Biliary diseases Flashcards
(114 cards)
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
What is the circulation of bile?
stored in the gallbladder-->absorbed through the gut unconjugated--> bile salts are absorbed in terminal ileum--> secreted back into the bile
26
What is cholestasis
a blockage of the bile ducts
27
What types of things can cause cholestasis
- gallstones
- tumors
- cysts
- pancreatic problems
- liver disease
28
How does a patient with cholestasis present
- RUQ pain
- colicky
- jaundiced
- dark urine
- weight loss
29
What would the liver enzymes look like in a patient with cholestasis
all be elevated
AST, ALT, alk phos
30
What other tests should be done if you suspect a patient has cholestasis?
US to look for cause of blockage
CT or MRI to look for liver disease
31
What is colelithiasis
gallbladder stones
32
What is the mechanism of gallstone formation
increased biliary secretion of cholesterol-->cholesterol crystals percipitate and form a stone
33
What are the two types of gallstones? Which is most common?
```
cholesterol stones (most common)
calcium bilrubinate stones
```
34
What is biliary sludge? What is its significance?
mucous like supersaturation of bile that is typically a precursor to stones
35
What are the risk factors for cholelithiasis?
4 F's
Fat, Fertile, Forty, Fair
36
How does gallbladder pain present?
pain in RUQ with radiation to the shoulder
37
Clinical presentation of cholelithiasis
- gallbladder pain with associated N/V
| - pain is often post prandial, especially in a meal high in fat
38
What would the LFTs look like in a patient with cholelithiasis
ideally they would be normal
39
What tests are done to diagnose cholelithiasis
- ultrasounds
- x ray
- hepatobiliary scan
40
When is cholelithiasis treated
when a patient is symptomatic
41
How is cholelithiasis treated
- laparoscopic cholecystectomy
- lithotripsy
- chenodeoxycholic and ursodeoxycholic acid (bile salts)
42
What is cholecystitis
inflammation of the cyst wall of the gallbladder
43
What is acute cholecystitis typically caused by
gallstone obstruction
44
Presentation of acute cholecystitis
- RUQ pain+ murphy's sign
- guarding
- fever
- leukocytosis
- N/V
- anorexia
45
What is the difference between acute cholecystitis and acalculus cholecystitis
the presence of gallstones
46
What is Courcolser's sign
a palpable gallbladder on physical exam because the gallbladder dilated die to obstruction of common bile duct
47
What will the LFTs and labs show if a patient has cholecystitis?
WBC, bili, AST/ALT, alk phos, amylase
ELEVATED
48
Imaging for acute cholecystitis
- RUG ultrasound
| - HIDA
49
What would a RUQ US show if a patient had acute cholecystitis
stones and inflammation of the gallbladder
50
What would a HIDA scan show if a patient had acute cholecystitis
obstruction in the cystic duct
51
What is the treatment for cholecystitis?
- lap cholecystectomy
- NPO, IVF, pain control
- IV abx
52
Which pain medication should you use caution with in a pateint with cholecystitis? Why?
morphine, causes spasm of the sphincter of Oddi
53
What abx are given to a patient with cholecystitis
3rd gen ceph+ flagyl
in severe cases, fluoroquinolone+flagyl
54
What are some complications of acute cholecystitis
- gangrene
- emphasematous cholecystitis
- empyema
- chronic cholecystitis
- cholangitis
- hydrops
- porceline gallbladder
55
What is choledocolithiasis
a gallstone in the common bile duct
56
What will the LFTs and labs look like in a patient with choledocolithiasis
- extremely elevated AST/ALT
- elevated bili
- slow rise in alk phos
57
What imaging is done for a patient with choledocolithiasis? What will they show?
