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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
Acute cholecystitis (calculous) on exam
``` Fever, tachycardia Ill appearing +/- lying still No jaundice, anicteric RUQ TTP +/- voluntary & involuntary guarding (+)Murphy’s sign ```
26
Acute cholecystitis (calculous) labs
Leukocytosis with a left shift +/- mild elevation AST/ALT Normal total bilirubin, alkaline phosphatase Normal serum amylase
27
Acute cholecystitis (calculous) imaging
*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)
28
Acute cholecystitis is anicteric/no jaundice except...
Mirizzi Syndrome but it's super rare
29
Elevated serum amylase makes you think
pancreatitis
30
Elevated total bilirubin or alk phos makes you think
biliary obstruction
31
Acute cholecystitis management
Admit, NPO IV fluids + empiric abx + pain control: Ketorolac, Morphine, Meperidine Cholecystectomy→ mainstay
32
Ketorolac is
Pain control, NSAID
33
Mepridine is
Pain control, opioid
34
Chronic inflammation of the gallbladder associated with gallstones (most) Cause: Repeated acute/subacute cholecystitis or prolonged mechanical irritation of the gallbladder wall (by stones)
Chronic cholecystitis
35
Presentation of cholecystitis
Minimal symptoms | +/- Asymptomatic for years,--> progress to symptomatic gallbladder disease or acute cholecystitis, or with complications
36
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
Acalculous cholecystitis
37
Presentation of acalculous cholecystitis
Present similar to acute (calculous) cholecystitis OR Sepsis-related cholestasis and jaundice
38
Who gets acalculous cholecystitis?
Hospitalized and critically ill patients: | Trauma/burn, postpartum (after prolonged labor), orthopedic surgery
39
If your patient has Critically ill patients with sepsis without a clear source OR jaundice, you should suspect
Acalculous cholecystitis
40
Workup for acalculous cholecystitis
Imaging (ultrasound, CT, HIDA scan) | Liver tests, CBC, electrolytes, pancreatic enzymes, UA
41
Treatment of acalculous cholecystitis
High morbidity + mortality rates *Prompt treatment* Risk of gallbladder gangrene and perforation Obtain blood cultures Abx Cholecystectomy vs. gallbladder drainage
42
Gallstones in common bile duct→ +/- block the flow of bile→ pancreatic & liver inflammation→ jaundice, elevated LFTs 10-15% of cholelithiasis cases
Choledocholithiaisis
43
Choledocholithiaisis presentation
``` Biliary-type pain more prolonged than biliary colic +/- Asymptomatic +/-Jaundice *Vital signs typically WNL* RUQ/epigastric tenderness +/- Courvoisier sign ```
44
Choledocholithiaisis labs
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
Choledocholithiaisis treatment
Removal of the CBD stone→ ERCP +/- Cholecystectomy
46
Complications of Choledocholithiaisis
Acute cholangitis | Acute pancreatitis
47
Imaging for choledocholithiaisis
US→ *initial* → cholelithiasis, CBD stone, CBD dilation >6 mm Unsure→ MRCP (confirm stone) or ERCP
48
``` 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 ```
Acute cholangitis
49
Charcot’s triad: Fever + Abdominal pain + Jaundice Reynolds Pentad Charcot + Mental status changes + hypotensio
Presentation of acute cholangitis
50
Acute cholangitis labs
``` 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
Imaging for acute cholangitis
Ultrasound, CT | MRCP(or EUS) → CBD dilation, CBD stone
52
Acute cholangitis treatment
“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
Leukocystosis is seen in
Acute cholecystitis and cholangitis
54
Cholestatic pattern means
↑ Bilirubin ↑ Alk. Phos ↑ GGT +/- ↑ AST/ALT
55
Cholestatic pattern is seen in
Choledocholithiasis | Acute cholangitis
56
Rare, women 30-65 | Autoimmune destruction of the intrahepatic bile ducts→ cholestasis→ +/- cirrhosis, liver failure
