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Medicine II > biliary tract > Flashcards

biliary tract Flashcards

1
Q

Hepatocellular pattern

A

Transaminase (AST and/or ALT)

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2
Q

usually when you have an elevation of ALT or AST you also have an elevation of ______ as well

A

bilirubin

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3
Q

MC Type of pattern you’ll see

A

transaminase dominant

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4
Q

upper limit of normal AST ALT

A

40

Normally b/w 15 and 20

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5
Q

fatty infiltration into liver that results in mild elevation of transaminases

A

fatty liver disease

other liver function tests should be normal

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6
Q

chronic hep b and C you see

A

asymptomatic pt

screen with ALT transaminase level and look for elevation

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7
Q

medications that can elevate transaminases

A

(Tylenol, Rifampin, INH, Antifungals, Methotrexate, NSAIDS),

Herbal drugs, occupational toxins

usually anything that utilizes the CYP450 system

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8
Q

uncommon etiologies for pts with transaminase predominant panel

A

Hemochromatosis (iron OVER)

Autoimmune Hepatitis

Alpha-1-AT deficiency

Wilson’s Disease (COPPER)

Unknown causes

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9
Q

Autoimmune Hepatitis can be diagnosed with

A

circulating autoantibodies and high serum globulin

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10
Q

” Alpha-1-AT deficiency is seen in what population

A

deficiency (rare; neonatal hepatitis)

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11
Q

” Wilson’s Disease is due to

A

rare; copper accumulation due to abnormal biliary copper transport

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12
Q

AST predominant ratio

A

ETOH-related hepatitis,
cirrhosis due to viral hepatitis,
Wilson dz

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13
Q

ALT predominant

A

usually all other casues of liver dz (not alcohol)

drug-induced liver, chronic viral hepatitis (B&C), occupational, toxin related hepatocellular damage, autoimmune hepatitis, Wilson’s, Hemochromatosis, Alpha-1-AT deficiency, congestive hepatopathy, Malignant infiltration of the liver

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14
Q

you want to confirm the elevation of transaminases for at least how long

A

> 3mo

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15
Q

AST>ALT

A
  1. AST>ALT consistent w/ ETOH (rarely >300)
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16
Q

ALT>AST consistent

A

consistent w/ viral (values often >500 greater than hepititis

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17
Q

correlative factors with elevated transaminases

A

Correct reversible factors: obesity, ETOH, drugs, thyroid, celiac dz

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18
Q

mild elevation recommendations

A

abstain from alcohol and medication recheck in 2 months

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19
Q

what to do if you suspect if suspect fatty liver, splenomegaly, or tumor/mass

A

ULS- can see fatty infiltration

right upper quadrant

also done with biliary tract dz

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20
Q

what to do if it looks like they have hep c

A

Hepatitis panel (A, B, C)

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21
Q

elevated hematocrit or signs and symptoms of hemachromatosis

A

Ferritin, Fe/TIBC

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22
Q

what to do if you suspect Wilsons

A

Copper & ceruloplasmin in young patients

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23
Q

when would you do a liver biopsy

A

if no other source can be ascertained

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24
Q

primarily alk phos is made

A

in liver and bones

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25
Q

if you don’t have any signs or symptoms of biliary tract disease and you have a high alk phos

A

might be coming from somewhere else need to evaluate alk pho iso enzyme

Based on alk phos isoenzyme, it will tell you the origin of Alk Phos-liver or bone

GGT will be coming from the liver

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26
Q

common etiologies of elevated Alk Phos

A

Metastatic or biliary Ca

PBC (primary biliary cirrhosis)

Fatty liver (mild elevation of Alk Phos and mild elevation of transaminases)

Biliary stones

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27
Q

Pt’s w/ bone cancer will show elevation in

A
  1. Pt’s w/ bone cancer will show elevation in Alk Phos
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28
Q

ULN for alk phos

A

Upper limit normal is 150

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29
Q

what population do you normally see an elevated alk phos

A

kids
can be around 400

also pregnant women

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30
Q

GGT increased will tel you the elevated alk phos will

A

. So if you have elevated Alk Phos and an elevated GGT then you know the problem is in the liver

