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Flashcards in Biliary Disease Deck (90)
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1

Function of bile

Digestion and absorption of fats
Vehicle for excretion of bilirubin, excess cholesterol and metabolic byproducts

2

Stones in the gallbladder

Cholelithiasis

3

Inflammation of the gallbladder

Cholecystitis

4

Stones in the common bile duct

Choledocholithiasis

5

Inflammation of the bile ducts

Cholangitis

6

Disruption of bile flow regardless of cause

Cholestasis

7

Risk factors for cholelithiasis

Four Fs (female, fluffy, forty, fertile)
Females, Age 40, Obese, Pregnant, Estrogen (OCTs, HRT)
Also rapid weight loss, family hx, ethnicity (Native Americans), diabetes

8

Types of stones

Cholesterol mostly
Can be pigment (black or brown)

9

Types of presentation of cholelithiasis

Asymptomatic incidental stones (MOST)
Uncomplicated disease (biliary colic and symptomatic in the absence of gallstone related complications)
Complicated gall stone disease with complications

10

Complications that can arise in complicated gallstone disease

Aute cholecystitis
Choledocholithiasis with or without acute cholangitis
Gallstone pancreatitis

11

Initial test of choice for cholelithiasis

Ultrasound (very sensitive to detect stones)

12

Other diagnostics for cholelithiasis

Abd plain film (only positive in some pts)
CT abdomen (less sensitive)

13

Tx for asymptomatic gallstones

Mostly don't need tx, manage expectantly

14

When to refer for cholecystectomy with asymptomatic gallstones

Increased risk of gallbladder cancer
Hemolytic disorders (sickle cell, G6PD etc)

15

Why does biliary colic/uncomplicated gallstone disease occur?

Gall bladder contracts forcing stone against outlet or cystic duct opening--increased intra gall bladder pressure resulting in pain--when relaxes, obstruction is relieved and pain subsides
**no inflammation of the gall bladder!

16

Classic description of biliary type pain in biliary colic

Intense RUQ/epigastric pain that may radiate to R shoulder blade
Constant and steady
Pain lasting at least 30 min then plateaus (<5-6 hrs)
Postprandial pain (fatty or greasy foods)
N/v, diaphoresis
Not worse with movement
Not relieved with squatting, bowel movements or gas
Noctural pain waking pt

17

PE for biliary colic

Often normal vitals (NO fever or tachycardia)
Not ill appearing
NO evidence of jaundice
Anicteric eyes
No peritoneal signs, - Murphys

18

Labs in biliary colic

Normal CBC, LFTS, amylase and lipase

19

Preferred diagnostic test for biliary colic

US (seeing gallstones or gallbladder sludge)

20

Management for uncomplicated gallstones/biliary colic

Cholecystectomy (prevents recurrence and complications)

21

What is functional gall bladder disorder/biliary dyskinesia?

Biliary type pain in ABSENCE of gallstones, sludge, microlithiasis or microcrystal disease
Results from gall bladder dysmotility

22

Labs in functional gall bladder disorder

Normal CBC, LFTS, amylase, lipase
Normal imaging and upper endoscopic exam

23

How to diagnose functional gall bladder disorder

Diagnosis of exclusion when have biliary type pain (make sure not PUD, functional dyspepsia or ischemia heart)
If no other causes, order CCK-stimulated cholescintigraphy (HIDA scan)

24

How HIDA scan is used in functional gallbladder disorder

CCK is given to stimulate GB to contract
Calculate GB ejection fraction
GBEF <35-40% is considered low and supports

25

Criteria to diagnose functional gallbladder disorder

Rome IV criteria REQUIRES
Biliary pain
Absence of gallstones of other structural pathology
Other criteria supportive but not required
Low ejection fraction on scintigraphy
Normal liver enzymes, conjugated bilirubin and amylase/lipase

26

How to exactly define biliary pain

Pain in epigastrium and or RUQ
Builds up to steady level and lasts at least 30 min
Occurs at variable intervals (not daily)
Is severe enough to interrupt daily activities or lead to an ED visit
Is not significantly (<20%) relieved by BMs, postural changes or acid suppression
Other things supportive:
Pain associated with n/v
Pain radiates to back and or right subscap region
Pain awakens pt from sleep

27

Management for functional gallbladder disorder

Cholecystectomy recommended for those with typical biliary type pain and low GBEF (<40%)

28

What is acute calculous cholecystitis?

Acute inflammation of the GB
-mostly complication of gallstone disease
Occurs with cystic duct obstruction and gallbladder inflammation (must have both!!)

29

Presentation of acute calculous cholecystitis

Begins as attack of biliary pain that progressively worsens (usually have had a previous experience)
Prolonged (>4-6 hrs) steady, severe RUQ or epigastric pain
May radiate to right shoulder or back
Fever, n/v, anorexia
Often hx of fatty food ingestion

30

What is seen on PE for acute calculous cholecystitis?

Fever and tachycardia
Ill appearing, lying still
No jaundice
Anicteric
Abd exam: RUQ tenderness, voluntary or involuntary guarding, + Murphy's sign