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Unit 2 Clin Med III > L10: Biliary disease > Flashcards

L10: Biliary disease Flashcards

1
Q

The 4 F’s of cholelithiasis

A

Female
Fat
Fertile
Forty

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2
Q

Risk factors for cholelithiasis

A 
Females, Age 40, Obesity
Pregnancy
Estrogen (OCPs, HRT)
Rapid weight loss
Family history/genetics
Ethnicity (Native Americans)
Diabetes
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3
Q

Most stones are _____

A

Cholesterol stones

vs brown/black pigment stones

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4
Q

Presentations of Cholithiasis

A
  1. Asymptomatic (incidental) gallstones (most)
  2. Uncomplicated gallstone disease: Biliary Colic (symptomatic) → In the absence of gallstone-related complications
  3. Complicated gallstone disease:
    1. Acute Cholecystitis
    2. Choledocholithiasis
    3. Acute cholangitis
      (4. Gallstone pancreatitis (not covered))
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5
Q

Diagnosis of choleithiisis

A

US

CT and plain films are less sensitive

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6
Q

Management of asymptomatic Cholelithiasis

A

No treatment

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7
Q

Asymptomatic cholelithiasis needs to be referred for surgery if…

A

Symptoms develop
Increased risk of gallbladder cancer
Hemolytic disorders

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8
Q

Biliary colic is considered _____

A

Uncomplicated gallstone disesase

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9
Q

No inflammation of GB → gallbladder contracts forcing a stone/sludge against outlet or cystic duct opening→ increased intra-gallbladder pressure→ pain→ gallbladder relaxes→ obstruction relieved

A

Biliary colic

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10
Q

“Biliary type pain” means

A

Intense RUQ (or epigastric) pain +/- radiate to the R shoulder blade
Constant and steady (not colicky)
Pain lasting at least 30 min, plateauing within 1 hour, lasts < 5-6 hours
Postprandial pain→ esp fatty/ greasy foods
N/V, diaphoresis
Not exacerbated by movement, not relieved (>20% reduction) by squatting, bowel movements, flatus
Nocturnal pain awakening pt
Recurrence is variable (not daily)
Severe → interruptive, ED visit

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11
Q

Biliary colic tx

A

cholecystectomy

prevent recurrence, complications

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12
Q

Biliary cholic on exam and labs

A

Normal vitals, appears well, no tachycardia, no jaundice (inc. eyes)

Abdomen→ benign +/- RUQ/epigastric TTP, no peritoneal signs

(-) Murphy’s sign

Normal labs→ CBC, LFTs, amylase, lipase

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13
Q

Preferred imaging to see gallstones or sludge in biliary colic

A

US

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14
Q

Functional gallbladder disorder used to be called

A

Functional dyskinesia

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15
Q

Gallbladder dysmotility→ biliary-type pain in the absence of

gallstones, sludge, microlithiasis, or microcrystal disease

A

Functional galbladder disorder

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16
Q

Functional gallbladder disorder is a diagnosis of _____

A

Diagnosis of exlusion

Basically rule everything else out and normal results on labs and imaging

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17
Q

Imaging that supports diagnosis of functional gallbladder disordeer

A

CCK (stimulates contraction) + HIDA (cholescintigraphy) → gallbladder ejection fraction (GBEF) calculation→ <35-40% low→ support diagnosis

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18
Q

Rome IV criteria for functional gallbladder disorder

A

Required: Biliary pain + Absence of gallstones, structural pathology

Supportive, not required:
Low ejection fraction on scintigraphy
Normal liver enzymes, conjugated bilirubin, and amylase/lipase

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19
Q

Required ROME IV criteria for biliary pain

A

Intense RUQ (or epigastric) pain

Recurrence is variable (not daily)

Not exacerbated by movement, not relieved (>20% reduction) by squatting, bowel movements, flatus

Pain lasting at least 30 min

Severe → interruptive, ED visit

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20
Q

Supporting ROME IV criteria for biliary pain

A

pain radiates to the R shoulder blade

N/V

Nocturnal pain awakening pt

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21
Q

A patient with functional gallbladder disorder gets a cholecystectomy if

A

Typical biliary-type pain and a low GBEF (< 40%)

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22
Q

Acute inflammation of the gallbladder
Complication of gallstone disease (most) or acalculous cholecystitis (rare)

