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clin med III, exam 2 > biliary > Flashcards

biliary Flashcards

1
Q

common bile duct has what three ducts entering into it

A
  • common hepatic duct
  • cystic duct
  • pancreatic duct
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2
Q

common bile duct enters at what part of the intestine? at what sphincter?

A
  • duodenum
  • sphincter of oddi
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3
Q

composition of bile

A
  • bile salts
  • phospholipids
  • biliruben
  • cholesterol
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4
Q

function of bile

A
  • digestion and absorption of fats (bile salts)
  • vehicle for excretion of biliruben, excess cholesterol and metabolic by-products
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5
Q

define Cholelithiasis

A
  • stones in the gallbladder
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6
Q

define cholecystitis

A

inflammation of the GB

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7
Q

define Choledocholithiasis

A

stones in the common bile duct

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8
Q

define cholangitis

A

inflammation of the bile ducts

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9
Q

define cholestasis

A
  • disruption of bile flow..regardless of cause
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10
Q

List the risk factors for cholelithiasis

A
  • the four F’s (female, fluffy, forty, fertile)
    • age over 40
    • females
    • pregnancy
    • obesity
    • estrogen
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11
Q

What are the two types of stones in cholelithiasis

A
  • cholesterol stones: most common
  • pigment stones: calcium bilirubinate
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12
Q

what is the initial test of choice in assesment of cholelithiasis

A

Ultrasound

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13
Q

when is cholecystectomy recommended with cholelithiasis

A

sympatomatic cholelithiasis

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14
Q

Define Biliary colic

A
  • temporary obstruction of cystic duct
    • usually caused by gallstone
    • as gallbladder relaxes, obstruction is relieved
  • no associated inflammation
  • **often initial presentation of symptomatic gallbladder disease
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15
Q

clinical presentation

  • intense, dull RUQ (or epigastric) pain that may radiate to R shoulder blade
  • constant and steady
  • triggers: eating (fatty foods)
  • N/V, diaphoresis
  • symptoms are temporary
    • typically 30 min
A

Biliary colic

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16
Q

what physical exam abdominal findings would you expect to see with Biliary colic

A
  • possible RUQ or epigastric tenderness
  • NO evidence of peritonitis (rebound)
  • Murphys sign Negative
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17
Q

What results are expected to be seen on US for Biliary colic

A
  • gallstones and/or gallbladder sludge expected
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18
Q

what CBC, LFTs, amylase and lipase results are expected with Biliary colic

A

NORMAL

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19
Q

What is Biliary Dyskinesia

A
  • AKA functional gallbladder disorder
  • biliary pain from primary gallbladder motility disturbance in the absence of gallstones of sludge
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20
Q

Patients who have typical biliary colic without evidence of gallstones or sludge on US and who have normal labs, could have what condition?? What is the preferred diagnostic tool?

A
  • biliary dyskinesia
  • HIDA scan with CCK​
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21
Q

what is the HIDA scan with CCK​

A
  1. CCK given to stimulate gallbladder to contract
  2. ejection fraction calculated
    1. EF is low in patients with biliary dyskinesia <35-40%
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22
Q

managment of biliary dyskinesia

A
  • cholecystectomy recommended if
    • fulfill criteria
      • RUQ, epigastric pain
      • recurrent but not daily
      • lasts > 30 min
    • gallbladder ejection fraction is reduced
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23
Q

Acute inflammation of the gallbladder that occurs in the setting of cystic duct obstruction AND gallbladder inflammation is

A

acute cholecystitis

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24
Q

most common cause of acute cholecystitis is

A

gallstones

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25
Q

clinical presentation

  • prolonged >4-6 hrs steady, severe RUQ or epigastric pain
    • +/- radiation to right shoulder or back
  • fever, N/V, anorexia
  • h/o fatty food ingestion
  • often prior h/o biliary colic
A

acute cholecystitis

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26
Q

would you expect jaundice in patient with acute cholecystitis

A

NO

27
Q

what abd exam findings would you expect with acute cholecystitis

A
  • RUQ tenderness
  • guarding and rebound
  • positive murphys sign
28
Q

what CBC finding is most consistent with acute cholecystitis

A
  • leukocytosis with a left shift
29
Q

what is the most common complication of acute cholecystitis

A
  • gangrene
    • ​elderly, diabetics, those that delay seeking tx
30
Q

What is the syndrome when gallstone becomes impacted in the neck of the gallbladder or cystic duct causing compression of the CBD and obstructive jaundice

A

Mirizzi syndrome

31
Q

What is the preferred initialy study in evaluation of acute cholecystitis? what do you expect to see

A
  • US
    • gallstones
    • wall thickening
    • pericholecystic fluid
    • positive “sonographic murphys sign”
  • HIDA scan done if uncertain
32
Q

managment of acute cholecystitis

A
  • hospital admission
  • early cholecystectomy
  • NPO
  • IV fluids, analgesia, abx (empiric)
33
Q

mechanical irritation from gallstones or repeated episodes of acute cholecystitis -> fibrosis and thickening of gallbladder can cause what condition

A

chronic cholecystitis

34
Q

porcelain gallbladder is associated with? what is it?