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31
Q

elevated alk phos and GGT increased what do you do

A

RUQ ULS

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32
Q

what are you looking for with a ULS if you know alk phos elevation is coming from the liver

A

dilated biliary ducts

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33
Q

why would you see an isolated elevation in bilirubin

A

Gilbert’s syndrome

mild elevation of just bilirubin

2 or 2.5 (normal 1 )

hereditary un-conjugated bilirubin that is relatively common

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34
Q

acute pancreatitis

A

inflammatory condition that causes inflammation of the pancreas usually due to

choledocholitahiasis
ETOH abuse

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35
Q

alcohol pt with abd pain

A

pancreatitis!

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36
Q

Pancreatic enzymes released into circulation causes

A

a. Hypotension
b. ARDS
c. Disturbance of coagulation cascade
d. Hypocalcemia

go into shock

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37
Q

predominant symptom of acute and chronic pancreatitis

A

PAIN

epigastric 
sharp
stabbing 
through and through 
doesn't wrap around (biliary tract)  BORING 
--> hot poker
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38
Q

pancreatitis is exacerbated by

A

Eating (PUD better w/eating)
ETOH
vomitting

turns out enzymes for digestion and hurts

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39
Q

physical exam findings with pancreatitis

A 
"	Abdominal rigidity
"	Voluntary guarding
"	Fever
"	Tachycardia
"	Shock
40
Q

pancreatitis dx test

A

” Abdominal pain film

“ CT abdomen is BEST

41
Q

common lab finding specific to pancreatitis

A

increase amylase & lipase

42
Q

other than increase in amylase what other labs diagnostics do we see

A

Hypocalcemia from release of pancreatic enzymes

Leukocytosis - elevation of WBC b/c inflammation present

BUN (b/c dehydration since they stopped eating or ARF)

Hyperglycemia b/c pancreas not working

LFTs (biliary obstruction pattern - Alk phos elevated)

43
Q

biliary obstruction pattern

A

predominantly alk phos

44
Q

Outcome of pancreatitis is influenced by -

A

a. Etiology: alcoholic doesn’t do as well
b. Co-morbidity: if they have hepatitis or HF not looking good

c. # of previous attacks:
in chronic pt who continues to drink alcohol

d. Severity of disease

45
Q

complications of pancreatitis

A
  1. Prolonged hospitalization
  2. Shock
  3. Hypoxia - pleural effusions, respiratory distress
  4. GI bleeding - pretty common
  5. 25% develop pseudocysts - need sx
  6. Pancreatic abscess - need sx
46
Q

Chronic Pancreatitis why do we see only slightly elevated amylases

A

not a lot of pancrease function left

can get just a mildly elevated amylase

need to go back to the history and see how much they are drinking and if they have ever had this before

47
Q

clincal findings in chronic pancreatitis

A

Similar presentation to acute

ETOH pt’s may develop pancreatic insufficiency

30% have steatorrhea due to chronic calcific pancreatitis and malabsorption (floaty, oily, greasy stools)

GI bleeding and pancreatic hemorrhage common

48
Q

Malabsorption seen with chronic pancreatitis

A

emaciation, peripheral edema, multiple

low total protein–> edema

bloated asceitis type belly

49
Q

why would we see DM with chronic pancreatitis

A

Diabetes from endocrine insufficiency

50
Q

jaundice with pancreatitis suggests

A

Jaundice suggests common bile obstruction

51
Q

prognosis of chornic pancreatitis

A

Chronic pancreatitis as a primary cause of death is rare

Usually a consequence of associated complications -

52
Q

management of chronic pancreatitis

A

a. ETOH abstinence!
b. Smaller, more frequent meals to reduce post prandial pancreatic secretions
c. Analgesics
d. Pancreatic enzymes w/ meals to reduce exogenous enzymes release
e. Restriction of dietary fat intake

