a cholescintigraphy?
- Taken up by hepatocytes which is then excreted into bile.
| - If the cystic duct is patent, tracer enters gallbladder, which can then be visualized.
30
Anatomy: What are the ducts that originate from the liver that converge and enter the duodeunum.
- Left Hepatic duct and Right hepatic duct (converge) and form the -->Common hepatic duct.
- Common hepatic duct and cystic duct come together and form the common bile duct
- Common bile duct & pancreatic duct go into--> Ampulla of Vater (goes into duodenum)
31
Bilirubin: Bilirubin is a product of the breakdown of what common cell?
- Old/damaged RBCs
32
Bilirubin: Bilirubin that is the product from a breakdown of old/damaged RBCs forms what type of bilirubin?
- Unconjugated (indirect) bilirubin.
33
Bilirubin: Conjugated bilirub is secreted from the liver into what?
- Bile
34
Bilirubin: Once bile is produced in the liver, what structure does it drain into?
- The biliary tree.
Summary: Bile produced in the liver-->drains into the biliary tree
- Bilirubin is a component of bile
- --From breakdown of old/damaged RBCs forms unconjugated (indirect) bilirubin
- -Liver conjugates this bilirubin --> makes conjugated (direct) bilirubin-->Conjugated bilirubin secreted into bile
35
Bilirubin S/Sx: Other than jaundice, what are other common symptoms related to an increase in bilirubin?
- Clay-colored stools
- Dark tea-colored urine
- Pruritis
36
Bilirubin: (T/F) Bilirubin is a component of bile.
- True
37
Bilirubin: The biliary tree is a system of vessels that direct secretions from which organs?
- Liver
- Gallbladder
- Pancreas
38
Bilirubin: The liver conjugates unconjugated (indirect) bilirubin to form what product?
- Conjugated (direct) bilirubin.
39
Bilirubin: What is the role of bile?
- Emulsify fats in the GI tract--> absorbed easier
40
Bilirubin: What structure conjugates the unconjugated (indirect) bilirubin.
- The liver
41
Bilirubin: Where is bile produced?
- In the liver
42
Bilirubin: Why is bile's emulsification of fats in the GI tracts helpful for the GI system?
- fats are absorbed easier.
-Bilirubin is a component of bile
--From breakdown of old/damaged RBCs forms unconjugated (indirect) bilirubin
Liver conjugates this bilirubin --> makes conjugated (direct) bilirubin
-->Conjugated bilirubin secreted into bile
43
Cholecystectomy/Cholecystotomy: Emergent action is needed for patients who...
- Have progressive S/Sx (i.e. high fever, hemodynamic instability, or intractable pain)
- Suspicion for gallbladder gangrene or perforation.
44
Cholecystectomy/Cholecystotomy: Proper action to take when the risks outweigh the benefits with no indication for emergent treatment?
- Gallbladder drainage with percutaneous cholecystotomy
- Resolves the acute episode in 90% of patients
- Once acute episode resolved, reassess risk for surgery, schedule elective cholecystectomy if possible.
45
Cholecystectomy/Cholecystotomy: What procedure is indicated for low-risk patients?
- Cholecystectomy during initial hospitalization (laparoscopic)
46
Cholecystectomy: How do most patients feel who were symptomatic with cholelithiasis after a cholecystectomy?
- Most patients had symptom relief after surgery
47
Cholecystectomy: Possible complications of the procedure?
| -up to 12% of Pts develop ______
- Bile leak
- Bleeding
- Abscess formation
- Biliary injury
- Bowel injury
* Up to 12% of patients develop diarrhea afterwards
48
Cholelithiasis: AKA?
- Gallstones
49
Cholelithiasis: Biliary colic may be associated with what other signs and symptoms?
- NV
- Diaphoresis
biliary colic= Pain that occurs when a gallstone is being passed and is blocking a bile duct, typically comes and goes in a fairly regular pattern
50
Cholelithiasis: Black pigment stones are formed in _____
Sterile bile
51
Cholelithiasis: Brown pigment stones are from:
- bacterial metabolism in biliary infection.
52
Cholelithiasis: Describe "biliary colic"
- Intense, dull discomfort
- Usually in RUQ
- (+/-) radiate to back (esp. R shoulder blade)
53
Cholelithiasis: Dx studies?
- U/S
| - Labs are normal (even during biliary colic)
54
Cholelithiasis: MGMT for asymptomatic PTs?
- Do NOT perform cholecystectomy
55
Cholelithiasis: MGMT for atypical symptoms with gallstones
- Lower relief rates after cholecystectomy than those with typical symptoms + stones
56
Cholelithiasis: MGMT for typical biliary symptoms + gallstones?
- Pain management during acute attack (NSAIDs or opioids)
| - Cholecystecomy or medical dissolution of stones
57
Cholelithiasis: MGMT for typical symptoms but no stones visualized?
- May have a functional gallbladder disorder.
58
Cholelithiasis: Patients with microlithiasis may have what kind of appearance on U/S?
- Sludge
59
Cholelithiasis: Pigment stones can present in what colors?
- Black stones
| - Brown stones
60
Cholelithiasis: PT demographic?
