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Clin Med III Exam I > Biliary diseases > Flashcards

Flashcards in Biliary diseases Deck (114)
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1
Q

What are the three traditional liver function tests

A

ALT, AST, alkaline phosphate

2
Q

Alanine aminotransferase (ALT)

A

released when hepatocytes are hurt or destroyed

3
Q

Aspartate aminotransferase (AST)

A

not specific for liver disease because it is found in the heart, intestine and pancreas as well as the liver

4
Q

When do alkaline phosphate levels rise

A

when there is obstruction or infiltrative diseases

5
Q

Where is alkaline phosphate found

A

liver (biliary tract), bones, intestines, placenta

6
Q

What is the first enzyme to be detected with damage to the liver

A

gamma-glutamyl transpeptidase (GGT)

7
Q

When do you check a GGT level

A

when you are unsure if the alk phos level is increased because of bone of liver

8
Q

Where is LDH found? When does it get elevated?

A

in the blood and liver, gets elevated with tissue damage

9
Q

What is bilirubin

A

yellow pigment formed in the liver by the breakdown of hemoglobin and excreted in bile

10
Q

When is bilirubin elevated

A
  • jaundice
  • liver disease and blockage of bile ducts
  • any process that breaks down RBCs
  • anything that affects the production or destruction of bilirubin
11
Q

When is unconjugated bilirubin made?

A

released from hemoglobin and converten, then is carried by proteins to the liver

12
Q

What makes bilirubin conjugated?

A

when sugars are attached

13
Q

What is the path of conjugated bilirubin

A

enters the bile–>passes from the liver to the small intestine–>eliminated in the stool

14
Q

Which type of bilirubin can have small amounts in the blood

A

unconjugated

15
Q

What is the hepatocellular pattern of liver enzymes? What does that tell you?

A

increased AST and ALT compared to alk phos

tells you there is an intahepatic injury

16
Q

What is the cholestatis pattern of liver enzymes?

A

increase in alk phos compared to AST and ALT

17
Q

What is isolated hyperbilirubinemia

A

increase in bilirubin with normal alk phos and AST/ALT

18
Q

What are some common diseases that show hepatocelluar injury

A
  • viral hepatitis
  • drugs/alcohol
  • environmental toxins
  • autoimmune hepatitis
  • wilson disease
  • ischemia
19
Q

What are some common diseases that show clolestatic injury

A
  • primary billiary cirrhosis
  • primary sclerosing cholangitis
  • cholanglocarcinoma
  • pancreatic cancer
  • choledocholithiasis
20
Q

What are the three components of bile

A
  • bile acids
  • phospholipids
  • cholesterol
21
Q

What are the primary bile acids? Where are they formed?

A

colic acid and chenodeoxycholic acid that are formed by cholesterol from the liver and amino acids

22
Q

What are secondary bile acids?

A

bacterial metabolites of primary bile acids formed in the colon

23
Q

What are the functions of bile?

A
  • excrete cholesterol

- aid in the digestion and absorption of fat and cholesterol/fat soluble vitamins in the intestines

24
Q

How does bile aid in the digestion of fats

A

forms micells that bind to the fat and aid in absorption through micellar transport mechanism

25
Q

What is the circulation of bile?

A

stored in the gallbladder–>absorbed through the gut unconjugated–> bile salts are absorbed in terminal ileum–> secreted back into the bile

26
Q

What is cholestasis

A

a blockage of the bile ducts

27
Q

What types of things can cause cholestasis

A
  • gallstones
  • tumors
  • cysts
  • pancreatic problems
  • liver disease
28
Q

How does a patient with cholestasis present

A
  • RUQ pain
  • colicky
  • jaundiced
  • dark urine
  • weight loss
29
Q

What would the liver enzymes look like in a patient with cholestasis

A

all be elevated

AST, ALT, alk phos

30
Q

What other tests should be done if you suspect a patient has cholestasis?

A

US to look for cause of blockage

CT or MRI to look for liver disease

31
Q

What is colelithiasis

A

gallbladder stones

32
Q

What is the mechanism of gallstone formation

A

increased biliary secretion of cholesterol–>cholesterol crystals percipitate and form a stone

33
Q

What are the two types of gallstones? Which is most common?

A
cholesterol stones (most common)
calcium bilrubinate stones
34
Q

What is biliary sludge? What is its significance?

A

mucous like supersaturation of bile that is typically a precursor to stones

35
Q

What are the risk factors for cholelithiasis?

A

4 F’s

Fat, Fertile, Forty, Fair

36
Q

How does gallbladder pain present?