53
Q

complications of chronic pancreatitis

A 
GI bleed
Biliary tract infection
Liver failure
Malabsorption
Electrolyte abnormalities
54
Q

what are cholesterol stones made of

A

80-90% cholesterol

10% pigmented bilirubin

55
Q

pigmented bilirubin stones are more common in

A

alcohol

only 10-20%

56
Q

which percent of the population has gallstones

which % is symptomatic

A

10% of US population has gallstones

50% of these will be symptomatic

57
Q

Cholelithiasis is most common with

A

4 F’s = Fat, Forty, Female, Fertile

58
Q

CM of biliary colic

A

”

RUQ to mid-epigastric pain

Colicy pain –> intermittent
“
Sharp, maybe severe

Radiates to back/R shoulder. wraps around

Classically follows ingestion of fatty meal (1-2 hrs after meal)

59
Q

PE with cholelithiasis

A

RUQ tenderness

(-)Murphy’s sign
inspiration cessation and pain

60
Q

Dx

A

Based on hx, PE, normal labs, abdominal US

Polyp doesn’t have an acoustic shadow but a stone does on US

61
Q

labs with biliary colic

A

amylase/lipase (pancreatitis)

CBC-infection or inflammation
cholecystitis you see elevation
cholelitahisis you should have normal cbc and normal liver test

maybeee elevation of alk phos

62
Q

dx for cholelithiasis

A

RUQ abd ULS

63
Q

management of biliary colic

A

need to have gallbladder out

cholecystectomy

NON surgical:

64
Q

non surgical mngmt of cholelithiasis

A
  1. Non-surgical tx; 50% recurrence rate
    a. Oral bile salts slowly dissolves stones
    b. Lithotripsy

c. ERCP –> scope down to the gallbladder; if small enough and one stone, then can grab it and take it out
i. Not commonly done anymore

65
Q

Prognosis for cholelithiasis

A
  1. Prognosis unrelated to severity of symptoms
  2. Complications increase with length of time symptoms are present
  3. Morbidity in pts who don’t have cholecystectomy
  4. If they don’t elect for sx then tell them to watch out for severe RUQ pain that doesn’t go away
66
Q

Morbidity in cholelithiasis pts who don’t have cholecystectomy

A

a. Acute cholecystitis
b. Cholangitis with liver abscess
c. Necrotizing pancreatitis
d. Gallstone ileus with SBO
e. Gallbladder CA

67
Q

CM of Acute Cholecystitis

A 
"	Severe, constant abd pain
"	Often epigastric, localizing to RUQ
"	Radiation to back, R shoulder
"	Exacerbation 1-2 hrs after meal
"	Fever
68
Q

acute cholecystitis is usually caused by

A

inflammation of the gallbladder from obstructing stone

69
Q

PE with acute cholecystitis

A

” Fever
“ RUQ tenderness
“ Involuntary guarding
“ (+) Murphy’s sign

70
Q

differentiating cholecystitis from cholelithiasis

A

SEVERE CONSTANT PAIN

N/V/F

71
Q

acute cholangitis

A

ascending infection of the biliary tract

results from acute cholecystitis

72
Q

iii. Charcot’s Triad

A

acute cholangitis

” RUQ pain
“ Shaking chills & Fever
“ Jaundice

surgical emergency gall bladder out RIGHT NOW

73
Q

Acute Cholecystitis lab

A 
"	Leukocytosis
"	Elevated Amylase, mild
"	Elevated ALT/AST, mild
"	Total bilirubin and Alk Phos typically not elevated
"	Order US
74
Q

Acute Cholangitis labs

A

Leukocytosis w/ left shift (immature cell indicative of bacterial infection)

Elevated Alk Phos, Total (direct) bili, GGT

Variable elevations in ALT, AST

75
Q

leukocytosis left shift is indicative of

A

bacterial infection

76
Q

diagnostic test of cholecystitis

A

US of RUQ w/ acute cholecystitis –> marked thickening of gallbladder wall w/ fluid surrounding the distended gallbladder

77
Q

mangmt of cholecystitis

A
  1. Admission
  2. IV empiric abx for gram negatives
  3. Pain management
  4. NPO, NG tube
  5. cholecystectomy
78
Q

NPO, NG tube used for cholecystitis because

A

Want the gallbladder to rest since gallbladder most active when we are eating (it squirts a bunch of enzymes to digest the food)

79
Q

Cholecystectomy definitive treatment because….

