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gi ii exam 2 > Tieman Hepatobiliary DSA > Flashcards

Tieman Hepatobiliary DSA Flashcards

1
Q

Asymptomatic Stones

A

found incidentally on ultrasound

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2
Q

Chronic cholecystitis (calculous and acalculous)

A

Biliary Colic
Visceral pain, self-limiting (< 6-8 hours), associated with fats or rich meals,
Few, if any, physical findings or lab abnormalities

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3
Q

Acute cholecystitis (calculous and acalculous)

A

Often starts out as biliary colic, but pain becomes parietal, persistent and escalating, N&V
PE: Systemic signs of inflammation, localized RUQ tenderness (Murphy’s sign)
Lab: mildly elevated WBC, normal or slightly elevated bilirubin, LFT’s and amylase
Acute acalculous usually in patients very ill with co-existing disease process
Usually a low-flow, ischemic condition

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4
Q

GALLBLADDER DISEASE—DIFFERENTIAL DIAGNOSIS

A 
Chronic:
PUD
GERD
Pancreatitis
Kidney pathology
Intestinal pathology
Lower chest pathology—Cardiac, pulmonary
Herpes Zoster
Acute:
	Appendicitis
	PTE
	Perforated duodenal ulcer
	Diverticulitis
	Pancreatitis
	Nephritis, Nephrolithiasis
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5
Q

Ultrasound

A

Stones vs. no stones
> 90% sensitivity and specificity for cholelithiasis > 2mm
Associated findings, eg. Wall thickness, fluid, dilated CBD, polyps, areas suspicious for CA

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6
Q

Cholescintigraphy (bile duct scan, HIDA scan)

A

Useful in ? Cases of acute calculous cholecystitis
Non-visualization of GB
Combined with CCK ejection fraction
CCKEF < 35% and producing biliary colic diagnostic for chronic acalculous cholecystitis

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7
Q

CT scan

A

may be useful to eliminate other conditions in differential diagnosis

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8
Q

treatment of asymptomatic gallbladder disease

and, to whom might we offer surgery?

A

No treatment—only 2-3%/year become symptomatic, rarely with complications

May offer surgery to:
Sickle cell patients
Native americans with large stones (risk of CA)
Porcelain Gallbladder (risk of CA)
Gallbladder polyps > 1cm (risk of CA)
Pt. with abnormal pancreatic duct drainage (risk of CA)
Transplant patients (Immunosupression)
People traveling to remote areas
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9
Q

GALLBLADDER DISEASETREATMENT- Chronic acalculous and calculous

A

Biliary Colic
30% may have only one attack

70% will have recurrent attacks, usually more frequent and severe
1-2%/year will develop complications
This group clearly benefits from laparoscopic cholecystectomy

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10
Q

GALLBLADDER DISEASETREATMENT- Acute calculous cholecystitis

A 
Hospitalization
Pain control
Rehydration
Broad-spectrum antibiotics
Laparoscopic cholecystectomy
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11
Q

GALLBLADDER DISEASETREATMENT - Acute acalculous cholecystitis

A

Usually already hospitalized for another reason
Broad-spectrum antibiotics
Laparoscopic cholecystectomy, if acceptable surgical risk
Percutaneous GB drainage, if unacceptable risk

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12
Q

CHOLEDOCHOLITHIASIS AND CHOLANGITIS- clinical picture

A

15% of patients with cholelithiasis also have choledocholithiasis
Routine vs. selective intraoperative cholangiogram debated among surgeons
Retained or recurrent stone
Clinical picture may range from asymptomatic to life-threatening
Major complications are obstruction, pancreatitis and ascending (suppurative) cholangitis

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13
Q

CHOLEDOCHOLITHIASIS AND CHOLANGITIS- SIGNS AND SYMPTOMS

A

Choledocholithiasis

  • Abdominal pain
  • Jaundice
  • Pruritis
  • Acholic stools

Ascending (suppurative) cholangitis
- Charcot’s Triad—RUQ abd. pain, jaundice and fever with shaking chills

  • Reynold’s pentad—Charcot’s triad + hypotension and altered sensorium
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14
Q

CHOLEDOCHOLITHIASIS AND CHOLANGITIS - DIAGNOSIS

A

LAB: Bili > 4.0, elevated amylase, elevated AP and GGTP, WBC elevated in cholangitis
US—only 50% accurate in identifying choledocholithiasis, may show ductal dilatation
MRCP
ERCP—advantage of being diagnostic and therapeutic

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15
Q

CHOLEDOCHOLITHIASIS - TREATMENT

A

CHOLEDOCHOLITHIASIS
Most, if not all, common duct stones should be removed because of the risk and severity of complications
At surgery, stones may be removed laparoscopically or by open surgery
ERCP with sphincterotomy and stone removal by balloon or basket

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16
Q

cholangitis treatment

A

Hydration, broad-spectrum antibiotics, ductal drainage (urgent, if Reynold’s Pentad present)
ERCP
PTC
Open surgery

17
Q

CHOLESTASIS- definition

A

The systemic retention of biliary constituents as a result of failure of formation and (or) the flow of bile

