B5-022 CBCL: Cholecystitis-lithiasis Flashcards
1
Q
drugs that increase risk of cholelithiasis
2
A
- octreotide
- clofibrate
2
Q
calcium bilirubinate polymer formed in gallbladder
A
black pigment stone
3
Q
mixture of cholesterol/fatty soap/calciu bilirubinate formed in bile duct
A
brown pigment stone
4
Q
[…] pigment stones are associated with chronic hemolysis and Crohn’s
A
black
5
Q
deconjugates bilirubin causing insoluble calcium bilirubin salts
A
bacterial B-glucoronidase
6
Q
> 80% of all gallstone cases are caused by
A
cholesterol stones
(cholesterol monohydrate crystal)
20% pigment stones
7
Q
conditions favor gallstone formation
A
lithogenic stage
first stage
8
Q
episodes of biliary colic after a fatty meal
A
symptomatic gallstones
third stage
9
Q
- usually asymptomatic
- may be discovered on imaging performed for reasons other than gallbladder disease
A
cholelithiasis
10
Q
- RUQ pain/tenderness
- fever
- positive murphy’s sign
A
acute cholecystitis
11
Q
what laboratory findings would you expect in acute cholecystitis?
A
- increased WBC
- mildy elevated bili
- mildly elevated transaminase
12
Q
best initial step for diagnosis of acute cholecystitis
A
RUQ ultrasound
13
Q
what should you see on ultrasound for diagnosis of acute cholecystitis?
A
- gallstones
- anterior wall >3mm thick
- pericholecystic fluid
14
Q
treatment of acute cholecystitis
A
- IV fluids
- antibiotics
- patient NPO
- monitor for 48 hours
if symptoms worsen, urgent cholecystectomy. if not, schedule in 6 weeks
15
Q
- fever
- RUQ pain/tenderness
- positive murphy’s sign
- scleral icterus/jaundice
A
choledocholithiasis
16
Q
what would you expect to see on US of choledocholithiasis?
A
- gallstones
- common bile duct >8 cm dilated
- obstruction of biliary tract at the level of common bile duct
17
Q
treatment for choledocholithiasis
A
ERCP spinchterotomy and retrieval of stone
elective cholecystectomy may follow
18
Q
- fever
- RUQ pain/tenderness
- positive Murphy’s sign
- scleral icterus/jaundice
- AMS
- hypotension
- sepsis
- Reynold’s pentad
A
acute ascending cholangitis
19
Q
Reynold’s pentad
A
- fever
- RUQ pain
- jaundice
- AMS
- hypotension
acute ascending cholangitis
20
Q
treatment of acute ascending cholangitis
A
- IV fluids, hemodynamic stabilization
- antibiotics
- urgent biliary drainage
- ERCP
elective cholecystectomy may follow
21
Q
expected lab findings for choledocholithiasis?
A
elevated WBCs
mildy elevated bili/transaminases
same for cholecystitis
22
Q
expected lab findings for acute ascending cholangitis?
A
- elevated WBCs
- mildly elevated bili/transaminases
- elevated alk phos
23
Q
charcot triad
A
jaundice
fever
RUQ pain
cholangitis
24
Q
infection of the biliary tree usually due to obstruction that leads to stasis/bacterial overgrowth
A
ascending cholangitis
25
presence of gallstone in common bile duct
choledocholithiasis
26
risk factors for cholelithiasis
* female
* fat (obesity)
* fertile (mulitparity)
* forty
* fair
| 5 Fs - First Aid
27
causes of cholelithasis
* elevated cholesterol/bilirubin
* decreased bile salts
* gallbladder stasis
28
which type of stones are radiolucent?
| 2
cholesterol stones
brown pigment
29
which type of stones are radiopaque?
black pigment stones
30
carries nutrient rich blood into the liver
portal vein
31
provides oxygenated blood to liver
hepatic artery
32
collect blood from liver and take it to IVC
hepatic veins
33
bile duct epithelial cells
cholangiocytes
34
liver resident macrophages
Kupffer cells
35
major storage site for vitamin A
stellate cells
36
form a heterodimer to transport cholesterol into the bile
ABCG5/ABCG8
37
major transporter for secretion of bile acids from hepatocytes into bile
BSEP
38
lipid translocator that moves phosphatidylcholine from the inner leaflet to outer leaflet of the canalicular membrane for extraction into the lumen by bile salts
MDR3
39
exports bilirubin from hepatocytes into bile
MRP2
40
mediates intestinal cholesterol absorption
NPC1L1
41
mediates hepatocytes apical cholesterol secretion into bile
ABCDG5
42
how do bile salts and phospholipids prevent cholesterol precipitation in the bile?
