Biliary Flashcards by Stephanie Escobar

RUQ pain radiating to the back after fatty meals
resolves within a few hours 
female
multigravida
obese

Cholelithiasis

Gallstones

How well did you know this?

Not at all

Perfectly

RUQ pain radiating to back +/− scapular pain,
persistent (4–6+ hours)
fever
Leukocytosis
tachycardia
Murphy’s sign (too painful to breath with palpation)

Acute cholecystitis
(Gallbladder infection 2/2 cystic duct obstruction)

How well did you know this?

Not at all

Perfectly

RUQ pain with jaundice but no systemic inflammatory signs
(no fever or leukocytosis)
Abnormal Bilirubin/ ALP levels

Choledocholithiasis

How well did you know this?

Not at all

Perfectly

Episodic RUQ pain aggravated by opioids

Sphincter of Oddi dysfunction

How well did you know this?

Not at all

Perfectly

Persistent RUQ pain
fever
jaundice

(Charcot’s triad)

Acute cholangitis

abnormal bili/ALP

How well did you know this?

Not at all

Perfectly

Severe epigastric pain
radiating straight through to back
(2/2 cholelithiasis, alcohol abuse, CF)
Abnormal lipase/amylase

Acute Pancreatitis

How well did you know this?

Not at all

Perfectly

a positive Murphy’s sign, fever, tachycardia, and elevated white blood cell (WBC) count,

Most likely diagnosis is:

acute cholecystitis

How well did you know this?

Not at all

Perfectly

Symptomatic cholelithiasis (gallstones) is usually managed as an outpatient, with eventual elective

laparoscopic cholecystectomy

How well did you know this?

Not at all

Perfectly

Acute cholecystitis requires hospital admission, intravenous (IV) antibiotics, and urgent

cholecystectomy

How well did you know this?

Not at all

Perfectly

U/S reveals:

Gallstones
gallbladder wall thickening >4 mm
pericholecystic fluid
+ sonographic Murphy’s

acute cholecystitis

How well did you know this?

Not at all

Perfectly

Fatty food ingestion triggers the release of ___, which leads to contraction of the gallbladder.

cholecystokinin (CCK)

How well did you know this?

Not at all

Perfectly

Main Risk Factors for Developing Cholesterol Gallstones?

Lithogenic bile
Obesity
High-fat diet
Hyperlipidemia
Hispanic

(6-7)

Increased estrogen
(females, pregnancy, OCPs)

Crohn’s disease
terminal ileal resection
Rapid weight loss after gastric surgery
Vagotomy (cutting vagal n. for PUD)
Statins
Total parenteral nutrition

How well did you know this?

Not at all

Perfectly

Black stones are often associated with

Hemolytic diseases such as:
Hereditary spherocytosis
Sickle cell disease
G6PD deficiency

(2/2 increased unconjugated bilirubin)

How well did you know this?

Not at all

Perfectly

Brown stones most often form within the bile ducts & are associated with

bacterial infection or parasites

ex: Chinese liver fluke
* brown stone common in asians

How well did you know this?

Not at all

Perfectly

Transient obstruction of the cystic duct →
visceral peritoneal stretch →
RUQ pain

Symptomatic cholelithiasis

How well did you know this?

Not at all

Perfectly

Persistent obstruction of the cystic duct → 
visceral peritoneal stretch → 
inflammation of the gallbladder → 
bacterial overgrowth → 
infection of the gallbladder → 
parietal peritoneum inflammation

Acute Cholecystitis

How well did you know this?

Not at all

Perfectly

Obstruction of the common bile duct (CBD)

Choledocholithiasis

How well did you know this?

Not at all

Perfectly

Obstruction of the CBD → 
bacterial overgrowth → 
infection of the entire biliary tree → 
ascends into the liver →
cholestasis

Acute Cholangitis

How well did you know this?

Not at all

Perfectly

Obstruction of the CBD and pancreatic duct (often at the ampulla of Vater) →
pancreatic enzyme release →
autodigestion/inflammation of pancreas →
cholestasis

Acute gallstone pancreatitis

Obstruction usually distal to pancreatic duct

How well did you know this?

Not at all

Perfectly

Large stone erodes into the duodenum →
gallbladder-duodenal fistula →
stone travels down the GI tract →
small bowel obstruction (not ileus!)

Gallstone ileus

How well did you know this?

Not at all

Perfectly

Large gallstone lodged in the cystic duct or in the neck of the gallbladder causing→
external compression of the common HEPATIC duct

Mirizzi’s syndrome

How well did you know this?

Not at all

Perfectly

Gallstone ileus is a mechanical small bowel obstruction,
typically as a result of the gallstone trapped at the _____

Patients present with a tumbling obstruction with transient episodes of diffuse abdominal pain and nausea and air in the biliary tree (from the cholecystoduodenal fistula).

terminal ileum

near the ileocecal valve

How well did you know this?

