Hepatobiliary Part 1 Paulson (Exam 3) Flashcards
Bile emulsifies fats in the GI tract for easier absorption. Bile is produced in the liver and drains into the biliary tree. Bilirubin is a component of bile from breakdown of old/damaged RBC’s. Which kind of bilirubin exists before it reaches the liver?
Unconjugated (indirect) bilirubin
The liver conjugates this bilirubin, making conjugated (direct) bilirubin with glucuronic acid. Conjugated bilirubin is secreted into bile and then into the intestines (duodenum). In the intestine, glucuronic acid is removed by bacteria. The resulting bilirubin is converted to what?
Urobilinogen
If the urobilinogen is oxidized by intestinal bacteria and becomes part of feces, what is it called?
Brown Stercobilin
If the urobilinogen is reabsorbed from the gut and enters the portal blood it is transported to where to become what?
Kidneys
Yellow urobilin
People with jaundice can have clay-colored stools, dark tea-colored urine, and what other annoying symptom?
Pruritis (itchy)
What can cause an increase in unconjugated (indirect) bilirubin?
- Hemolytic anemia
- Decreased uptake of bilirubin by liver (CHF: decreased bloodflow to liver; Gilbert Syndrome)
- Decreased conjugation of bilirubin by liver (Crigler-Najjar syndrome: enzyme missing; Gilbert syndrome: reduced qty of enzyme, not as severe as Crigler-Najjar. Both reduce uptake and conjugation)
What can cause an increase in conjugated (direct) bilirubin?
- Liver doesn’t secrete the bilirubin into bile ducts (any disease that damages liver ie: hepatitis, toxin-induced liver failure; Dubin Johnson syndrome, Rotor Syndrome: genetic defect impairs secretion of bilirubin into bile)
- Biliary tree is obstructed (Intrahepatic: primary biliary cirrhosis {autoimmune destruction of bile ducts}, cancer, granuloma; extrahepatic: stones, stricture, cancer)
What LFT is elevated when the bile duct is obstructed?
ALP or alkphos
What are the 5 F’s of cholelithiasis (gallstones)?
Fat Forty Female Fertile Fair skin
Most gallstones are from what steroid molecule?
Cholesterol
Black stones are pigmented and formed in sterile bile, however, brown pigmented stones are from bacterial metabolism. Which is worse?
Brown, biliary infection, can kill you
80% of gallstones will remain asymptomatic unless complicated by obstruction/inflammation. If they are symptomatic it is usually from what?
Intermittent blockage of cystic duct by a stone
A symptom of cholelithiasis is biliary cholic, where you might experience what feelings?
Intense, dull discomfort, usually in RUQ that may radiate to the back (esp R shoulder blade)
Gallstones are also typically associated with what symptoms?
Nausea, vomitting, diaphoresis (sweating)
What can trigger gallstone symptoms?
Fatty meal
How would you diagnose a gallstone?
Ultrasound, labs normal even during biliary colic
Gallstones often cast what on US?
A shadow
Are gallstones gravitationally dependent on US?
Yes
What is the pain management during acute gallstone attack?
NSAIDs or opiods
Toradol (steroid)
Cholecystectomy (only for symptomatic)
Up to 12% of patients develop what after a cholecystectomy?
Diarrhea, increase in bile in intestines causes a laxative effect
Acute cholecystitis caused by calculous is most common in which pt population?
Fat forty female fertile fair skin
Acute cholecystitis that is acalculous is most common in?
Critically ill pts
Bedridden elderly pts
Those pts on TPN
Calculous caused acute cholecystitis is usually caused when a ____ becomes obstructed by a stone.
Duct
For calculous cholecystitis, bacterial inflammation may have a role in 50-85% of pts. What are the most common organisms?
E coli, Streptococcus, Clostridium