A

a. 30-40% will progress to gangrenous cholecystitis and perforation without surgery

80
Q

vi. Treatment of acute cholecystitis vs acute cholangitis

A

1Don’t need to know details

Can wait a day or 2 depending on how busy the OR is, etc

Ascending cholangitis = they need emergency sx right now

81
Q

Primary Sclerosing Cholangitis is usually associated with this dz and seen with abnormal liver function

A

Associated w/ inflammatory bowel disease

82
Q

c. Primary Sclerosing Cholangitis

A

inflammation and fibrosis in the biliary tree need to screen for it because

83
Q

complications of primary sclerosing cholangitis

A

Primary Biliary cholangitis (primary biliary cirrhosis)

ii. Recurrent pyogenic cholangitis
iii. Cholangiocarcinoma

84
Q

Rare bile duct cancer, often associated with PSC, presenting with painless jaundice, right upper quadrant abdominal pain, and weight loss

A

Cholangiocarcinoma

85
Q

Intrabiliary pigment stone formation, resulting in stricturing of the biliary tree and biliary obstruction with recurrent bouts of cholangitis, found almost exclusively in people who live or who have lived in Southeast Asia

A

Recurrent pyogenic cholangitis

86
Q

Rare T-lymphocyte-mediated attack on small intralobular bile ducts; affects women (95%) age 30-65

A

Primary Biliary cholangitis (primary biliary cirrhosis)

87
Q

An obese 37-year-old female is in the emergency room for right-sided abdominal pain and excessive flatulence. This episode has persisted for several hours. On physical exam you palpate her right upper quadrant while she takes a deep breath. The patient experiences pain and has a transient pause in inspiration. What is the most likely diagnosis?

A

acute cholecystitis

+Murphy’s sign makes acute cholecystitis most likely; biliary colic may present with similar symptoms but will not have +Murphy’s sign

88
Q

A 50-year-old woman presents to the clinic with a two-day history of right upper quadrant pain. She has a history of hypercholesterolemia and her examination is significant for a positive Murphy’s sign. What is the preferred imaging modality?

A

abdominal ultrasound

89
Q

A 72-year-old man presents with concerns of “looking yellow.” He is asymptomatic but admits to an unintentional 15 pound weight loss over the last two months. Physical examination reveals jaundice, mild epigastric tenderness, and palpable periumbilical nodules. Which of the following is the most likely diagnosis?

A

pancreatic cancer

90
Q

A 43-year-old woman presents with episodic epigastric pain that frequently follows a fatty meal and can last anywhere from 15 minutes to approximately two hours. At times the pain radiates toward her right shoulder. She has associated nausea without vomiting. Which of the following is the most appropriate next step in managing this patient?

A

US of the abdomen

91
Q

A 57 y/o male has routine lab work for a physical exam; he is generally healthy and asymptomatic. His fasting labs reveal an elevated Alk Phos; the remainder of his CMP is normal, as is his CBC. What is the next step in the evaluation of this abnormal result?

A

order serum GGT and alkaline phosphatase isoenzyme

92
Q

A 63 y/o male c/o abdominal pain x 1 week with anorexia, no weight loss or vomiting, no jaundice. Labs reveal AST 250 (normal 10-40), ALT 150 (normal 10-40), Alk Phos 185 (normal 40-150); amylase and lipase are both mildly elevated. Which of these is the most likely etiology of these abnormal lab results?

A

alcohol use

93
Q

normal alk phos

A

44-147

94
Q

why would you see an increase in bilirubin and ALP in a pt with chronic pancreatitis

A

secondary to extra hepatic biliary obstruction

95
Q

crampy

sharp

RUQ

A

cholecystitis

usually follows fatty meal

96
Q

charcot’s triad

A

for acute cholagitis

fever chills
RUQ pain
jaundice

97
Q

reynold’s triad

A

fever chills
RUQ pain
jaundice
(carchot’s )

shock and altered mental status acute cholangitis

Medicine II (21 decks)

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