Cystic duct obstruction

A

Acute cholecystitis (calculous)

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23
Q

Acute cholecystitis (calculous) presentation

A

Previous episodes of biliary pain→ attack of biliary pain that progressively worsens: >4-6 hours steady, severe RUQ or epigastric pain +/- radiate to right shoulder/back
Fever, N/V/A
+/- history of fatty food ingestion

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24
Q

Acute cholecystitis (calculous) complications

A 
Gangrene (common, 20%)
• Older, DM, delay tx, Sepsis-like 
Perforation (10%)
Delay tx, refractory to tx
Often after gangrene
Cholecystoenteric fistula
Gallstone ileus
Emphysematous cholecystitis, empyema, hydrops
Mirizzi syndrome (1%)
Stone cystic duct or Hartmann’s pouch→ compress common hepatic duct→ jaundice
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25
Q

Acute cholecystitis (calculous) on exam

A 
Fever, tachycardia
Ill appearing +/- lying still
No jaundice, anicteric
RUQ TTP +/- voluntary &amp; involuntary guarding
(+)Murphy’s sign
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26
Q

Acute cholecystitis (calculous) labs

A

Leukocytosis with a left shift
+/- mild elevation AST/ALT
Normal total bilirubin, alkaline phosphatase
Normal serum amylase

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27
Q

Acute cholecystitis (calculous) imaging

A

US (preferred) → gallstones, edema, wall thickening >4-5 mm, pericholecystic fluid, (+) sonographic Murphy’s sign

HIDA→ if uncertain. (+): failure to visualize gallbladder (cystic duct obstruction)

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28
Q

Acute cholecystitis is anicteric/no jaundice except…

A

Mirizzi Syndrome but it’s super rare

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29
Q

Elevated serum amylase makes you think

A

pancreatitis

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30
Q

Elevated total bilirubin or alk phos makes you think

A

biliary obstruction

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31
Q

Acute cholecystitis management

A

Admit, NPO
IV fluids + empiric abx + pain control:
Ketorolac, Morphine, Meperidine

Cholecystectomy→ mainstay

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32
Q

Ketorolac is

A

Pain control, NSAID

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33
Q

Mepridine is

A

Pain control, opioid

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34
Q

Chronic inflammation of the gallbladder associated with gallstones (most)

Cause:
Repeated acute/subacute cholecystitis or prolonged mechanical irritation
of the gallbladder wall (by stones)

A

Chronic cholecystitis

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35
Q

Presentation of cholecystitis

A

Minimal symptoms

+/- Asymptomatic for years,–> progress to symptomatic gallbladder disease or acute cholecystitis, or with complications

36
Q

Acute necroinflammatory disease of the gallbladder (in the absence of gallstones)

Gallbladder stasis and ischemia→ local inflammatory response in the gallbladder wall
Secondary bacterial infection (common)
Severe→ perforation

A

Acalculous cholecystitis

37
Q

Presentation of acalculous cholecystitis

A

Present similar to acute (calculous) cholecystitis
OR
Sepsis-related cholestasis and jaundice

38
Q

Who gets acalculous cholecystitis?

A

Hospitalized and critically ill patients:

Trauma/burn, postpartum (after prolonged labor), orthopedic surgery

39
Q

If your patient has Critically ill patients with sepsis without a clear source OR jaundice, you should suspect

A

Acalculous cholecystitis

40
Q

Workup for acalculous cholecystitis

A

Imaging (ultrasound, CT, HIDA scan)

Liver tests, CBC, electrolytes, pancreatic enzymes, UA

41
Q

Treatment of acalculous cholecystitis

A

High morbidity + mortality rates

Prompt treatment

Risk of gallbladder gangrene and perforation
Obtain blood cultures
Abx
Cholecystectomy vs. gallbladder drainage

42
Q

Gallstones in common bile duct→ +/- block the flow of bile→ pancreatic & liver inflammation→ jaundice, elevated LFTs
10-15% of cholelithiasis cases

A

Choledocholithiaisis

43
Q

Choledocholithiaisis presentation

A 
Biliary-type pain more prolonged than biliary colic
\+/- Asymptomatic
\+/-Jaundice
*Vital signs typically WNL*
RUQ/epigastric tenderness
\+/- Courvoisier sign
44
Q