forming mixed micelles
43
stimulates gallbladder contraction after a meal
CCK
44
* produced in the ileum in response to bile acid absorption
* regulates bile acid synthesis
FGF19
45
[...] pigment stones are formed in the gallbladder due to hypersecretion of bilirubin
black
46
chronic hemolytic anemia is associated with [...] pigment stones
black
47
usually formed in the biliary tract and associated with chronic biliary tract infection
brown pigment stone
48
deconjugates bilirubin and contributes to brown stone formation in the biliary tract
bacterial B-glucoronidase
49
acute cholecystitis is most often to result of gallstone blockage of the
cystic duct
50
blockages of the ampulla of Vater leads to
jaundice
51
pro-nucleating agent in supersaturated bile
mucin
52
high molecular weight glycoprotein secreted by the gallbladder with the ability to bind lipids and bile pigment
mucin
53
anti-nucleating agent
apolipoprotein AII
54
bile stasis and decreased function of the spinchter of Oddi cause bacteria to migrate into the biliary tract causing
acute ascending cholangitis
55
ascending cholangitis caused by choledocholithiasis is often a result of
bacteria entering the biliary tree through the ampulla of Vater
56
which serum markers indicate biliary tract injury?
ALP
GGT
57
major basolateral conjugated bile acid uptake transporter
NTCP
58
mutation of [...] results in decreased hepatic uptake of bile acids from the portal blood
NTCP
59
mutation of [...] results in impaired canilicular bile acid secretion into the bile results in intrahepatic bile acid accumulation
BSEP
60
* canalicular phospholipid transporter
* mutation associated with intrahepatic cholestasis PFIC-3
ABCB4 (MDR3)
61
mutation of [...] is associated with PFIC-1
ATP8B1
62
mutation of [...] is associated with hypercholesterolemia and premature atherosclerosis due to reduced cholesterol conversion to bile acids
CYP7A1
63
best initial method for evaluating gallbladder pathology
US
64
characteristic features of ascending cholangitis
fever
jaundice
RUQ pain
65
result of bacterial infection-mediated release of beta-glucuronidase
brown pigment stones
66
increased unconjugated bilirubin precipitates as [...], resulting in brown pigment stones
calcium salts
67
range in color from yellow to dark green and are due to the supersaturation of bile with cholesterol
cholesterol stones
68
[...] stones are associated with infected bile and can often be found outside the gallbladder in the intrahepatic or extrahepatic ducts
brown stones
69
* biliary colic
* hx of cholecystectomy
* common bile duct dilation
spinchter of Oddi dysfunction
70
treatment for spinchter of Oddi dysfunction
sphincterotomy via ERCP
71
best diagnotic modality for spinchter of Oddi malfunction
manometry via ERCP
| measures pressures
72
often confused with cholelithiasis until the patient's symptoms persist post cholecystectomy
spinchter of Oddi malfunction
73
thin layer of mineralization outling the gallbladder wall on US
porcelain gallbladder
74
calcified gallbladder due to chronic cholecystitis
porcelain gallbladder
| often asymptomatic and found on incidental imaging
75
most common cause of porcelain gallbladder
recurrent biliary colic
76
gallbladder wall thickening on US is characteristic of
cholecystitis
77
distended gallbladder with clear fluid accumulation as a result of long standing cystic duct blockage
hydrops of gallbladder
78
gallbladder distention and stones pressing the gallbladder wall cause ischemia and necrosis
gangrenous cholecystitis
79
gallbladder calcification increases the risk for
gallbladder carcinoma
80
do asymptomatic patients generally require cholecystectomy?
no
| exception: porcelain gallbladder and Native Americans
81
patients at risk for gallbladder cancer should have a cholecystectomy. what populations would this include?