A
  • chronic cholecystitis
  • calcium deposition within a chronically inflammed GB
35
Q

chronic cholecystitis is associated with development of what

A

carcinoma of GB

36
Q

patients who are critically ill who present similarly to acute cholecystitis but do not have gallstones and may have jaundice could have

A
  • acalculous cholecystitis
37
Q

choledocholithiasis will cause bile flow flow which leads to primary symptom

A

jaundice

38
Q

Courvoisier’s sign

A

palpable gallbladder

39
Q

clinical presentation

  • typically normal vital signs (uncomplicated dz)
  • CBC: no leukocytosis
  • Elevated LFTs
    • increase in serum biliruben, alk phos, GGT, AST and ALT
  • normal amylase and lipase
  • RUQ or epigastric tenderness
  • may appear jaundiced
    • courvoisier’s sign
A

choledocholithiasis

40
Q

what is the initial test of choice in evaluation of choledocholithiasis? what do you expect to see?

A
  • RUQ US
    • CBD stone
    • CBD dilation (> 6 mm(
    • gallstones in bladder
41
Q

if diagnosis of choledocholithiasis is uncertain after US, what other imaging modalities can you use?

A
  • endoscopic ultrasound (EUS)
  • magnetic resonance cholangiopancreatography (MRCP)
    • great imaging of biliary and pancreatic ducts
42
Q

complications of choledocholithiasis

A
  • acute cholangitis
  • acute pancreatitis
43
Q

what is the preferred therapeutic test for choledocholithiasis

A
  • ERCP
    • ​remove stones
    • insert stents
  • follow up with cholecystectomy
44
Q

What is ascending cholangitis

A
  • infection of biliary tract
  • associated with biliary obstruction
  • bacteria infects bile: ascending infection from duodenum
45
Q

managment of suppurative acute cholangitis

A
  • “pus under pressure” -> surgical emergency
46
Q

What is Charcot’s triad and what is it associated with

A
  • ascending cholangitis
  • Charcot’s triad
    • Fever
    • Abdominal pain
    • Jaundice
47
Q

What is Reynold’s pentad and what is it associated with

A
  • Ascending cholangitis
  • Reynolds pentad
    • fever
    • abd pain
    • jaundice
    • mental status changes and hypotension
48
Q

What LFT would you expect to see with Ascending cholangitis

A
  • cholestasis causes
    • elevated
      • conjugated bili
      • alk phos
      • GGT
      • ? AST/ALT
49
Q

managment of Ascending cholangitis in patients with charcot’s triad and abnormal LFTs

A
  • ERCP
    • ​confirms diagnosis
    • stone extraction
    • provides biliary drainage -> life saving
50
Q

Primary biliary cholangitis primarily affects what patient population

A

females

51
Q

what is Primary biliary cholangitis

A
  • autoimmune destruction of small intrahepatic bile ducts which causes cholestasis
    • leads to cirrhosis and liver failure
52
Q

clinical presentation

  • fatigue
  • pruritis
  • jaundice, RUQ pain, skin hyperpigmentation, xanthomas, hepatomegaly
  • elevated alk phos, GGT, 5-NT
  • AMA +
A

Primary biliary cholangitis

53
Q

what is a cholestatic pattern of LFTs

A
  • elevated alk phos
  • elevated GGT
  • elevated 5-NT
54
Q

what antibodies are elevated in Primary biliary cholangitis

A

antimitochondrial antibodies (AMA)

55
Q

Primary biliary cholangitis is diagnosed via

A
  • need at least 2 of following
    • elevated alk phos
    • + AMA titer
    • histologic evidence with liver biopsy
  • managment: refer to GI, monitor bone density
56
Q

inflammation/fibrosis/stricturing of medium and large ducts in the intrahepatic and/or extrahepatic biliary tree is consistent with

A
  • Primary sclerosing cholangitis
57
Q

risk factors for Primary sclerosing cholangitis

A
  • men
  • inflammatory bowel disease
    • ​mostly UC
58
Q

complications of Primary sclerosing cholangitis

A
  • progresses to cirrhosis
  • Cholangiocarcinoma
59
Q

clinical presentation

  • asymptomatic
  • fatigue
  • pruritis
  • jaundice
  • hepatomegaly
A

Primary sclerosing cholangitis

60
Q

what imaging modalities are used in assesment of Primary sclerosing cholangitis

A
  • MRCP: multifocal stricturing with intrahepatic/extrahepatic ductal dilations
  • ERCP
61
Q

What is Gilbert’s syndrome

A
  • deficiency in enzyme for glucuronidation of biliruben in liver (conjugation)
  • suspect in pt with unconjugated hyperbilirubinemia in absence of hemolysis
62
Q

What are the risk factors for gallbladder ca

A
  • cholelithiasis
  • gallbladder polyps > 1 cm
  • porcelian GB
  • chronic infection (salmonella)
63
Q

biliary ampullary cancer is associated with what two conditions

A
  • FAP: familial adenomatous polyposis
  • HNPCC: hereditary non-polyposis colon cancer

clin med III, exam 2 (6 decks)

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