Choledocholithiaisis labs

A

BC→ no leukocytosis
LFTs: (cholestasis)
1. Elevated ALT + AST → Early in the course of biliary obstruction
2. Cholestatic pattern→ increased in serum bilirubin, Alk.Phos, and gamma-glutamyl
transpeptidase (GGT); exceeding elevations in ALT and AST→ Late
Normal amylase and lipase

45
Q

Choledocholithiaisis treatment

A

Removal of the CBD stone→ ERCP +/- Cholecystectomy

46
Q

Complications of Choledocholithiaisis

A

Acute cholangitis

Acute pancreatitis

47
Q

Imaging for choledocholithiaisis

A

US→ initial → cholelithiasis, CBD stone, CBD dilation >6 mm
Unsure→ MRCP (confirm stone) or ERCP

48
Q 
Inflammation of the biliary duct system
Bacterial infection in pt with biliary obstruction:
• Choledocholithiasis
• Benign biliary stricture
• S/p ERCP, Malignancy
Bacteria ascend from duodenum
A

Acute cholangitis

49
Q

Charcot’s triad:
Fever + Abdominal pain + Jaundice
Reynolds Pentad
Charcot + Mental status changes + hypotensio

A

Presentation of acute cholangitis

50
Q

Acute cholangitis labs

A 
Leukocytosis w/ a left shift
Elevated CRP or ESR
Liver tests→ cholestasis
• ↑ Bilirubin
• ↑ Alk. Phos
• ↑ GGT
• +/- ↑ AST/ALT
Serum amylase or lipase can be ↑ 3-4 x normal→ pancreatitis
(+) blood cultures (25-40%)
51
Q

Imaging for acute cholangitis

A

Ultrasound, CT

MRCP(or EUS) → CBD dilation, CBD stone

52
Q

Acute cholangitis treatment

A

“Pus under pressure” → surgical emergency→ Consult surgery, GI

Significant morbidity and mortality

Admit→ monitor for + treat sepsis

Empiric Abx

ERCP sphincterotomy + stone extraction +/- stent→ drainage + relief of obstruction

+/- Cholecystectomy

53
Q

Leukocystosis is seen in

A

Acute cholecystitis and cholangitis

54
Q

Cholestatic pattern means

A

↑ Bilirubin
↑ Alk. Phos
↑ GGT
+/- ↑ AST/ALT

55
Q

Cholestatic pattern is seen in

A

Choledocholithiasis

Acute cholangitis

56
Q

Rare, women 30-65

Autoimmune destruction of the intrahepatic bile ducts→ cholestasis→ +/- cirrhosis, liver failure

A

Primary biliary cholangitis

57
Q

Primary biliary cholangitis aka

A

Primary biliary cirrhosis

58
Q

Primary biliary cholangitis presentation

A

+/- Asymptomatic
Fatigue, pruritus, jaundice, RUQ discomfort, skin hyperpigmentation, xanthelasmas, hepatomegaly
Autoimmune conditions: Sjögren syndrome + autoimmune thyroid disease

59
Q

Primary biliary cholangitis complications

A 
Cirrhosis
Hepatocellular carcinoma
Malabsorption  steatorrhea
Fat-soluble vitamin deficiencies
Metabolic bone disease: osteopenia, osteoporosis
60
Q

Primary biliary cholangitis diagnostics

A 
Liver tests→ cholestatic pattern
Elevated Alk. Phos, GGT, 5-NT (5’-nucleotidase)
\+/- slightly elevated ALT/AST 
• ↑ bilirubin (later in disease)
• Antimitochondrial antibodies (AMA) (95%)
Serologic hallmark
ANA (70%)
Hyperlipidemia→ +/- strikingly elevated
61
Q

Primary biliary cholangitis management

A

Refer to GI:
Meds management
Treat complications

62
Q

PBC vs PSC: labs

A

Both have cholestatic patterns

PBC has strikingly high hyperlipidemia

63
Q

PBC vs PSC: genderr

A

PBC: women
PSC: men

64
Q

PBC vs PSC: genderr

A

PBC: women
PSC: men

65
Q

Primary biliary cholangitis diagnosis

A 
Diagnosis:
No extrahepatic biliary obstruction
No comorbidity affecting the liver
2+ of following: 
1. Elevated Alk. Phos (1.5x upper limit)
2. + AMA
3. Histologic: (+) liver biopsy
66
Q