- Increases after 40 YO
- MC in women
- Prevalent in Western countries
61
Cholelithiasis: PTs are typically asymptomatic unless the condition is complicated by ______
obstruction/inflammation -->80% will remain asymptomatic
-If symptomatic: usually from intermittent blockage of cystic duct by a stone (Pt will have biliary colic, often assoc. with N/V and diaphoresis)
62
Cholelithiasis: S/Sx?
- Asymptomatic
- Usually an incidental finding
- Usually no positive exam findings
63
Cholelithiasis: Typical duration of biliary colic?
- Usually lasts at least 30 minutes, plateaus by 60, then subsides.
64
Cholelithiasis: What are the "4 Fs" of cholesterol stones?
- Fat
- Forty
- Female
- Fertile
65
Cholelithiasis: What are the two main categories of cholelithiasis?
- Cholesterol
| - Pigment stones
66
Cholelithiasis: What often triggers biliary colic?
- A fatty meal
67
Cholelithiasis: What would you see on U/S?
| -Labs?
- **Echogenic foci that cast an acoustic shadow.
- Gravitationally dependent
- Those with microlithiasis may have the appearance of sludge
Labs: Normal-->Even during biliary colic
68
Cholelithiasis: Which is more common in Western countries, cholesterol or pigment stones?
- Cholesterol
| - 90% of all gallstones in Western countries.
69
Chronic cholecystitis: Describe.
- Chronic inflammation of the gallbladder wall.
| - Almost always associated with gallstones
70
Chronic cholecystitis: How common is bacteria present in the bile of these patients?
>25% of PTs
71
Chronic cholecystitis: How does the presence of multiple episodes of biliary colic correlate with symptoms?
- Presence does not necessarily correlate with symtpoms.
72
Chronic cholecystitis: Likely etiology?
- From repeated episodes of acute or subacute cholecystitis or gallstones that cause persistent irritation to gallbladder wall
- -> fibrosis & thickening of gallbladder
73
Chronic cholecystitis: S/Sx?
Patient may describe **multiple episodes of biliary colic
| --Presence does not necessarily correlate with symptoms
74
Chronic cholecystitis: Tx?
- Cholecystectomy
75
Chronic cholecystitis: What is a condition that is almost always associated with this?
- Gallstones
76
Chronic cholecystitis: What would you find on U/S?
- Cholelithiasis
| - (+/-) Wall thickening from scarring
77
Increased conjugated (direct) bilirubin: What are intrahepatic causes of a biliary tree obstruction?
- Primary biliary cirrhosis
- Cancer
- Granuloma
78
Increased conjugated (direct) bilirubin: What are reasons or conditions that the liver wouldn't seecrete the bilirubin into bile ducts?
- Any dz that damages the liver (i.e. hepatitis, toxin- induced liver failure)
- Dubin-Johnson syndrome
- Rotor syndrome
79
Increased conjugated (direct) bilirubin: What are the extrahepatic causes of a biliary tree obstruction?
- Stones
- Stricture
- Cancer
80
Increased conjugated (direct) bilirubin: What are the two categories of conditions that would obstruct the biliary tree?
- Intrahepatic
| - Extrahepatic
81
Increased unconjugated bilirubin: Describe Crigler-Najjar syndrome.
Crigler-Najjar syndrome is a rare inherited disorder affecting the metabolism of bilirubin, a chemical formed from the breakdown of the heme in red blood cells. (prevents conjugation to direct bilirubin in the liver)
82
Increased unconjugated bilirubin: Describe Gilbert syndrome.
Gilbert Syndrome is a mild genetic disorder in which the liver does not properly process bilirubin.
83
Increased unconjugated bilirubin: What conditions lead to a decreased uptake of bilirubin by the liver?
- CHF
- Gilbert syndrome
(leads to increased unconjugated bilirubin since the liver isnt uptaking it)
84
Increased unconjugated bilirubin: What conditions lead to a decrease in conjugation of bilirubin by the liver?
- Crigler-Najjar syndrome
| - Gilbert syndrome
85
Increased unconjugated bilirubin: What hematologic disorder leads to an increased production of bilirubin?
- Hemolytic anemia
86
Jaundice: Comes from an increase in either...
- Unconjugated bilirubin
| - Conjugated bilirubin.
87
Porcelain gallbladder: Describe.
| -may be a form of chronic cholecystitis in >___%
- Calcification of the gallbladder wall.
| - May be a form of chronic cholecystitis in >95%
88
Porcelain gallbladder: How is this condition typically diagnosed?
- Incidentally on X-ray
89
Porcelain gallbladder: How often is this condition associated with cholelithiasis?
>95% of PTs
90
Porcelain gallbladder: (T/F) Unlike other forms of cholecystitis, this condition is typically symptomatic.
- False
| - Usually asymptomatic.
91
Porcelain gallbladder: These PTs are at an increased risk for what conditions?
- Gallbladder carcinoma
92
Porcelain gallbladder: Tx?
- Resection
93
Porcelain gallbladder: While this condition may be suspected incidentally on X-ray, what imaging modality would confirm the diagnosis?
- U/S [OR]
| - CT
94
What are some major functions of the liver?
- Gluconeogenesis & Glycogenolysis --> provides glucose
- Detoxification
- Produces bile
- Produces proteins like clotting factors