Not at all

Perfectly

A mechanical small bowel obstruction 2/2 gallstone trapped in the terminal ileum (near the ileocecal valve)

Gallstone ileus

How well did you know this?

Not at all

Perfectly

Patients present with:
transient episodes of diffuse abdominal pain
nausea
air in the biliary tree (from the cholecystoduodenal fistula)

Gallstone ileus

How well did you know this?

Not at all

Perfectly

Ultrasound Demonstrates Gas Bubbles in the Gallbladder Wall

emphysematous cholecystitis

Emphysematous cholecystitis, an infection due to gas-forming organisms. This diagnosis is common in

older men, often with diabetes mellitus

Emphysematous cholecystitis complications | gallbladder needs to be SAPeD off

Sepsis Abscess (intra-abdominal) Perforation (gallbladder) Death Bile cultures will often grow: Clostridium or E. coli Treat with: IV ABx & cholecystectomy

Pneumobilia (air in biliary tree) | MCC (2)

recent instrumentation gallstone ileus (NOT emphysematous cholecystitis that is GAS not AIR)

__ may be negative for gallstones due to radiolucent. stones

CT | get an U/S

Significantly elevated ALP and GGT out of proportion to AST and ALT suggest what primary pathology?

Biliary *Gamma-glutamyl transferase (GGT)

Significantly elevated AST and ALT out of proportion | to ALP and GGT suggest what primary pathology?

Hepatocellular | like hepatitis

__ (lab) is the test of choice to rule out pancreatitis.

Lipase Lipase = higher sensitivity for pancreatitis than amylase

RUQ pain in critically ill patients who are: hospitalized (for other reasons) or fasting for prolonged periods (on total peripheral nutrition)

Acalculous cholecystitis

Ultrasound will typically demonstrate a thickened gallbladder wall or pericholecystic fluid without stones.

Acalculous cholecystitis | If U/S is negative, a HIDA scan is obtained

Acalculous cholecystitis Treatment: IV antibiotics & emergent cholecystectomy If the patient is UNSTABLE: ______ is performed followed by cholecystectomy once the patient is medically stable.

Percutaneous cholecystostomy | tube to drain the gallbladder

Post- cholecystectomy cystic duct stump leak is treated with: _____ & stenting of the sphincter of Oddi.

Endoscopic-retrograde cholangiopancreatography (ERCP) HIDA scan is obtained to r/o a bile leak and/or a bile duct injury

Suspected Common Bile Duct injury s/p cholecystectomy management:

1. HIDA scan (obtained to r/o a bile leak or a bile duct injury) 2. Hepatico-jejunostomy (if injury is present)

Gallbladder infection antibiotic of choice:

1st line: Cefoxitin (2º ceph; covers anaerobes) Alternatives: (piperacillin/ tazobactam) (ampicillin/sulbactam) In severe cases: 3rd & 4th gen cephalosporins

``` Calcified gallbladder (porcelain) = increased risk of _____ ``` Tx: _____

malignancy cholecystectomy

Postcholecystectomy syndrome is persistent abdominal pain or dyspepsia either postoperatively (early) or months to years (late) after cholecystectomy. U/S followed by ______ is the next best step

direct visualization via endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP)

``` Biliary cyst presents with: RUQ-pain Fever Juandice elevated LFTs & WBCs ``` Treatment:

Treatment: Cyst resection (to ↓ risk of malignancy) ± Roux-en-Y hepaticojejunostomy (percutaneous drainage) Diagnosis: Ultrasound ± CT scan or MRCP ``` Complications: Cholangiocarcinoma (malignancy) Acute cholangitis (infection) Pancreatitis Stone formation ```

Cholangiocarcinoma is a biliary tract epithelial malignancy. Most often occurs in those who have: fibropolycystic liver disease or ____ 2/2 ____

primary sclerosing cholangitis 2/2 ulcerative colitis (↑CEA & ↑CA 19-9)

Porcelain gallbladder usually shows a calcified rim in the gallbladder wall with a central bile-filled dark area. It is associated with an increased risk for ____ and requires cholecystectomy.

gallbladder adenocarcinoma

gallstone pancreatitis complicated by acute cholangitis in a hypotensive pt w/ altered mental status ( aka unstable) Next best step in management:

Endoscopic retrograde cholangiopancreatography (ERCP) (to relieve the biliary obstruction/stone)

A HIDA scan is used to diagnose____ in patients with equivocal ultrasound findings

Acute Cholecystitis ______________________ HIDA INTERPRETATION HIDA scan used to assess function or integrity of biliary tract. acute cholecystitis: No GB visualization in 1hr acute acalculous cholecystitis: no GB in 1hr visualization w/o stones or partial filling of GB chronic cholecystitis: ↓ GB ejection fraction + stones chronic acalculous cholecystitis (GB dyskinesia) : ↓ GBEF w/o stones

Biliary dilation suggests ____

cholangitis | Infection/Obstruction of the common bile duct

A ___ is used to diagnose cholecystitis in patients with equivocal ultrasound findings