18
Q

intrahepatic vs extrahepatic cholestasis

A

INTRAHEPATIC
Usually a failure of formation of bile at the hepatocyte level
Elevated transaminases and unconjugated bilirubin
Can also be an obstructive process confined to the intrahepatic bile ducts

EXTRAHEPATIC
Obstructive process of the extrahepatic bile ducts
Elevated AP, GGTP and conjugated bilirubin

19
Q

Neonatal obstructive jaundice

A

Must be considered in any newborn jaundice presenting or persisting after 14 days old
Elevated conjugated bilirubin, AP, GGTP
Often, but not always, with acholic stools
Most common causes are
Biliary atresia
Less common causes are congenital biliary tract anomalies, choledochal cysts, and infections

20
Q

BILIARY ATRESIA

A

Post-natal destruction of EH bile ducts with resultant injury and fibrosis of IH bile ducts
Unknown etiology
~30% of neo-natal cholestatic jaundice
Females > males
Associated with extra-hepatic anomalies
Most common cause of hepatic death and reason for liver transplantation in children
Diagnosed by lab, US, MRC and liver bx
Treated by Porto-enterostomy (Kasai procedure)
Best results if done at < 60 days of age
If Kasai procedure fails, liver transplant

21
Q

CHOLEDOCHAL CYSTS

A

Less common cause of pediatric obstructive jaundice (2-4%)
5 types—type V (intrahepatic) called Caroli’s disease
60-70% are found at age <10
Present with obstructive jaundice, acholic stools, pruritis, abd. pain, and/or fever
Diagnosed by typical lab pattern of obstructive jaundice, US, MRCP, and ERCP
Should usually be surgically resected because of risk of malignancy and cholangitis

22
Q

PRIMARY SCLEROSING CHOLANGITIS

A

Auto-immune disease
Patchy inflammation, fibrosis and destruction of IH and EH bile ducts
Obstruction—cirrhosis—liver failure
Young patient (25-45 year olds)
2:1 men:women
*** 80% have IBD (2-4% of IBD patients develop PSC)

23
Q

PRIMARY SCLEROSING CHOLANGITIS– things we must differentiate it from

A

Must differentiate from Primary Biliary Cirrhosis (women ages 20-60, intrahepatic ductal fibrosis)
Antibodies somewhat helpful
Anti-nuclear and anti-smooth muscle + in ~20%
Anti-mitochondrial rarely +, if + that suggests PBC
pANCA + if colitis present, but doesn’t distinguish from colitis w/o PSC
Usually requires MRCP or ERCP and liver biopsy for definitive diagnosis

Must be differentiated from Secondary Sclerosing Cholangitis 
Post-surgical trauma
Infection
Toxins
Cholangiocarcinoma
Aids-associated cholangiopathy
24
Q

PRIMARY SCLEROSING CHOLANGITIS- treatment

A

Asymptomatic
- No specific treatment

Mild-moderate symptoms

  • Medical treatment of jaundice, pruritis, cholangitis
  • Monitor for colonic neoplasia and IBD
  • Monitor for cholangiocarcinoma (6-11% in PSC)

Severe symptoms or liver failure

  • Liver transplant
  • – Excellent survival unless cholangiocarcinoma has developed
25
Q

GALLBLADDER CARCINOMA

A

Most common biliary tract cancer
Elderly females (3-4:1, females:males)
Long-standing, large gall stones or porcelain gall bladder
Frequently aymptomatic
Found in histology post-op cholecystectomy
Often presents as acute cholecystitis
May sometimes be seen on US pre-op, CT may help stage
80% adenocarcinoma—spreads by lymphatic and hematogenous channels
Only curative modality is surgery
Extent of surgery depends on stage of disease (TNM)

26
Q

CHOLANGIOCARCINOMA

A

Rare tumors
60-80% found at bifurcation (Klatskin tumors)
20-40% found in distal CBD
Clinical presentation = obstructive jaundice with weight loss and anorexia, CEA and/or CA 19-9 may be elevated
MRCP, ERCP or PTC will show obstructing lesion
Only curative modality is surgery
Only ~50% resectable
5-year survival rate only 15% for Klatskin tumors and 25-30% for distal CBD tumors

27
Q

HEPATOCELLULAR CARCINOMA

A

Fairly uncommon malignancy in US, but common in certain other countries, probably related to diet and/or environmental factors
Usually seen in patients with Chronic Hep B or C, but also seen in patients with cirrhosis from any cause
High-risk patients may benefit from biennial liver sonography
Symptoms usually low-grade or absent, but may present with catastrophic bleeding

28
Q

HEPATOCELLULAR CARCINOMA- dx and treatment

A

Diagnosis made with LFT’s, Serum Alpha fetoprotein, CT angiogram and liver biopsy
May be amenable to resection if localized w/o metastases
Liver Transplantation if:
1 lesion <5 cm, or no more than 3 which are < 3 cm in diameter w/o vascular invasion
Systemic Therapy with sorafenib or gemcitabine-based chemotherapy, if metastatic

gi ii exam 2 (16 decks)

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