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Foundations III-GI > Biliary Dz > Flashcards

Biliary Dz Flashcards

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1
Q

describe the composition of Bile and how much is secreted daily?

A

Water, electrolytes, bile salts, phospholipids, bilirubin & cholesterol

500mL daily

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2
Q

describe the function of bile

A

Digestion and absorption of fats (bile salts)

Vehicle for excretion of bilirubin, excess cholesterol and metabolic by-products

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3
Q

what is cholangitis?

A

inflammation of the bile ducts

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4
Q

Risk factors for cholelithiasis

A

Four F’s (female, fluffy, forty, fertile)

Age over 40
Females MC (3:1)
Pregnancy
Obesity
Rapid Weight Loss
Estrogen (BCP’s)
Ethnicity (native americans hispanics)
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5
Q

what is the most common type of stones in cholelithiasis?

A

cholesterol stones (80%)

also pigment stones (calcium, bilirubin, proteins)

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6
Q

presentation of cholelithiasis

A

majority are asxs.

sxs: biliary colic and complications

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7
Q

complications of cholelithiasis

A

Acute Cholecystitis
Acute Choledocholithiasis
Ascending Cholangitis
Acute Pancreatitis

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8
Q

diagnosis of cholelithiasis

A

1 is Ultrasound – shows gallstones, wall thickening, pericholecystic fluid

also, CT

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9
Q

management of asxs. cholelithiasis

A

cholecystectomy NOT recommended

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10
Q

management for sxs. cholelithiasis

A

CCY (cholecystectomy) – prophylactive recommended to prevent recurrent sxs/complications

sxs = biliary colic, acute cholecystitis, choledocholithasis, ascending cholangitis

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11
Q

what is biliary colic?

A

temporary obstruction of cystic duct usu. d/t gallstone

pressure rises –> pain

gallbladder relaxes –> obstruction relieved

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12
Q

Presentation of biliary colic

A

Dull constant RUQ pain w/ possible radiation to R shoulder blade

assoc sxs: N/V, diaphoresis

sxs are temporary (no more than 4-6hrs)

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13
Q

PE findings for biliary colic

A 
don't appear acutely ill
normal VS
NO jaundice
sclera anicteric
\+/- RUQ TTP
no peritonitis
Murphy's sign neg
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14
Q

lab studies for biliary colic

A

CBC
LFTs
Amylase, Lipase

all labs NORMAL

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15
Q

diagnostic studies for biliary colic

A

Ultrasound – gallstones and/or gallbladder sludge

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16
Q

what is biliary dyskinesia?

A

aka functional gallbladder d/o

consider in pt’s w/ typical biliary colic:

  • NO gallstones or sludge
  • normal labs

consider HIDA w/ CCK

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17
Q

what if you suspect biliary dyskinesia but the pt has gallstones?

A

do NOT give CCK

start with US

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18
Q

what information does a HIDA Scan w/CCK tell you?

A

ejection fraction (EF)

normal gallbladder fills w/in 30mins

<35-40% = abnormal gallbladder motility

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19
Q

when is CCY recommended w/ suspected biliary dyskinesia

A
  • pt reports typical biliary sxs
  • HIDA w/ CCK EF <35-40% (reproduces sxs)
  • other dx r/o (PUD, gastritis, GERD, cardiac ischemia)
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20
Q

what is acute cholecystitis?

A

Acute inflammation of the gallbladder d/t sustained obstruction of cystic duct

MCC cholesterol stones

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21
Q

presentation of acute cholecystitis?

A

steady severe RUQ pain +/- radiation to R shoulder/flank

N/V, diaphoresis, Fv

sxs. persistant (longer than 4-6hrs)

prior h/o biliary colic

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22
Q

abnormal PE findings for acute cholecystitis?

A 
ill appearing
fever, tachycardia
RUQ TTP
\+/- guarding, rebound
\+ Murphy's sign
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23
Q

complications for acute cholecystitis?

A

gangrene, perforation, generalized peritonitis, cholecystoenteric fistula
gallstone ileus

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24
Q

Lab studies for acute choleystitis?

