Biliary disease

Question 0

What are most gallstones made out of?

Answer 0

Cholesterol

Question 1

Emphysematous cholecystitis

Answer 1

Common in elderly, diabetic males

Infection of the gallbladder by gas-forming bacteria
2/2 vascular compromise, immunosuppression and gallstones

Dx: air-fluid levels in the gallbladder on X-ray or curvilinear gas shadow on U/S

Tx: fluid, antibiotics, surgery

Question 2

Murphy’s sign

Answer 2

Inspiratory arrest with deep palpation of the RUQ

Seen in acute cholecystitis

Question 3

U/S findings for acute cholecystitis

Answer 3

Gallstones, bile sludge, pericholecystic fluid, thickened gallbladder wall, gas in the gallbladder, ultrasonic Murphy’s sign

Question 4

How to diagnose cholecystitis when U/S is equivocol?

Answer 4

HIDA scan: uses a radiotracer excreted through the biliary system to visualize the glassbladder

Question 5

What medication to use for acute cholecystitis if surgery can’t happen?

Answer 5

Ursodeoxycholic acid

Question 6

Cholecystitis vs cholangitis vs cholelithiasis vs choledocolithiasis vs primary biliary cirrhosis vs primary sclerosing cholangitis

Answer 6

Cholecystitis: infection of the gallbladder, usually 2/2 obstruction
Ascending cholangitis: an acute bacterial infection of the biliary tree 2/2 obstruction (cholecystitis is infxn of gallbladder)

Cholelithiasis = gallstones in the gallbladder
Choledocolithiasis = gallstones in the common bile duct

Primary biliary cirrhosis: autoimmune disorder of destruction of the intrahepatic bile ducts
Primary sclerosing cholangitis: idiopathic disorder of progressive inflammation and fibrosis of extra and intra-hepatic bile ducts

Gallstone ileus: stone travels from gallbladder to the small bowel through a cholecystoduodenal fistula and causes blockage

Question 7

Labs in choledocolithiasis

Answer 7

Increased alkaline phosphatase and total and direct bilirubin

Question 8

Diagnostic labs of ascending cholangitis

Answer 8

Increased bilirubin and alk phos

Question 9

Diagnostic tests for primary sclerosing cholangitis

Answer 9

Increased alk phos, increased bilirubin

Question 10

Presentation and treatment of choledocolithiasis

Answer 10

Presents: biliary colic, jaundice, fever, and/or pancreatitis

Tx: ERCP with sphincterotomy followed by cholecystectomy

Question 11

Presentation of ascending cholangitis

Answer 11

Charcot’s triad: RUQ pain, jaundice, and fever/chills
Reynold’s pentad: Charcot’s triad + septic shock + AMS
-present in acute suppurative cholangitis and suggests sepsis

Question 12

Diagnosis and treatment of ascending cholangitis

Answer 12

ERCP is both diagnostic and therapeutic

Acute suppurative cholangitis: needs emergent bile duct decompression via ERCT/sphincterotomy, percutaneous transhepatic drainage, or open decompression

Question 13

Presentation of gallstone ileus

Answer 13

Subacute SBO in elderly women; may have no hx of biliary colic

AXR: SBO and pneumobilia (gas in the biliary tree)
Upper GI contrast: no contrast in the colon

Question 14

Primary sclerosing cholangitis presentation

Answer 14

Presents in young males with ulcerative colitis

Progressive jaundice, pruritis, and fatigue

Question 15

Diagnosis of primary sclerosing cholangitis

Answer 15

Increased alk phos and bilirubin
MRCP/ERCP = multiple bile duct strictures and dilatation
Liver biopsy: periductal sclerosis (onion skinning)

Question 16

Tx of primary sclerosing cholangitis

Answer 16

High dose ursodiol
ERCP with dilation and stenting of stricutres
Liver transplantation is definitive