obstructive jaundice and biliary calculus disease

Question 1

clinical presentation of ductal adenocarcinoma of the pancreas

Answer 1

abdo pain

weight loss, anorexia, cachexia

nausea, vomiting, diarrhea, steatorrhea

hepatomegaly

RUQ or epigastric mass

jaundice

dark urine

ascites

courvoisier’s sign (painless enlarged gallbladder with mild jaundice)

Question 2

what is a diagnostic approach to pancreatic cancer

Answer 2

CT or U/S to ID and visualize mass

if no mass seen, can do ERCP/MRCP and/or endoscopic U/S–> if low suspicion of malignancy, can do serologic testing for tumour markers

proceed to biopsy

Question 3

treatment of pancreatic cancer

Answer 3

if resectable–> surgical or laparoscopic resection

if borderline resectable–> neoadjuvant therapy in addition to surgical

if unresectable–> consider nonsurgical tx

Question 4

what causes biliary colic

Answer 4

a stone obstructing gallbladder outflow

Question 5

what do you ask on history for biliary colic

Answer 5

associated symptoms

jaundice

color of urine or stool

fever or weight loss

N/V/D

pain that radiates to the SHOULDER, pain that occurs over a few hours but gets better, pain that is worse with fatty meals

fatty food intolerance

Question 6

what are some symptoms of biliary colic

Answer 6

several hours post ingestion of large fatty meal

epigastric/RUQ

pain that lasts several hours and is constant during that time, but then resolves

no fever or jaundive

Question 7

what is the first choice imaging test for biliary tract disease

Answer 7

U/S

Question 8

should you operate on asymptomatic gallstones

Answer 8

no

operate is symptomatic

Question 9

what are the three types of gallstones? which are most common?

Answer 9

1. cholesterol—most common
2. brown pigment–from pathologic biliary stasis
3. black pigment–from excessive heme turnover

Question 10

what are the risk factors for cholesterol gallstones

Answer 10

age

sex

pregnancy

obesity

ethnicity (aboriginal)

Question 11

treatment for gallstones

Answer 11

analgesia

outpatient surgical opinion with or without elective cholecystectomy depending on frequency of symptoms

patient education

Question 12

what are the common finding on ultrasound for cholecystitis

Answer 12

stone in neck of gallbladder

wall thickening more than 4mm

peri-cholecystic fluid

sonographic murphy’s sign

Question 13

what liver enzymes may be elevated in inflammation/injury to the biliary tree

Answer 13

ALP

GGT

Question 14

what differentiates cholecystitis from biliary colic

Answer 14

fever and elevated WBCs

Question 15

how do you manage cholecystitis

Answer 15

NPO with IV fluids

abx to cover gram negative organisms

surgery–> MIS or open for cholecystectomy

do surgery early if possible, within 3-4 days

*if more than 5-7 days of symptoms, surgery may not be safe
can also consider percutaneous cholecystostomy to place a tube for drainage and maybe remove later

Question 16

what type of bilirubin is “direct”

Answer 16

conjugated–post hepatic

*if this is elevated, it is due to obstruction

Question 17

what is choledocholithiasis

Answer 17

stone in the CBD

Question 18

symptoms of choledocholithiasis

Answer 18

obstruction to flow leads to pain, JAUNDICE with or without fever and elevated WBCs

Question 19

investigations for choledocholithiasis

Answer 19

U/S for duct dilation and stone

Question 20

treatment for choledocholithiasis

Answer 20

1. ERCP–> helpful but not entirely benign
   - -diagnostic imaging modality
   - -remove stones
   - -widen the sphincter
   - -place a stent
2. surgery to remove the stones
   - -open common bile duct exploration is uncommon
3. decompress proximally via percutaneous trans-hepatic biliary drainage

other options:
MRCP (high res images of biliary tree, pancreas can show subtle anatomic variations/strictures/masses)

endoscopic U/S

Question 21

what does charcot’s triad describe

Answer 21

classic triad of symptoms of cholangitis

RUQ pain
fever
jaundice

Question 22

what is Reynaud’s pentad

Answer 22

charcot’s triad (RUQ pain, fever, jaundice) for cholangitis plus SHOCK and CONFUSION

Question 23

treatment for cholangitis

Answer 23

rescuscitation (ABCs) with fluids and abx with or without ICU if severe or very shocky

urgent ERCP

Question 24

what most commonly causes pancreatitis

Answer 24

alcohol and gallstones

Question 25

how does pancreatitis usually present

Answer 25

LUQ pain

Question 26

investigations for pancreatitis

Answer 26

CBC, lytes, LIPASE

U/S to look for stones

CT to look at the pancreas and direct treament

Question 27

what is gallstone pancreatitis

Answer 27

accounts for nearly 40% of acute pancreatitis, with stones passing or obstructing in the SPHINCTER OF ODDI

Question 28

how do you treat gallstone pancreatitis

Answer 28

resuscitate with fluids, NPO, analgesics

wait and see with close monitoring

if after 48 hours the patient continues to get worse, then may do ERCP for stubborn stones and often move gallbladder too

*80-90% get better over time with spontaneous passage of the stone in the first 24-48 hours

Question 29

list 2 possible complications from not removing gallstones/the gallbladder

Answer 29

rare

1. mirizzi’s syndrome—dilated cystic duct from stone can imact the CBD and cause obstruction
2. gallstone ileus–mechanical obstruction NOT an ileus due to chronic inflammation causing cholecysto-enteric fistula
   - -stone moves thru the small bowel and lodged at the narrow areas, most commonly at terminal ileum/ileocecal valve
   - -REQUIRES OR–open terminal ileum, milk proximally, remove a healthier section of small bowel
3. maybe gallbladder cancer

Question 30

what is courvoisier’s sign/law

Answer 30

in the presence of a palpably enlarge gallbladder which is non-tender and accompanied by mild painless jaundice, the cause is unlikely to be gallstones and is more likely malignancy

Question 31

what should you suspect in a patient with non tender palpable RUQ mass?

Answer 31

unlikely to be stone related MUST rule out malignancy

malignancy could be of gallbladder, bile duct, head of pancreas