A

CBC - elevated WBC w/ L-shift

LFT’s usu. normal

UA - elevated urobilinogen

pancreatic enzymes: poss. mild elevated of amylase

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25
diagnostic studies for acute cholecystitis?
1st study = U/S - gallstones, wall thickening, pericholecystic fluid, positive sonograph Murphy's sign HIDA -- used to confirm if ??
26
management for acute cholecystitis?
``` hospital admission, analgesia (ketorolac, morphine, meperdine), NPO IV fluids w/electrolytes IV abx early CCY (laparoscopic) ```
27
which abx can be used for acute cholecystitis?
Single agent: Piperacillin-tazobactam (Zosyn) IV Ampicillin-Sulbactam (Unasyn) IV Ticarcillin clavulanate (Timentin) IV combo: - 3rd gen cephalosporin (ceftriaxone) + metronidazole - Cipro + metronidazole (flagyl)
28
which pt's w/ acute cholecystitis need an emergent CCY?
If severe complication (gangrene, perforation, peritonitis etc) Clinical deterioration despite supportive therapy
29
management for acute cholecystitis with ASA class I and II?
CCY recommended during initial hospitalization in healthy low risk pt's
30
management for pts with acute cholecystitis ASA III, IV, V?
continue supprotive therapy consult specialist for surg. clearance med therapy fails --> consider percutaneous CCY tube for decompression
31
what is chronic cholecystitis?
chronic inflammation of gallbladder assoc w/ mechanical irritation
32
what is acalculous cholecystitis?
- common in critically ill pts - assoc. w/ stasis and ischemia - similar to acute cholecystitis but no gallstones & may have jaundice
33
Tx for acalculous cholecystitis?
prompt tx! | CCY vs. cholecystostomy
34
how can you check for secondary infection w/ acalculous cholecystitis?
check blood cultures, start broad spectrum abx | risk of gallbladder gangrene
35
what is choledocholithiasis?
Stone in common bile duct (CBD) will block bile flow and cause jaundice
36
choledocholithiasis presentation?
p/w biliary type pain (RUQ or epig, N/V) may be asxs. jaundice: pruritis, tea colored urine, light colored stool
37
uncomplicated choledocholithiasis abnormal PE findings?
jaundice +/- RUQ TTP if fever, jaundice, leukocytosis, and more prominent abd TTP --> think cholangitis
38
Labs for choledocholithiasis?
CBC: no leukocytosis LFTs (cholestasis): increased conjugated bilirubin, elevated alk phos pancreatic enzymes: normal amylase, lipase
39
imaging studies for choledocholithiasis?
confirm dx w/ imaging RUQ U/S = initial test - CBD stone, dilated CBD, gallstones in gallbladder if uncertain --> consider MRCP (biliary and pancreatic ducts)
40
management of choledocholithiasis?
Stone must be removed to prevent cholangitis and pancreatitis Consider prophylactic Abx ERCP –preferred therapeutic test CCY to follow
41
What is ascending cholangitis?
Infection of the biliary tract MCly the CBD assoc. w/ biliary obstruction (CBD stone) bacteria infects bile pus under pressure --> surgical emergency
42
ascending cholangitis?
RUQ/epigastric abd. pain, reports of jaundice, fever, h/o biliary colic or disease
43
abnormal PE findings for ascending cholangitis?
acutely ill appearing, diaphoretic, fever, tachycardia, hypotension, jaundice, icterus, RUQ/epigastric TTP, guarding, mental status changes
44
what is charcot's triad?
dx'ing ascending cholangitis fever/chills RUQ pain jaundice
45
what is reynold's pentad?
charcot's ( fever, chills, RUQ pain, jaundice) + hypotension and mental status changes
46
labs for ascending cholangitis?
CBC: marked leukocytosis LFTs (cholestasis): incr conjugated bili and alk phos pancreas enzymes: normal/mildly elevated UA: elevated urobiinogen
47
what imaging should you order in pts w/ ascending cholangitis dx in question
U/S | MRCP (CBD dilation and stone)
48
general management of ascending cholangitis?