A

pain in RUQ with radiation to the shoulder

37
Q

Clinical presentation of cholelithiasis

A
  • gallbladder pain with associated N/V

- pain is often post prandial, especially in a meal high in fat

38
Q

What would the LFTs look like in a patient with cholelithiasis

A

ideally they would be normal

39
Q

What tests are done to diagnose cholelithiasis

A
  • ultrasounds
  • x ray
  • hepatobiliary scan
40
Q

When is cholelithiasis treated

A

when a patient is symptomatic

41
Q

How is cholelithiasis treated

A
  • laparoscopic cholecystectomy
  • lithotripsy
  • chenodeoxycholic and ursodeoxycholic acid (bile salts)
42
Q

What is cholecystitis

A

inflammation of the cyst wall of the gallbladder

43
Q

What is acute cholecystitis typically caused by

A

gallstone obstruction

44
Q

Presentation of acute cholecystitis

A
  • RUQ pain+ murphy’s sign
  • guarding
  • fever
  • leukocytosis
  • N/V
  • anorexia
45
Q

What is the difference between acute cholecystitis and acalculus cholecystitis

A

the presence of gallstones

46
Q

What is Courcolser’s sign

A

a palpable gallbladder on physical exam because the gallbladder dilated die to obstruction of common bile duct

47
Q

What will the LFTs and labs show if a patient has cholecystitis?

A

WBC, bili, AST/ALT, alk phos, amylase

ELEVATED

48
Q

Imaging for acute cholecystitis

A
  • RUG ultrasound

- HIDA

49
Q

What would a RUQ US show if a patient had acute cholecystitis

A

stones and inflammation of the gallbladder

50
Q

What would a HIDA scan show if a patient had acute cholecystitis

A

obstruction in the cystic duct

51
Q

What is the treatment for cholecystitis?

A
  • lap cholecystectomy
  • NPO, IVF, pain control
  • IV abx
52
Q

Which pain medication should you use caution with in a pateint with cholecystitis? Why?

A

morphine, causes spasm of the sphincter of Oddi

53
Q

What abx are given to a patient with cholecystitis

A

3rd gen ceph+ flagyl

in severe cases, fluoroquinolone+flagyl

54
Q

What are some complications of acute cholecystitis

A
  • gangrene
  • emphasematous cholecystitis
  • empyema
  • chronic cholecystitis
  • cholangitis
  • hydrops
  • porceline gallbladder
55
Q

What is choledocolithiasis

A

a gallstone in the common bile duct

56
Q

What will the LFTs and labs look like in a patient with choledocolithiasis

A
  • extremely elevated AST/ALT
  • elevated bili
  • slow rise in alk phos
57
Q

What imaging is done for a patient with choledocolithiasis? What will they show?

A

RUQ US and CT- dilated ducts

MRCP

ERCP

58
Q

What is the treatment for choledocolithiasis

A

sphincterotomy with stenplacement via ERCP

59
Q

What is a complication of choledocolithiasis

A

cholangitis

60
Q

What is cholangitis

A

inflammation of the bile duct

61
Q

What is Charcot’s triad

A

fever, jaundice, severe RUQ pain

62
Q

What is Reylonds pentad

A

fever, jaundice, severe RUG pain, hypotension, AMS

63
Q

How does cholangitis present

A
  • Charcot’s triad
  • pruritis
  • dark urine
  • acholic stools
64
Q

How do you treat cholangitis

A
  • endoscopic sphincterotomy and stone extraction
  • IV abx
  • lap cholecystectomy following ERCP
65
Q

What abx are given to a patient with cholangitis

A

ampicillin+gentamycin
OR
cipro+flagyl

66
Q

What is primary sclerosing cholangitis

A

diffuse inflammation of the biliary system

67
Q

What can primary sclerosing cholangitis lead to

A

fibrosis and strictures

68
Q

What is the clinical presentation of primary sclerosing cholangitis

A
  • progressive obstructive jaundice
  • fatigue
  • pruritis
  • anorexia
  • indigestion
69
Q

What would a patients alk phos look like if they had PSC

A

elevated

70
Q

How do you diagnosed PSC

A

ERCP or MRI

71
Q

What would a liver biopsy show in a patients with PSC

A

-periductal fibrosis

72
Q

What are the complications of PSC

A
  • cholangiocarcinoma
  • gallstone
  • cholecystitis
  • gallbladder polyps
73
Q

How do you treat acute bacterial PSC

A

cipro

74
Q

How do you treat chronic PSC

A
  • balloon dilitation or stenting
  • resection of dominant structures

if PSC+ liver cirrhosis–> liver transplant

75
Q

What is the function of the sphincter of Oddi

A

prevent reflux of duodenal juices into the pancreatic duct and common bile duct

76
Q

What role does the pancreas have in digestion

A

its secretions provide enzymes and bicarbonate needed to affect the major digestive activity

77
Q

What are the two most common types of acute pancreatitis

A
  • interstitial pancreatitis (most common)

- necrotizing pancreatitis

78
Q

Causes of acute pancreatitis

A
  • gallstones
  • alcohol
  • idiopathic
  • post ERCP
  • smoking
  • Rx
  • infection
  • trauma
79
Q

Complications of acute pancreatitis

A
  • multisystem organ failure (renal and ARDS)
  • ileus
  • pseudocyst
  • pancreatic necrosis
80
Q

