Biliary Disorders

Question 1

gallstones due to increased circulating cholesterol OR bile over-concentration from incomplete or infrequent emptying

Answer 1

cholelithiasis

Question 2

what are gallstones mostly composed of?

Answer 2

cholesterol

Question 3

a patient presents with RUQ pain + tenderness that is worse with fatty, greasy, and large meals, peaks 30 mins postprandial and causes substernal chest pain and radiates to right scapula, flank, or shoulder. Dx?

Answer 3

cholelithiasis

Question 4

pain that comes and goes

Answer 4

biliary colic

Question 5

what can be a clinical finding in cholelithiasis under the RUQ costal margin?

Answer 5

murphy sign; inspiration stops due to deep palpation

Question 6

what is the 1st line imaging for suspected cholelithiasis?

Answer 6

RUQ ultrasound

Question 7

what is the treatment of choice for cholelithiasis in symptomatic patients?

Answer 7

laparoscopic cholecystectomy

Question 8

what 2 pain meds can be used for cholelithiasis?

Answer 8

NSAIDs
dicyclomine (anticholinergic)

Question 9

during which trimester is preferred for a laparoscopic cholecystectomy in a pregnant patient with symptomatic cholelithiasis?

Answer 9

2nd trimester

Question 10

what are 4 indications for a prophylactic cholecystectomy in patients with asymptomatic cholelithiasis?

Answer 10

calcified gallbladder
gallstones > 3cm in diameter
LITH gene
bariatric / cardiac transplant candidates

Question 11

what treatment can be used for cholelithiasis to dissolve small cholesterol stones and is useful to reduce the risk of stone formation during rapid weight loss?

Answer 11

ursodeoxycholic acid

Question 12

inflammation and infection within the gallbladder due to a stone becoming impacted in the cystic duct and inflammation develops behind the obstruction

Answer 12

acute cholecystitis

Question 13

what is the most common cause of acute cholecystitis?

Answer 13

cholelithiasis

Question 14

a patient presents with diaphoresis, N/V/D, acute unrelenting and severe epigastric/RUQ pain postprandial. on physical exam, patient is guarding and positive murphy sign with a fever. Dx?

Answer 14

acute cholecystitis

Question 15

what sign will indicate worsening obstructive pathology in a patient with acute cholecystitis?

Answer 15

jaundice

Question 16

what labs are likely seen in acute cholecystitis? (2)

Answer 16

leukocytosis
mildly elevated AST/ALT

Question 17

what lab results can indicate worsening obstructive pathology in acute cholecystitis?

Answer 17

elevated bilirubin
elevated alk phos

Question 18

what is the 1st line study for acute cholecystitis? what will it show (3)?

Answer 18

transabdominal ultrasound

double wall sign
pericholecystic fluid
sonographic murphy sign

Question 19

what imaging can be used for acute cholecystitis if US results are negative, and is useful in diagnosing acalculous cholecystitis?

Answer 19

HIDA scan

Question 20

what is the medical management for acute cholecystitis? (4)

Answer 20

NPO
IV hydration
pain control (NSAIDs, morphine, hydromorphone, opiates)
ceftriaxone + metronidazole

Question 21

what is the surgical treatment/treatment of choice for acute cholecystitis?

Answer 21

laparoscopic cholecystectomy

Question 22

what is the treatment of choice for acute cholecystitis if a patient is too high risk for surgery?

Answer 22

cholecystostomy tube + antibiotics

Question 23

when do cholecystitis complications occur most?

Answer 23

when gallbladder cannot be removed

Question 24

chronic inflammation of the gallbladder due to repeated episodes of acute cholecystitis or irritation of the gallbladder by stones

Answer 24

chronic cholecystitis

Question 25

what is the treatment of choice for chronic cholecystitis?

Answer 25

laparoscopic cholecystectomy

Question 26

a stone obstructing flow within the common bile duct proximal to or distal to the pancreatic duct

Answer 26

choledocholithiasis

Question 27

a patient presents with jaundice, biliary colic, referred pain, N/V/D, and **acholic stools**. on physical exam, they have RUQ +/- MEG tenderness to palpation. Dx?

Answer 27

choledocholithiasis

Question 28

what sign indicates post-hepatic obstruction of the bile duct?

Answer 28

acholic stools

Question 29

what will labs show in a patient with choledocholithiasis? (4)

Answer 29

significantly elevated AST/ALT elevated bilirubin elevated alk phos elevated amylase + lipase

Question 30

elevated amylase and lipase in choledocholithiasis indicates what?

Answer 30

secondary pancreatitis

Question 31

what is the 1st line imaging study for choledocholithiasis?

Answer 31

transabdominal ultrasound

Question 32

what is the diagnostic and treatment modality of choice with confirmed or high-risk bile duct stone in choledocholithiasis?

Answer 32

endoscopic retrograde cholangiopancreatography (ERCP)

Question 33

what size common bile duct is suggestive of choledocholithiasis?

Answer 33

> 6mm

Question 34

bacterial infection of the biliary tract that is most commonly caused by organisms ascending from the duodenum during episodes of biliary obstruction

Answer 34

acute cholangitis

Question 35

a patient presents with severe, episodic RUQ pain persisting for hours, fever, and jaundice. Dx?

Answer 35

cholangitis (charcot triad)

Question 36

a patient presents with severe, episodic RUQ pain persisting for hours, fever, jaundice, AMS, and hypotension. Dx?

Answer 36

suppurative cholangitis (reynolds pentad)

Question 37

what labs will be present in a patient with cholangitis? (5)

Answer 37

significantly elevated AST/ALT elevated bilirubin elevated alk phos elevated amylase + lipase leukocytosis

Question 38

what is the 1st line diagnostic for cholangitis?

Answer 38

transabdominal US

Question 39

what is the initial treatment for all patients with cholangitis? (3)

Answer 39

IV fluids analgesics ciprofloxacin + metronidazole OR piperacillin-tazobactam

Question 40

what is the treatment for a patient with unstable/septic cholangitis? (2)

Answer 40

biliary drainage cholecystectomy when stable