Primary biliary cholangitis
57
Primary biliary cholangitis aka
Primary biliary cirrhosis
58
Primary biliary cholangitis presentation
+/- Asymptomatic Fatigue, pruritus, jaundice, RUQ discomfort, skin hyperpigmentation, xanthelasmas, hepatomegaly Autoimmune conditions: Sjögren syndrome + autoimmune thyroid disease
59
Primary biliary cholangitis complications
``` Cirrhosis Hepatocellular carcinoma Malabsorption steatorrhea Fat-soluble vitamin deficiencies Metabolic bone disease: osteopenia, osteoporosis ```
60
Primary biliary cholangitis diagnostics
``` 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
Primary biliary cholangitis management
Refer to GI: Meds management Treat complications
62
PBC vs PSC: labs
Both have cholestatic patterns | PBC has strikingly high hyperlipidemia
63
PBC vs PSC: genderr
PBC: women PSC: men
64
PBC vs PSC: genderr
PBC: women PSC: men
65
Primary biliary cholangitis diagnosis
``` 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
Sclerosing, inflammatory, and obliterative process of intrahepatic and/or extrahepatic biliary tree Chronic/progressive unknown etiology M>F, 40 years
Primary Sclerosing Cholangitis
67
Primary Sclerosing Cholangitis presentation
``` Asymptomatic Fatigue Pruritus Jaundice Hepatomegaly ``` IBD, UC
68
Primary Sclerosing Cholangitis labs
``` Cholestatic liver tests→ especially with underlying IBD Increased IgM levels (+)P-ANCA Autoantibodies (ANA, ASMA) (-) AMA ```
69
Primary Sclerosing Cholangitis complications
``` End-stage liver disease Cholestasis Fat-soluble vitamin deficiencies Metabolic bone disease Cholangitis and cholelithiasis Hepatobiliary cancer→ cholangiocarcinoma Colon cancer→ with UC ```
70
Primary Sclerosing Cholangitis management
refer to GI
71
Primary Sclerosing Cholangitis imaging
Cholangiography MRCP, ERCP, or percutaneous transhepatic cholangiography (PTC) → multifocal stricturing + dilation of intrahepatic and/or extrahepatic bile ducts
72
PBC vs PSC: imaging
PBC: none? PSC: MRCP, ERCP, cholangiography
73
PBC vs PSC: imaging
PBC: none? PSC: MRCP, ERCP, cholangiography
74
Inherited disorder Deficiency in enzyme for glucuronidation of bilirubin in liver (conjugation)
Gilbert syndrome
75
Gilbert syndrome presentation
Adolescence/post-puberty, M>F Mild intermittent episodes of jaundice Asymptomatic with normal exam Triggers: dehydration, fasting, menstruation
76
Gilbert syndrome labs
Unconjugated hyperbilirubinemia in the absence of hemolysis Normal CBC, blood smear, reticulocyte count Normal liver tests
77
Liver biopsy for primary sclerosing cholangitis
may support diagnosis but isn't diagnostic | probably not the answer on the test
78
Most common cancer arising in the biliary tract
Gallbladder cancer
79
Gallbladder cancer
Rare, highly fatal malignancy Often found incidentally during workup for cholelithiasis Age, W>M
80
Gallbladder cancer presentation
+/-Asymptomatic +/- mimic cholelithiasis +/- suggestive of malignancy (weight loss) +/- jaundice Think painless obstructive jaundice
81
Risk factors for gallbladder cancer
``` Gallstone disease Porcelain gallbladder Gallbladder polyps PSC Chronic infection (salmonella, Helicobacter) Obesity ```
82
Cholangiocarcinoma
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
Association with PSC and choledochal cysts
Cholangiocarcinoma
84
Cholangiocarcinoma presentation
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
Ampullary cancer
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
Ampullary cancer presentation
``` Obstructive jaundice (most common), Occult GI bleed with microcytic anemia, abdominal pain ```
87
Familial Adenomatous Polyposis (FAP) or Hereditary Non- Polyposis Colon Cancer (HNPCC) PLUS Jaundice =
Ampullary cancer

Unit 2 Clin Med III (9 decks)

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