Lecture 4 - Jaundice and GB Disorders Flashcards
Impaired bilirubin excretion, Hepatocellular dysfunction, and Biliary Obstruction are all causes of jaundice due to increased levels of what type of bilirubin?
Conjugated (direct)
What is the defect in Rotor Syndrome?
What type of hyperbilirubinemia?
- Reduced hepatic reuptake of bilirubin conjuagtes
- Conjugated (direct) hyperbilirubinemia
Intrahepatic cholestasis of pregnancy is associated with what type of hyperbilirubinemia?
Conjugated (direct)
Intrahepatic cholestasis of pregnancy typically occurs during what trimester and with what symptoms?
- Third
- Itching, GI symptoms, and abnormal liver excretory function tests
Hemolysis, hematomas, and hemolytic anemias can lead to what type of hyperbilirubinemia?
Unconjugated (indirect)
Phenobarbital will reduce serum bilirubin in what 2 disorders of unconjugated hyperbilirubinemia?
- Crigler-Najjar Type 2
- Gilbert’s syndrome
Posthepatitis hyperbilirubinemia is due to impaired?
Increased levels of what type of bilirubin?
- Impaired bilirubin uptake and storage
- Unconjugated (indirect) hyperbilirubinemia
Hepatocellular dysfunction (i.e., hepatitis/cirrhosis, drugs/biliary cirrhosis/sepsis, infection/cholangitis/sarcoidosis and lymphoma) is associated with increased levels of what type of bilirubin?
Conjugated (direct)
You can fractionate AlkPhos by ordering GGT, and if the GGT is elevated the most common source of the jaundice is from where?
Liver
Diagnosis of obstructive jaundice (conjugated) typically begins with what type of imaging modality?
Can be followed by?
- Ultrasound = first
- Followed by cholangiography
Cholestatic disease is when the primary injury occurs where?
Which labs elevated?
- Bile ducts
- AlkPhos and bilirubin = elevated
What are 8 causes of severe elevations in serum transaminases (>15x normal)?
- Acute viral hepatitis (A-E, herpes)
- Medications/toxins
- Ischemic hepatitis
- Autoimmune hepatitis
- Wilson disease
- Acute bile duct obstruction
- Acute Budd-Chiari syndrome
- Hepatic artery ligation
Persistent mild elevation of aminotransferase levels (ALT and AST) are common in clinical practice and most often caused by?
NAFLD
Acute cholecystitis is associated with what lab finding?
Leukocytosis
Biliary dyskinesia presents with what symptom complex?
- Episodes of RUQ pain
- Severe pain that limits activities of daily living
- Nausea associated w/ episodes of pain
Biliary dyskinesia presents clinically with RUQ pain that is similar to?
Biliary Colic
For patients who are suspected to have Biliary Dyskinesia, which diagnostic criteria should be considered?
Rome III diagnostic criteria for functional GB disorders
What are the ultrasound and liver enzyme, conjugated bilirubin, and amylase/lipase levels like in Biliary Dyskinesia?
All NORMAL
What is considered a normal HIDA scan of the GB?
GB visualized within 1 hour of injection, tracer also seen in small bowel
What is considered an abnormal HIDA scan?
GB not seen –> stone in cystic duct or cholecystitis
A CCK-HIDA scan looks at ejection fraction and what is considered an abnormal ejection fraction %?
Associated with what disorder?
- Abnormal ejection fraction = <35-38%
- Choleycystectomy
Diagnosis of Choledocholithiasis can be made with what imaging modalities?
Which specifically visualizes dilated ducts?
- Ultrasound/CT (dilated ducts)
- EUS
- MRCP
- ERCP
What is a protective factor for gallstones in women?
In men?
- Consumption of caffeinated coffee –> Women
- High intake of Mg and poly-/monounsaturated fats –> Men
Chron disease is a risk factor what what type of gallstones?
Pigment stones
What are the major symptoms of Cholelithiasis?
1) Biliary colic = severe steady ache in RUQ or epigastrium that begins suddenely; often occurs 30-90 mins after meal, occasionally radiates –> right scapula or back
2) N/V
What is the best diagnostic imaging test for Cholelithiasis?
What would you expect to see?
- Ultrasonography
- Stones seen as well as an “acoustic shadow” that they cast
What are essential findings in the diagnosis of Acute Cholecystitis?