HIDA scan

A rare complication of hepatic or bilio-pancreatic procedures. Presents with: RUQ pain Jaundice & Upper gastrointestinal bleeding (aka Melena)

Hemobilia | bleeding into the biliary tract

Dyskinesia or stenosis of the sphincter leading to cholestasis worsened with opioids

Sphincter of Oddi dysfunction

``` Most likely diagnosis: RUQ pain jaundice fever, hypotension leukocytosis hyperbilirubinemia elevated alkaline phosphatase (ALP) +/- altered mental status ```

acute cholangitis 2/2 gallstone impaction (CBD)

Pale/white (acholic) poop is due to:

prolonged biliary obstruction | would not be expected in patients with acute gallstone cholangitis

Acute biliary obstruction can lead to an increased level of _____ which may cause dark (Coca-Cola-colored) urine.

conjugated bilirubinemia

Acute biliary obstruction can lead to an increased level of conjugated bilirubinemia which may cause ___ urine.

dark (Coca-Cola-colored)

Charcot’s triad consists of _____ Classically associated with Cholangitis

fever RUQ pain jaundice (not always seen on PE)

Reynold’s pentad implies cholangitis with septic shock. It includes Charcot’s triad plus ______ & ______.

hypotension & altered mental status

Reynold’s pentad implies cholangitis with ____.

septic shock | Fever, RUQ pain, Juandice (Charcot's triad) + AMS, Hypotension

Once the Patient is Fluid resuscitated, started on Antibiotics, and the diagnosis of Cholangitis is established via U/S & blood cultures What is the next step in treatment:

ERCP (drain the infected bile/ biliary decompression) If ERCP is unsuccessful → PTC --------------------------------------------------------- ERCP a scope is inserted through the mouth to the sphincter of Oddi → sphincterotomy → wire is passed through ampulla → stone removed/bile drained into duodenum → place stent. Percutaneous Transhepatic drainage (PTC) The bile is drained via a catheter inserted directly into the liver.

Once the patient’s sepsis 2/2 cholangitis has completely RESOLVED Next, step in management

Cholecystectomy

Bloody diarrhea in a patient who presents with | cholangitis is suggestive of ulcerative colitis with

primary sclerosing cholangitis (PSC)

Characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts. Cholangiography shows multifocal areas of alternating stricturing and dilation of intrahepatic and/or extrahepatic bile ducts (“pearls on a string”)

primary sclerosing cholangitis (PSC) 2/2 ulcerative colitis (IBD)

``` If a patient (generally a middle-aged woman) presents with: pruritus, fatigue, mildly elevated ALP, normal AST/ALT, normal RUQ U/S ``` then suspect a diagnosis of

primary biliary cholangitis (PBC) Patients test positive for the anti-mitochondrial antibody (AMA). Complications: cirrhosis, hepatobiliary cancers, malabsorption, & osteopenia.

Suppurative cholangitis | aka

acute cholangitis complicated by septic shock

Think ____ if pt also having symptoms of IBD (bloody diarrhea)

sclerosing cholangitis

``` Suspect ______ if there is: pruritis elevated ALP no duct dilatation (+) Anti Mito-Ab ```

primary biliary cholangitis

Epigastric pain radiating straight through to the back bilious vomiting/ nausea hypoactive bowel sounds imaging = gas in the small & large bowel. Focal dilated loop of proximal small bowel w/o air fluid levels.

Acute pancreatitis MCC 2/2 cholelithiasis (gallstones) *Treatment is supportive if not 2/2 to gallstones

Criteria for the diagnosis of acute pancreatitis: Require 2 of 3: 1. Sudden/Persistent epigastric pain radiating to the back 2. Elevated Lipase or Amylase 3x> normal ``` 3. Characteristic findings of acute pancreatitis on imaging such as (3-4) ```

enlarged pancreas sentinel loops [dilated loops of proximal small bowel in the LUQ on XR] colon cutoff sign [distended proximal colon with abrupt collapse in the LUQ at the splenic flexure]

Criteria for the diagnosis of acute pancreatitis: | Require 2 of 3:

1. Epigastric pain radiating to the back 2. Elevated Lipase or Amylase (3x normal) 3. sentinel loops [dilated small bowel] or gas on imaging

Main Pulmonary Complications of Acute Pancreatitis?

Pleural Effusions (mostly on the left side) & acute respiratory distress syndrome (ARDS) -diffuse bilateral pulmonary infiltrates *PE = severe pancreatitis

__ & __ are the most common causes of | acute pancreatitis

Gallstones | Alcohol

Most sensitive lab value for diseases of the liver or biliary. Used to confirm hepatic origin of elevated ALP levels. ↑ with Cholestasis (obstructive or nonobstructive) & Alcohol use

Gamma-glutamyl transferase (GGT) *Not elevated in bone disease (unlike, ALP)

Biliary Flashcards

(70 cards)