biliary Flashcards
(63 cards)
1
Q
common bile duct has what three ducts entering into it
A
- common hepatic duct
- cystic duct
- pancreatic duct
2
Q
common bile duct enters at what part of the intestine? at what sphincter?
A
- duodenum
- sphincter of oddi
3
Q
composition of bile
A
- bile salts
- phospholipids
- biliruben
- cholesterol
4
Q
function of bile
A
- digestion and absorption of fats (bile salts)
- vehicle for excretion of biliruben, excess cholesterol and metabolic by-products
5
Q
define Cholelithiasis
A
- stones in the gallbladder
6
Q
define cholecystitis
A
inflammation of the GB
7
Q
define Choledocholithiasis
A
stones in the common bile duct
8
Q
define cholangitis
A
inflammation of the bile ducts
9
Q
define cholestasis
A
- disruption of bile flow..regardless of cause
10
Q
List the risk factors for cholelithiasis
A
- the four F’s (female, fluffy, forty, fertile)
- age over 40
- females
- pregnancy
- obesity
- estrogen
11
Q
What are the two types of stones in cholelithiasis
A
- cholesterol stones: most common
- pigment stones: calcium bilirubinate
12
Q
what is the initial test of choice in assesment of cholelithiasis
A
Ultrasound
13
Q
when is cholecystectomy recommended with cholelithiasis
A
sympatomatic cholelithiasis
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
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
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
17
Q
What results are expected to be seen on US for Biliary colic
A
- gallstones and/or gallbladder sludge expected
18
Q
what CBC, LFTs, amylase and lipase results are expected with Biliary colic
A
NORMAL
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
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
21
Q
what is the HIDA scan with CCK
A
- CCK given to stimulate gallbladder to contract
- ejection fraction calculated
- EF is low in patients with biliary dyskinesia <35-40%
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
- fulfill criteria
23
Q
Acute inflammation of the gallbladder that occurs in the setting of cystic duct obstruction AND gallbladder inflammation is
A
acute cholecystitis
24
Q
most common cause of acute cholecystitis is
A
gallstones
25
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**
acute cholecystitis
26
would you expect jaundice in patient with acute cholecystitis
NO
27
what abd exam findings would you expect with acute cholecystitis
* RUQ tenderness
* guarding and rebound
* **positive murphys sign**
28
what CBC finding is most consistent with acute cholecystitis
* **leukocytosis with a left shift**
29
what is the most common complication of acute cholecystitis
* **gangrene**
* ****elderly, diabetics, those that delay seeking tx
30
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
**Mirizzi syndrome**
31
What is the preferred initialy study in evaluation of acute cholecystitis? what do you expect to see
* US
* gallstones
* wall thickening
* pericholecystic fluid
* positive "sonographic murphys sign"
* HIDA scan done if uncertain
32
managment of acute cholecystitis
* hospital admission
* **early cholecystectomy**
* NPO
* IV fluids, analgesia, abx (empiric)
33
mechanical irritation from gallstones or repeated episodes of acute cholecystitis -\> fibrosis and thickening of gallbladder can cause what condition
chronic cholecystitis
34
**porcelain gallbladder** is associated with? what is it?
* chronic cholecystitis
* calcium deposition within a chronically inflammed GB
35
chronic cholecystitis is associated with development of what
carcinoma of GB
36
patients who are critically ill who present similarly to acute cholecystitis but **do not have gallstones** and may have jaundice could have
* acalculous cholecystitis
37
**choledocholithiasis** will cause bile flow flow which leads to primary symptom
jaundice
38
Courvoisier's sign
palpable gallbladder
39
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
choledocholithiasis
40
what is the initial test of choice in evaluation of choledocholithiasis? what do you expect to see?
* RUQ US
* CBD stone
* CBD dilation (\> 6 mm(
* gallstones in bladder
41
if diagnosis of choledocholithiasis is uncertain after US, what other imaging modalities can you use?
* endoscopic ultrasound (**EUS**)
* magnetic resonance cholangiopancreatography (**MRCP**)
* great imaging of biliary and pancreatic ducts
42
complications of choledocholithiasis
* acute cholangitis
* acute pancreatitis
43
what is the preferred therapeutic test for choledocholithiasis
* **ERCP**
* ****remove stones
* insert stents
* follow up with cholecystectomy
44
What is ascending cholangitis
* **infection of biliary tract**
* associated with **biliary obstruction**
* bacteria infects bile: ascending infection from duodenum
45
managment of suppurative acute cholangitis
* "pus under pressure" -\> surgical emergency
46
What is **Charcot's triad** and what is it associated with
* ascending cholangitis
* Charcot's triad
* **Fever**
* **Abdominal pain**
* **Jaundice**
47
What is Reynold's pentad and what is it associated with
* Ascending cholangitis
* Reynolds pentad
* **fever**
* **abd pain**
* **jaundice**
* **mental status changes and hypotension**
48
What LFT would you expect to see with Ascending cholangitis
* cholestasis causes
* elevated
* conjugated bili
* alk phos
* GGT
* ? AST/ALT
49
managment of Ascending cholangitis in patients with charcot's triad and abnormal LFTs
* **ERCP**
* ****confirms diagnosis
* stone extraction
* provides biliary drainage -\> life saving
50
Primary biliary cholangitis primarily affects what patient population
**females**
51
what is Primary biliary cholangitis
* **autoimmune** destruction of small intrahepatic bile ducts which causes **cholestasis**
* leads to cirrhosis and liver failure
52
clinical presentation
* **fatigue**
* **pruritis**
* jaundice, RUQ pain, skin hyperpigmentation, xanthomas, hepatomegaly
* elevated **alk phos**, GGT, 5-NT
* AMA +
Primary biliary cholangitis
53
what is a cholestatic pattern of LFTs
* elevated **alk phos**
* elevated GGT
* elevated 5-NT
54
what antibodies are elevated in Primary biliary cholangitis
antimitochondrial antibodies (AMA)
55
Primary biliary cholangitis is diagnosed via
* need at least 2 of following
* **elevated alk phos**
* **+ AMA titer**
* histologic evidence with liver biopsy
* managment: refer to GI, monitor bone density
56
inflammation/fibrosis/stricturing of medium and large ducts in the intrahepatic and/or extrahepatic biliary tree is consistent with
* Primary sclerosing cholangitis
57
risk factors for Primary sclerosing cholangitis
* **men**
* **inflammatory bowel disease**
* ****mostly UC
58
complications of Primary sclerosing cholangitis
* progresses to cirrhosis
* **Cholangiocarcinoma**
59
clinical presentation
* asymptomatic
* fatigue
* **pruritis**
* **jaundice**
* hepatomegaly
Primary sclerosing cholangitis
60
what imaging modalities are used in assesment of Primary sclerosing cholangitis
* **MRCP**: multifocal stricturing with intrahepatic/extrahepatic ductal dilations
* ERCP
61
What is Gilbert's syndrome
* deficiency in enzyme for glucuronidation of biliruben in liver (conjugation)
* suspect in pt with **unconjugated hyperbilirubinemia** in absence of hemolysis
62
What are the risk factors for gallbladder ca
* cholelithiasis
* gallbladder polyps \> 1 cm
* porcelian GB
* chronic infection (salmonella)
63
biliary ampullary cancer is associated with what two conditions
* FAP: familial adenomatous polyposis
* HNPCC: hereditary non-polyposis colon cancer