* porcelain gallbladder
* Native Americans
82
the presence of [...] suggests the patient has a high risk for developing ascending cholangitis
jaundice
83
the presence of [...] in the stool gives it its brown color
bilirubin
84
choledocholithiasis, biliary atresia, and hepatitis can decrease [...], causing stool to appear pale in color
bilirubin release into intestine
85
conjugated bilirubin is exported across the [...] of the hepatocytes into systemic circulation
basolateral side
86
[...] causes black stones in the gallbladder
hemolytic anemia
87
risk factors for cholesterol stones
* female
* fat
* fertile
* fair
* fourty
88
which type of pigment stone is more frequently formed in bile ducts?
brown
89
composed of calcium salts of unconjugated bilirubin and cholesterol
brown pigment stones
90
which type of stone is associated with chronic bacterial or parasitic infection of the bile duct?
brown pigment
91
what happens to unconjugated bilirubin in the presence of calcium?
forms highly insoluble calcium salts and complexes with other liquids to form pigmented stones
92
formed in the gallbladder and consist of crosslinked unconjugated bilirubin polymer and calcium salts
black pigment
93
bile acid sequestrants
| 2
* cholestipol
* cholestyramine
94
2 drug classes used to treat hypercholesterolemia
* bile acid sequestrants
* statins
95
2 drug classes used to treat hypertriglyceridemia
PPARa agonists fibrates (**gemfibrozil**)
niacin
96
activates PPARa to increase biliary cholesterol secretion and decrease bile acid synthesis
gemfibrozil
| **contributes to cholesterol supersaturation in bile**
97
thought to decrease lipids by inhibiting adipose lipid release
niacin
98
how does rapid weight loss contribute to the development of gallstones?
* causes adipose to release a large amount of cholesterol via lipolysis
* causes increased hepatic cholesterol uptake and biliary cholesterol hypersecretion
| causes cholesterol superaturation in bile
99
do incidentally detected gallstone in patients without symptoms need treatment?
no
100
describe appropriate management of acute cholecystitis
* IV antibiotics and observe
* if improvement in 48 hrs -> schedule elective cholecsytectomy within 6 weeks
* if no improvement/worsening--> urgent cholecystectomy
101
contraindicated in pregnancy due to potential risk of miscarriage and effects on fetus
NSAIDs
102
what can be used in pregnant women for pain management?
acetaminophen
opioids
103
what does the Reynold's pentad indicate?
ascending cholangitis progressing to septic shock
104
what lab findings indicate acute pancreatitis?
serum lipase 3x upper limit of normal
glucose of 190 ml/dl
105
* itching
* dark-colored urine
* light colored stool
| indicates a problem with
indicates a problem with bile excretion
106
how do issues with bile excretion cause dark colored urine?
when bile cant be excreted by the intestine, it is excreted by kidneys
107
first line treatment for PBC
ursodiol
| UCDA
108
promotes biliary secretion, decreases inflammation and cell death, reduces the hydrophobicity of bile acid pool
| medication
ursodiol
109
characterized by pruritis, elevated serum bile acids and developing 2nd/3rd trimester
ICP
| resolves quickly after delivery
110
treatment for ICP
ursodiol
| UDCA
111
what is the cause of gallstone in Crohn's disease?
* decreased bile acid reabsorption
* lower bile acids in bile
* increased bilirubin -> cholesterol supersaturation
112
acute necroinflammatory disease of the gallbladder without evidence of gallstones or duct obstruction
acalculous cholecystitis
113
due to gallstone impaction of the cystic duct resulting in inflammation and gallbladder wall thickening
calculous cholecystitis
114
* due to gallbladder stasis, hypoperfusion, or infection
* seen in critically ill patients
acalculous cholecystitis
115
results from gallbladder stasis and ischemia, which then cause a local inflammatory response in the gallbladder wall
acalculous cholecystitis
116
treatment of acalculous cholecystitis
* IV fluids
* pain control
* antibiotics
* cholecystectomy
117
* critically ill patients with sepsis without a clear source or jaundice
* fever, abdominal pain
acalculous cholecystitis
118
ischemia, sepsis, gallbladder stasis cause
acalculous cholecystitis
119
* direct hyperbilirubinemia
* scleral icterus for years
* hyperpigmentation of liver
Dubin Johnson
120
* indirect hyperbilirubinemia
* can remain asymptomatic until adulthood
Crigler-Najjar type II
121
most common inherited hyperbilirubinemia
Gilberts
122
presents with indirect hyperbilirubinemia in times of stress
Gilbert
123
jaundice and unconjugated hyperbilirubinemia between the 3rd and 8th day of life
physiologic neonatal jaundice
124
what causes physiologic neonatal jaundice?
* increased fetal RBC turnover
* immature newborn liver (decreased UDP)