Symptoms of acute pancreatitis

A
  • mid epigastric pain alleviated by sitting forward
  • radiation of pain to back
  • N/V
  • dyspnea
  • anorexia
81
Q

what are the physical exam findings of mild to moderate pancreatitis

A
  • epigastric tenderness
  • jaundice
  • nausea
82
Q

What are the physical exam findings of severe pancreatitis

A
  • tachypnea
  • hypoxemia
  • hypotension
  • Cullen’s sign
  • Grey turner sign
83
Q

What labs are done for acute pancreatitis

A
  • amylase
  • lipase
  • CBC with diff
  • metabolic panel
  • LFTs
  • LDH
  • C reactive protein
  • fasting triglycerides
84
Q

Common imaging done in patients with acute pancreatitis

A
  • abd CT with contrast
  • abd US
  • MRI
85
Q

What is the IV contrast used for in a CT scan if done for a patient with acute pancreatitis`

A

to distinguish necrosis from inflammation

86
Q

What is needed for a diagnosis of pancreatitis

A

> 2 of the following:

- midepigastric pain +/- radiation to the back
- lipase and/or amylase 3x ULN
- CT confirmation
87
Q

How do you manage a patient with acute pancreatitis

A
  • admit to hospital
  • determine underlying cause
  • NPO
  • IVF
  • analgesia
  • antiemetic
88
Q

What scores predict the severity of acute pancreatitis

A
  • Ranson criteria
  • Apache II score
  • SIRS score
  • BISAP
89
Q

What is chronic pancreatitis

A

irreversible damage to the pancreas

90
Q

What histologic abnormality are typically present with chronic pancreatitis

A
  • chronic inflammation
  • fibrosis
  • progressive destruction of exocrine and endocrine tissue
91
Q

What causes chronic pancreatitis

A
  • alcohol abuse
  • idiopathic
  • smoking
  • cystic fibrosis
  • genetic defects
  • autoimmune pancreatitis
92
Q

What are some complications of chronic pancreatitis

A
  • DM/impaired glucose tolerance
  • gastroparesis
  • malabsorption
  • biliary stricutre
  • pancreatic carcinoma
93
Q

What are the symptoms of chronic pancreatitis

A
  • and pain
  • anorexia/weight loss
  • maldigestion
  • N/V
  • steatorrhea
94
Q

What is the treatment for chronic pancreatitis

A
  • low fat diet
  • pain management (challenging)
  • whipple
95
Q

What is diverticulosis

A

sac like protrusions in the colon

96
Q

What is a diverticula bleed

A

painless bleeding of the diverticula

97
Q

What is diverticulitis

A

inflammation of diverticulum

98
Q

How is diverticulosis diagnosed

A

colonoscopy

99
Q

What is the most common type of diverticulosis

A

sigmoid diverticulosis

100
Q

What are some risk factors for diverticulosis

A
  • age
  • constipation
  • high fat diet
  • obesity/ physical inactivity
  • genetics
101
Q

What studies can provide an incidental finding of diverticulosis

A
  • CT
  • MRI
  • barium enema
102
Q

What are some of the complications of diverticulitis

A
  • bowel obstruction
  • abscess
  • fistula
  • perforation
103
Q

What are the symptoms of diverticulitis

A
  • LLQ abd pain (constant)
  • N/V
  • fever
  • change in bowel habits
104
Q

What imaging is done to diagnose diverticulitis

A

CT of abd/pelvis with IV contrast +/- PO contast

105
Q

What is the medical management for diverticulitis

A
  • abx (coverage for enterobacteriaciae ad gram - anaerobes)
  • IVF
  • analgesia and antiemetics
106
Q

When do you need emergency surgery in the case of diverticulitis

A

if there is a free perforation or large bowel obstruction

107
Q

When is urgent surgery needed with diverticulitis

A
  • failure of medical treatment

- coloninc obstruction or abscess

108
Q

When is surgery for diverticulitis elective

A
  • persistent pain
  • fistula development
  • hx of complicated diverticulitis
  • immunocompromised pt with prior acute diverticulitis
109
Q

What are the options for diverticulitis surgery

A

One stage procedure: colon resection with primary anastamosis

Two stage procedure: colonic rescection with end colostomy then primary anastamosis with diverting ileostomy

110
Q

What are the symptoms of a diverticula bleed

A
  • painless hematochezia
  • painless maroon color mixed with stool
  • bloating, cramping, urgency
111
Q

How do you diagnose a diverticula bleed

A
  • colonscopy
  • nuclear scintigraphy
  • angiography
112
Q

How do you manage a patient with a diverticula bleed

A
  • two large bore IVs with NS
  • type and cross for blood
  • transfuse PRBCs as needed
  • NG tube to r/o UGI bleed
113
Q

How is active diverticula bleeding treated

A

submucosal epi or tamponade via endoscopy

114
Q

When would you do surgical intervention in a patient with a diverticula bleed

A
  • if patient is hemodynamically unstable
  • if endoscopic or angiographic therapy is not successful
  • patients with recurrent episodes of bleeding