RUQ US and CT- dilated ducts
MRCP
ERCP
58
What is the treatment for choledocolithiasis
sphincterotomy with stenplacement via ERCP
59
What is a complication of choledocolithiasis
cholangitis
60
What is cholangitis
inflammation of the bile duct
61
What is Charcot's triad
fever, jaundice, severe RUQ pain
62
What is Reylonds pentad
fever, jaundice, severe RUG pain, hypotension, AMS
63
How does cholangitis present
- Charcot's triad
- pruritis
- dark urine
- acholic stools
64
How do you treat cholangitis
- endoscopic sphincterotomy and stone extraction
- IV abx
- lap cholecystectomy following ERCP
65
What abx are given to a patient with cholangitis
ampicillin+gentamycin
OR
cipro+flagyl
66
What is primary sclerosing cholangitis
diffuse inflammation of the biliary system
67
What can primary sclerosing cholangitis lead to
fibrosis and strictures
68
What is the clinical presentation of primary sclerosing cholangitis
- progressive obstructive jaundice
- fatigue
- pruritis
- anorexia
- indigestion
69
What would a patients alk phos look like if they had PSC
elevated
70
How do you diagnosed PSC
ERCP or MRI
71
What would a liver biopsy show in a patients with PSC
-periductal fibrosis
72
What are the complications of PSC
- cholangiocarcinoma
- gallstone
- cholecystitis
- gallbladder polyps
73
How do you treat acute bacterial PSC
cipro
74
How do you treat chronic PSC
- balloon dilitation or stenting
- resection of dominant structures
if PSC+ liver cirrhosis--> liver transplant
75
What is the function of the sphincter of Oddi
prevent reflux of duodenal juices into the pancreatic duct and common bile duct
76
What role does the pancreas have in digestion
its secretions provide enzymes and bicarbonate needed to affect the major digestive activity
77
What are the two most common types of acute pancreatitis
- interstitial pancreatitis (most common)
| - necrotizing pancreatitis
78
Causes of acute pancreatitis
- gallstones
- alcohol
- idiopathic
- post ERCP
- smoking
- Rx
- infection
- trauma
79
Complications of acute pancreatitis
- multisystem organ failure (renal and ARDS)
- ileus
- pseudocyst
- pancreatic necrosis
80
Symptoms of acute pancreatitis
- mid epigastric pain alleviated by sitting forward
- radiation of pain to back
- N/V
- dyspnea
- anorexia
81
what are the physical exam findings of mild to moderate pancreatitis
- epigastric tenderness
- jaundice
- nausea
82
What are the physical exam findings of severe pancreatitis
- tachypnea
- hypoxemia
- hypotension
- Cullen's sign
- Grey turner sign
83
What labs are done for acute pancreatitis
- amylase
- lipase
- CBC with diff
- metabolic panel
- LFTs
- LDH
- C reactive protein
- fasting triglycerides
84
Common imaging done in patients with acute pancreatitis
- abd CT with contrast
- abd US
- MRI
85
What is the IV contrast used for in a CT scan if done for a patient with acute pancreatitis`
to distinguish necrosis from inflammation
86
What is needed for a diagnosis of pancreatitis
>2 of the following:
- midepigastric pain +/- radiation to the back
- lipase and/or amylase 3x ULN
- CT confirmation
87
How do you manage a patient with acute pancreatitis
- admit to hospital
- determine underlying cause
- NPO
- IVF
- analgesia
- antiemetic
88
What scores predict the severity of acute pancreatitis
- Ranson criteria
- Apache II score
- SIRS score
- BISAP
89
What is chronic pancreatitis
irreversible damage to the pancreas
90
What histologic abnormality are typically present with chronic pancreatitis
- chronic inflammation
- fibrosis
- progressive destruction of exocrine and endocrine tissue
91
What causes chronic pancreatitis
- alcohol abuse
- idiopathic
- smoking
- cystic fibrosis
- genetic defects
- autoimmune pancreatitis
92
What are some complications of chronic pancreatitis
- DM/impaired glucose tolerance
- gastroparesis
- malabsorption
- biliary stricutre
- pancreatic carcinoma
93
What are the symptoms of chronic pancreatitis
- and pain
- anorexia/weight loss
- maldigestion
- N/V
- steatorrhea
94
What is the treatment for chronic pancreatitis
- low fat diet
- pain management (challenging)
- whipple
95
What is diverticulosis
sac like protrusions in the colon
96
What is a diverticula bleed
painless bleeding of the diverticula
97
What is diverticulitis
inflammation of diverticulum
98
How is diverticulosis diagnosed
colonoscopy
99
What is the most common type of diverticulosis
sigmoid diverticulosis
100
What are some risk factors for diverticulosis
- age
- constipation
- high fat diet
- obesity/ physical inactivity
- genetics
101
What studies can provide an incidental finding of diverticulosis
- CT
- MRI
- barium enema
102
What are some of the complications of diverticulitis
- bowel obstruction
- abscess
- fistula
- perforation
103
What are the symptoms of diverticulitis
- LLQ abd pain (constant)
- N/V
- fever
- change in bowel habits
104
What imaging is done to diagnose diverticulitis
CT of abd/pelvis with IV contrast +/- PO contast
105
What is the medical management for diverticulitis
- abx (coverage for enterobacteriaciae ad gram - anaerobes)
- IVF
- analgesia and antiemetics
106
When do you need emergency surgery in the case of diverticulitis
if there is a free perforation or large bowel obstruction
107
When is urgent surgery needed with diverticulitis
- failure of medical treatment
| - coloninc obstruction or abscess
108
When is surgery for diverticulitis elective
- persistent pain
- fistula development
- hx of complicated diverticulitis
- immunocompromised pt with prior acute diverticulitis
109
What are the options for diverticulitis surgery
One stage procedure: colon resection with primary anastamosis
Two stage procedure: colonic rescection with end colostomy then primary anastamosis with diverting ileostomy
110
What are the symptoms of a diverticula bleed
- painless hematochezia
- painless maroon color mixed with stool
- bloating, cramping, urgency
111
How do you diagnose a diverticula bleed
- colonscopy
- nuclear scintigraphy
- angiography
112
How do you manage a patient with a diverticula bleed
- two large bore IVs with NS
- type and cross for blood
- transfuse PRBCs as needed
- NG tube to r/o UGI bleed
113
How is active diverticula bleeding treated
submucosal epi or tamponade via endoscopy
114
When would you do surgical intervention in a patient with a diverticula bleed
- if patient is hemodynamically unstable
- if endoscopic or angiographic therapy is not successful
- patients with recurrent episodes of bleeding