Sclerosing, inflammatory, and obliterative process of intrahepatic and/or extrahepatic biliary tree
Chronic/progressive unknown etiology
M>F, 40 years

A

Primary Sclerosing Cholangitis

67
Q

Primary Sclerosing Cholangitis presentation

A 
Asymptomatic
Fatigue
Pruritus
Jaundice
Hepatomegaly

IBD, UC

68
Q

Primary Sclerosing Cholangitis labs

A 
Cholestatic liver tests→ especially with underlying IBD
Increased IgM levels
(+)P-ANCA
Autoantibodies (ANA, ASMA)
(-) AMA
69
Q

Primary Sclerosing Cholangitis complications

A 
End-stage liver disease
Cholestasis
Fat-soluble vitamin deficiencies
Metabolic bone disease
Cholangitis and cholelithiasis
Hepatobiliary cancer→ cholangiocarcinoma
Colon cancer→ with UC
70
Q

Primary Sclerosing Cholangitis management

A

refer to GI

71
Q

Primary Sclerosing Cholangitis imaging

A

Cholangiography
MRCP, ERCP, or percutaneous transhepatic cholangiography (PTC) → multifocal stricturing + dilation of intrahepatic and/or extrahepatic bile ducts

72
Q

PBC vs PSC: imaging

A

PBC: none?
PSC: MRCP, ERCP, cholangiography

73
Q

PBC vs PSC: imaging

A

PBC: none?
PSC: MRCP, ERCP, cholangiography

74
Q

Inherited disorder
Deficiency in enzyme for
glucuronidation of bilirubin in
liver (conjugation)

A

Gilbert syndrome

75
Q

Gilbert syndrome presentation

A

Adolescence/post-puberty, M>F
Mild intermittent episodes of jaundice
Asymptomatic with normal exam
Triggers: dehydration, fasting, menstruation

76
Q

Gilbert syndrome labs

A

Unconjugated
hyperbilirubinemia in the absence of hemolysis
Normal CBC, blood smear, reticulocyte count
Normal liver tests

77
Q

Liver biopsy for primary sclerosing cholangitis

A

may support diagnosis but isn’t diagnostic

probably not the answer on the test

78
Q

Most common cancer arising in the biliary tract

A

Gallbladder cancer

79
Q

Gallbladder cancer

A

Rare, highly fatal malignancy
Often found incidentally during workup for cholelithiasis
Age, W>M

80
Q

Gallbladder cancer presentation

A

+/-Asymptomatic +/- mimic cholelithiasis
+/- suggestive of malignancy (weight loss)
+/- jaundice

Think painless obstructive jaundice

81
Q

Risk factors for gallbladder cancer

A 
Gallstone disease
Porcelain gallbladder
Gallbladder polyps
PSC
Chronic infection (salmonella, Helicobacter)
Obesity
82
Q

Cholangiocarcinoma

A

Arise from epithelial cells of the bile ducts
Intrahepatic, perihilar, or distal (extrahepatic) biliary tree
Excludes of gallbladder and ampulla of vater
Rare, M>F (slight)
Association with PSC and choledochal cysts

83
Q

Association with PSC and choledochal cysts

A

Cholangiocarcinoma

84
Q

Cholangiocarcinoma presentation

A

Jaundice, pruritus, abdominal pain, anorexia,
weight loss, palpable gallbladder (Courvoisier sign)

+/- Labs show cholestasis (obstructive pattern)

↑ CA 19-9 (screening in those with PSC)

85
Q

Ampullary cancer

A

Rare Arise within the Ampullary (ampulla of vater) complex distal to the bifurcation of the distal CBD and pancreatic duct

Increased incidence with Familial Adenomatous Polyposis (FAP) and Hereditary Non- Polyposis Colon Cancer (HNPCC)

86
Q

Ampullary cancer presentation

A 
Obstructive jaundice (most common),
Occult GI bleed with microcytic anemia, abdominal pain
87
Q

Jaundice

Familial Adenomatous Polyposis (FAP) or Hereditary Non- Polyposis Colon Cancer (HNPCC)

PLUS

A

Ampullary cancer

Unit 2 Clin Med III (9 decks)

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