biliary disease

Question 1

Cholelithiasis

pain presents where?

more in women or men??

Answer 1

Gallstones are usually asymptomatic in most patients and often found incidentally on imaging studies for other issues

Classic pain presentation is RUQ with radiation to the R shoulder and infrascapular area

-more common in women with 8.6% prevalence vs. men with 5.5% prevalence

Question 2

Gallstones are classified according to ??

symptoms will develop in how many pts??

Answer 2

chemical composition

Majority are cholesterol stones in the US
less than 20% are composed of calcium bilirubinate

Symptoms will develop in 10-25% of patients over time

Question 3

gallstone on US

Answer 3

opaque

Question 4

Gallstone/pain tx

Answer 4

NSAIDs
Laparoscopic cholecystectomy for symptomatic disease
Ursodeoxycholic acid

Question 5

Laparoscopic cholecystectomy for what pts??

Only done in asymptomatic if ??

Answer 5

symptomatic disease

-if porcelain gallbladder, stones >3cm, or if a patient is a candidate for bariatric surgery or cardiac transplant

Question 6

what is Ursodeoxycholic acid ??

do gallstones recur?

Answer 6

A bile salt given orally for up to 2 years which can help dissolve some cholesterol stones in patients who are unable to have or refuse to have surgery (elderly, other risk factors)

Gallstones usually reoccur by 5 years after medication is stopped

also given to liver failure/transplant/cirrhotic pts, eliminates itching in skin

Question 7

porcelain GB on XR

caused by ??

removed??

Answer 7

rim enhancing

continued insult to GB over time, pancreatic/GB/GI cancer

not all need to be removed, but indication for removal esp. with symptoms

Question 8

case: N/V 30 min after eating, steady RUQ tenderness and epigastric pain, low grade temp 100F

Answer 8

probably not E.coli, too quick of presentation (usually takes 24 hrs)

S. aureus, B. cereus: more acute FBI

has this happened before?

Question 9

?? is associated with gallstones 90% of the time

Answer 9

Cholecystitis

Often precipitated by a fatty meal (burger)
Vomiting may give temporary relief

Question 10

Acute Cholecystitis: physiology

Answer 10

a stone becomes impacted in the cystic duct and inflammation develops around the obstruction

Question 11

When not caused by stones acute cholecystitis could be caused by ??

Answer 11

CMV, cryptosporidiosis or microsporidiosis in advanced HIV patients; or by vasculitis

Question 12

acute cholecystitis labs

Answer 12

WBCs often elevated, LFTs and bilirubin can be elevated, serum amylase may also be mildly elevated

Question 13

other cholecystitis pain

Answer 13

stones may hang around, or stones may have caused hepatic problems so have pain even after removal

Question 14

Murphy’s sign

Answer 14

positive when you palpate the RUQ and ask the patient to breathe deeply
POSITIVE if patient develops pain that radiates to the R infrascapular area or if patient’s inspiration stops short

Question 15

Sonographic Murphy’s sign

Answer 15

positive when a patient reports maximum discomfort when the ultrasound probe is over the gallbladder

Question 16

U/S may show ??

Answer 16

gallstones, biliary sludge, biliary ductal dilation, gallbladder wall thickening, pericholecystic fluid (around GB), and/or a positive sonographic Murphy’s sign

Question 17

If ultrasound is not convincing, next step would be to do a ??

Test most reliable when ??

Answer 17

hepatic iminodiacetic acid scan (HIDA)

when bilirubin is under 5mg/dL

positive when GB does not light up but cystic bile duct does?? listen 15 min

Question 18

Gangrene of the gallbladder

Answer 18

Symptoms of acute cholecystitis severe and lasting 24-48h
Due to ischemia from splanchnic vasoconstriction
Could lead to perforation, abscess
Obese, elderly, diabetics at higher risk (can’t perceive pain as much)

Question 19

Acalculous cholecystitis

What can be done if patient too unstable for cholecystectomy?

Answer 19

Should be considered if fever and RUQ pain 2-4 weeks after major surgery or in critically ill ICU patients

drain GB (loaded with sludge) cholecystotomy drain placed (can have in for a longer than year!) 
to avoid sepsis
sometimes a bridge to sx

Question 20

Chronic Cholecystitis Results from ??

Answer 20

repeated episodes of acute cholecystitis or from chronic irritation of the gallbladder due to stones
Occasionally chronic inflammation creates polypoid changes inside the gallbladder giving the gallbladder a strawberry appearance

Question 21

chronic cholecystitis: Hydrops of the gallbladder can occur if ??

Answer 21

the cholecystitis subsides but the cystic duct obstruction persists generating a gallbladder filled with mucoid fuid

Question 22

cholecystitis tx

Answer 22

Acute cholecystitis can often improve with gut rest, pain medications, and antibiotics

A cephalosporin + metronidazole
Fluoroquinolone + metronidazole
Piperacillin/tazobactam
Carbapenem (imipenem, meropenem, ertapenem)

Question 23

chonic cholecystitis tx: Given high risk for recurrence, ?? can be planned when symptoms improve

Answer 23

interval cholecystectomy

don’t want to do when acute, risk of perforation and infection

Question 24

case 2: sclera icterus
some episodic N/V +/- epigastric pain

questions?

