Jaundice and Gallbladder Disease - Bernadino

Question 1

How do you differentiate Hepatocellular vs. Cholestatic conditions using lab findings?

Answer 1

• Heptocellular
  
  • AST/ALT
  • Suggests parenchymal inflammation
• Cholestatic
  
  • Elevation of bilirubin or alk phos
  • Intrahepatic vs extrahepatic obstruction

Question 2

What does the evaluation of jaundice include?

Answer 2

• complete blood count (CBC)
• determination of bilirubin (total and direct fractions)
  
  • UA →urinalysis that is positive for bilirubin indicates the presence of conjugated bilirubinemia
• aspartate transaminase (AST)
• alanine transaminase (ALT)
• γ-glutamyl transpeptidase, and alkaline phosphatase levels
• second-line serum investigations may include:
  
  • hepatitis A IgM antibody
  • hepatitis B surface antigen and core antibody
  • hepatitis C antibody
  • autoimmune markers such as antinuclear, smooth muscle, and liver-kidney microsomal antibodies
  • amylase
• Imaging:
  
  • US and CT scanning are useful in distinguishing an obstructing lesion from hepatocellular disease in the evaluation of a jaundiced patient

Question 3

What are the etiologies of jaundice based on age (infants, adolescants, young adults, elderly)?

Answer 3

• Infants:
  
  • physiologic jaundice
  • metabolic/congenital
• Adolescants:
  
  • Gilbert’s syndrome
  • viral hepatitis
• Young adults:
  
  • viral hepatitis
  • alcohol
  • biliary tract pathology
  • autoimmune disease
• Elderly:
  
  • Malignancy
  • Toxin or drug
  • Stones

Question 4

What are the causes of Unconjugated (indirect) hyperbilirubinemia?

Answer 4

• Hemolysis
• Gilbert’s syndrome
• Medication

Question 5

What are the causes of Conjugated (direct) hyperbilirubinemia?

Answer 5

• Intrinsic liver disease
• Medication
• Biliary tract obstruction

Question 6

What are some types of physical evidence of chronic liver disease?

Answer 6

• spider hemangiomas
• ascites
• splenomegaly
• fetor hepaticus
• caput medusa
• asterixis
• edema
• palmer erythema
• testicular atrophy
• gynecomastia
• proximal muscle wasting
• parotid gland enlargement
• Dupuytren’s contractures
• Jaundice
• xanthelasma

Question 7

What is Spontaneous Bacterial Peritonitis?

Answer 7

• In the setting of ascites
• Neutrophil >250/mm³
• Culture positive

Question 8

How do you manage portal hypertension?

Answer 8

• Non-selective beta blocker
• Oral nitrates
  
  • decrease pressure
• TIPPS
  
  • surgery to place shunt in IVC and portal veins
  • shunting non-detoxified blood up to heart/brain → encephalopathy
• Low sodium, fluid restriction
• Diuretics

Question 9

How does the SAAG (Serum Ascites Albumin Gradient) help determine liver dysfunction?

Answer 9

• > 1.1 → Portal HTN, portal or hepatic vein thrombosis, right heart failure
• < 1.1 → malignancy, infection, TB, serositis

Question 10

What is the common clinic presentation of patients with gallstones?

Answer 10

• Asymptomatic (most)
• Biliary Pain
  
  • Colic – Rapid creschendo / Slower decreschendo
  • Varying duration – minutes to several hours
  • Spasm of GB and cystic in setting of obstruction
  • Often postprandial → after fatty meal
  • RUQ or epigastrium
  • Radiate to the interscapular region or right shoulder
• Nausea and vomiting
• Fever (if blockage, e.g. acute cholecystitis)

Question 11

What are the risk factors for developing cholesterol stones?

Answer 11

• Increasing age
• Female gender
• Rapid weight loss
• Native –American heritage
• Hyperalimentation (gallbladder stasis)
• Elevated triglyceride levels
• Medications (fibric acid derivatives, estrogens, octreotide)
• Ileal disease, resection or bypass

Question 12

What are the risk factors for developing pigment stones?

Answer 12

• Increasing age
• Chronic hemodialysis
• Alcoholic liver disease
• Biliary infection
• Asian heritage
• Hyperalimentation (gallbladder stasis)
• Duodenal diverticulum
• Truncal vagotomy primary biliary cirrhosis

Question 13

What is the difference between Acute cholecystitis, Chronic cholecystitis, and Acalculus cholecystitis?

Answer 13

• Acute cholecystitis
  
  • gallstone obstructing biliary tree → causing acute infection
• Chronic cholecystitis
  
  • dysfunctional gallbladder contractions
  • chronic inflammation of gallbladder
• Acalculus cholecystitis (rare)
  
  • no gallstone
  • gallbladder stasis and ischemia
  • usually critically ill patients (burn/trauma)

Question 14

What is Charcot’s triad?

Answer 14

Fever + Pain + Jaundice

seen in ascending cholangitis

Question 15

What causes 40% of Acute Pancreatitis in the US?

Answer 15

Gallstone Pancreatitis

• Mechanism:
  
  • stone passage
  • stone obstruction
  • biliopancreatic reflux