Admit to hospital Consult GI (emergent) NPO/IV fluids broad-based abx for coverage of gram + and - bacteria ERCP w/ sphincterotomy and stone extraction follow w/CCY
49
Abx for ascending cholangitis?
Ceftriaxone + Metronidazole Cipro (good concentration in bile ducts) + Metronidazole Piperacillin/Tazobactam
50
what is imperative in management of ascending cholangitis?
relief of biliary obstruction
51
describe ERCP use in ascending cholangitis?
Sphincterotomy CBD stone extraction Relief of obstruction +/- stent placement
52
difference in presentation in btwn biliary colic and acute cholecystitis?
biliary colic: temporary RUQ, pain episodes, No fever, no leukocytosis, No jaundice acute cholecystitis: persistent RUQ pain, fever, leukocytosis, no jaundice
53
difference between choledocholithiasis and ascending cholangitis presentation?
Choledocholithiasis: RUQ/epigastric pain, jaundice, no fever, no leukocytosis ascending cholangitis: RUQ/epigastric pain, jaundice, fever, leukocytosis
54
what labs do you want to order for eval of biliary dz?
CBC w/differential – r/o infxn Amylase/lipase – r/o pancreatitis (mild “bump” w/acute biliary dz) LFTS - - ↑ Alk Phos/Conjugated Bilirubin = Cholestasis - - AST/ALT may have transient elevations
55
when do you order U/s?
TOC for eval of biliary dz shows gallstones, wall thickening, pericholecystic fluid, ductal dilation, CBD stones
56
when is MRCP helpful?
for diagnosing stones/obstruction in the CBD when US non-diagnostic
57
when do you order a HIDA scan?
confirm dx of cystic duct obstruction in cholecystitis can use CCK to measure EF for biliary dyskinesia
58
when do you order ERCP?
to relieve CBD obstruction choledocholithiasis/cholangitis
59
what is primary biliary cirrhosis (PBC)
Autoimmune destruction of small intrahepatic bile ducts --> cholestasis leads to cirrhosis and liver failure primarily females 35-60y/o
60
presenation of PBC?
fatigue, pruritis (before jaundice) also arthritis, RUQ pain, skin hyperpigmentation, xanthomas, hepatomegaly, CREST sx
61
Labs for PBC?
LFTs (cholestatic pattern): elevated alk phos and GGT anti-mitochondrial antibody (AMA) = hallmark ANA, IgM, hyperlipidemia
62
diagnosis for PBC?
Liver Bx- confirms diagnosis and stage of disease
63
management of PBC?
Urso Monitor bone density (DEXA) d/t increased risk of osteoporosis
64
what are s/s of primary sclerosing cholangitis (PSC)?
Asxs, fatigue, pruritis (after jaundice) also, jaundice, steatorrhea, osteoporosis
65
what is PSC?
Inflammation/fibrosis of medium & larger intra/extra hepatic ducts Progresses to cirrhosis
66
complications of PSC?
``` Biliary stricture Cholangitis Cholangiocarcinoma Gallbladder cancer Colon cancer (if IBD present) ```
67
Dx for PSC?
Abnormal LFTs | P-ANCA, ASMA, ANA, IgM
68
imaging for PSC?
ERCP-diagnostic and therapeutic MRCP (diagnostic) --Multifocal stricturing with intrahepatic/ extrahepatic ductal dilation liver bx = usu. nondiagnostic
69
management of PSC
Monitor bone density Manage biliary strictures with ERCP Monitor for complications (cholangiocarcinoma, cholangitis, etc) Liver transplant with advanced disease
70
what is Gilbert's syndrome?
Deficiency in enzyme for glucuronidation of bilirubin in liver (conjugation) Suspect in pt with unconjugated hyperbilirubinemia in absence of hemolysis
71
Biliary neoplasms risk factors?
Cholelithiasis Gallbladder polyps >1cm Salmonella infection
72
presentation for gallbladder CA
can be clinically indistinguishable from cholelithiasis May have Sx suggestive of malignancy
73
presentation for cholangiocarcinoma
jaundice, vague upper abd pain, anorexia, weight loss, pruritis
74
labs for cholangiocarcinoma
``` show cholestasis (obstructive pattern) Elevated conjugated bilirubin and alk phos ``` ↑ CA 19-9
75
presentation for amupllary cancer?
obstructive jaundice (most common), occult GIB with microcytic anemia, abdominal pain

Foundations III-GI (8 decks)

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