Answer 24

when N/V: sometimes after food
color: yellow/green stool
darker urine
itchy skin

recent travel?
some etOH

Question 25

Choledocholithiasis and Cholangitis

Cholangitis suspected if ??

Answer 25

Often a h/o epigastric pain accompanied by jaundice
Sometimes patients present with painless jaundice as their chief complaint

Cholangitis suspected if there are signs of sepsis
Etiology is a stone in the bile duct which requires an ERCP for diagnosis and possible intervention

Question 26

Charcot’s Triad

Answer 26

Frequently occurring attacks of RUQ abdominal pain
Jaundice associated with RUQ pain
Chills and fever

Question 27

Reynold’s Pentad

Answer 27

The classic findings of Charcot’s triad for acute cholangitis PLUS:
Altered mental status
Hypotension

Indicates probable supperative cholangitis and is an endoscopic emergency

Question 28

Cholangitis: labs can demonstrate ??

CT??

Answer 28

striking increases in LFTs and hyperbilirubinemia
Serum amylase may be elevated indicating a secondary pancreatitis

CT may demonstrate dilated bile ducts

Question 29

ERCP ??

Answer 29

ERCP provides the most accurate determination of the extent of the obstruction especially when bile duct diameter is >6mm, when ductal stones are seen on ultrasound, or when bilirubin is >4mg/dL

Sphincterotomy with stone extraction or stenting can be done as needed during this procedure

Question 30

cholangitis tx

Answer 30

Bile duct stones should be removed even in asymptomatic patients

If a patient has concurrent cholecystitis, cholecystectomy is generally performed during the same hospital stay
If no signs of cholecystitis, cholecystectomy can be done electively in 2 weeks

Question 31

Cholangitis: Antibiotics targeted towards??

Answer 31

G- pathogens are often administered acutely via IV, and patients are sent home on ~2 weeks of p.o. agents
Ciprofloxacin/metronidazole, cefuroxime/metronidazole, amoxicillin/clavulanate

Question 32

case 3: 3 weeks post liver transplant for hepC w/ cirrhosis

itching/yellowing

Answer 32

Biliary Stricture

Question 33

Biliary Stricture

Benign biliary strictures are generally due to ??

what developments/common complications

Answer 33

injury around a surgical anastomosis ~95% of the time
5% of cases can be due to direct injury to the abdomen, pancreatitis, or prior endoscopic sphincterotomy

Jaundice can develop rapidly if complete occlusion occurs
Cholangitis is the most common complication of stricture
Biloma or infected fluid collection/abscess could also arise

Question 34

biloma

Answer 34

backup of bile fluid

Question 35

MRCP vs. ERCP

risk?

Answer 35

MRCP is valuable in demonstrating strictures
ERCP permits biopsy to evaluate for possible malignancy, sphincterotomy to allow closure of a bile leak, and dilation/stent placement

Risk of post-ERCP pancreatitis in challenging cases

Question 36

ERCP

Answer 36

endoscope into mouth thru duodenum, up retrograde to GB

Question 37

case 4: hx of UC, poor compliance with management
yellow skin/eyes
diffuse pruritis

Answer 37

yellow/green stools
dark urine

Upon further questioning, patient reports he hasn’t been eating well and had noticed the yellowing slowly over the past 2 months
Patient also with fatigue and loose stools
Labs reveal high direct and indirect bilirubin, elevated LFTs
MRCP is performed

Question 38

MRCP shows punctuated strictures: “string of pearls”

Answer 38

Primary Sclerosing Cholangitis

Question 39

Primary Sclerosing Cholangitis

Answer 39

Most common in men aged 20-50 years
Often associated with ulcerative colitis
Progressive jaundice over time, pruritus, labs consistent with cholestasis

Diagnosis on MRCP with classic cholangiographic findings
10-20% risk of cholangiocarcinoma

Question 40

tx: Acute bacterial cholangitis component of Primary Sclerosing Cholangitis

Answer 40

Treated with antibiotics targeted towards gram negative pathogens (ciprofloxacin, 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems)

Question 41

more Primary Sclerosing Cholangitis tx

Answer 41

Ursodeoxycholic acid can improve LFTs and decrease itching
Possible balloon intervention of some of the sclerosed areas
Possible stenting as a short term solution to relieve symptoms
Long-term stenting may increase complications
Liver transplantation for those with cirrhosis and clinical decompensation

Question 42

Primary Sclerosing Cholangitis px

Answer 42

Average survival 9-17 years and up to 21 years in some studies
Survival may be less with a dominant bile duct stricture
Higher risk for colon cancer associated with longer survival
Survival rates with liver transplantation are as high as 85% at 3 years