- Steady, severe pain
- Tenderness in the RUQ or epigastrium
- N/V
- Fever and leukocytosis
Acute Calculous Cholecystitis is caused by gallstones lodged where?
Where does the inflammation develop?
- Cystic duct
- Inflammation of GB develops behind the obstruction
Is Acute Acalculous Cholecystitis a true cholecystitis?
How does this occur?
- True cholecystitis + no stones
- Due to acute illness (i.e., burns or major surgery), fasting, carcinoma of GB, or infections of GB
Acute Cholecystitis often occurs after?
What are the signs/symptoms?
- Large fatty meal –> acute attack
- Epigastric/RUQ tenderness (often w/ Murphy Sign)
- Muscle guarding and rebound tenderness
- Sometimes palpable gallbladder
What are the 5 relevant elevated labs for Acute Cholecystitis?
1) Leukocytosis
2) Bilirubinemia
3) Serum AST
4) AlkPhos and GGT
5) Serum amylase
Plan film (XR) of the abdomen in a pt w/ Acute Cholecystitis may show?
Radiopaque gallstones
99Tc hepatobiliary imaging (aka HIDA scan) of pt w/ Acute Cholecystitis is used to demonstrate what?
Obstructed (cystic) duct
Which findings on abdominal ultrasonography are suggestive of Acute Cholecystitis?
- GB wall thickening
- Pericholecystic fluid
- Sonographic Murphy sign
Gangrene of the GB is a possible complication of Acute Cholecystitis and may lead to what further complications?
GB perforation usually w/ formation of pericholecystic abscess and rarely to generalized peritonitis
Choledocholithiasis is due to an obstruction by stones where?
Common bile duct (CBD)
Obstructions in the common bile duct are most reliably detected with which 2 imaging modalities?
- ERCP
- EUS
If a patient presents with signs/symptoms of acute cholecystitis but they have jaundice what does this suggest?
Possible Choledocholithiasis
What is the procedure of choice for Choledocholithiasis?
- ERCP w/ sphincterotomy and stone extraction or stent placement
- Then laparoscopic cholecystectomy
Choledocholithiasis can lead to what complication?
Acute ascending cholangitis (AC)
What is the Charcot Triad of Ascending Cholangitis?
RUQ pain + Fever (and chills) + Jaundice
What is the Reynold Pentad of Ascending Cholangitis?
- Charcot Triad
- Altered mental status (confusion)
- Hypotension
Appearance of the Reynold Pentad in ascending cholangitis signifies what and why is it significant?
Acute suppurative cholangitis = endoscopic EMERGENCY!
What is Murphy’s Sign?
Present when deep inspiration or cough during palpation of the RUQ produces increased pain or inspiratory arrest
Choledocholithiasis has similar signs and symptoms as Ascending Cholangitis, which lab value can help determine that the problem is in fact Ascending Cholangitis?
Leukocytosis
Which imaging modality is preferred for Chronic Cholecystitis?
Usually shows what?
Ultrasonography –> stones within a contracted GB
Chronic Cholecystitis is often what for years?
Asymptomatic
Complications of Chornic Cholecystitis?
Porcelain GB
How is the the Porcelain GB seen in Chronic Cholecystitis often discovered?
Most likely on plain XR –> showing an incidental calcified lesion
What is the significance in prognosis of finding a porcelain GB?
Risk of GB cancer (poor prognosis)
What is the procedure of choice for most patients undergoing elective cholecystectomy for cholelithiasis?
Laparoscopic cholecystectomy
What are the mainstays of treatment for Acute Cholecystitis?
- No oral intake (NPO)
- Nasogastric suction
- IV fluids and electrolytes
- Analgesia (meperidine or NSAIDs)
- Antibiotics
- Surgery (as soon as pt stabilized)
In pts with a suspected or confirmed complication associated with acute cholecystitis what is the treatment?
Urgent cholecystectomy
How is cholangitis treated?
- Treat like acute cholecystitis
- No PO, hydrate, analgesia, and antibiotics
- Stones should be removed surgically or endoscopically
What is the treatment of Primary Sclerosis Cholangitis (PSC)?
- No satisfactory therapy
- Cholestyramine may control pruritus
- Liver transplantation considered in pts w/ end-stage cirrhosis
