Biliary System

Question 1

Labs elevated and/or positive w/ PBC (3)

Answer 1

AMA
ALP
IgM

Question 2

PBC treatment

Answer 2

ursodeoxycholic acid 13-15 mg/kg/day

Question 3

PSC MRCP findings

Answer 3

beaded bile ducts (strictures and dilations)

Question 4

PSC biopsy findings

Answer 4

onion-skin fibrosis

Question 5

Imaging/procedural monitoring for PSC (2)

Answer 5

annual MRCP or US
colonoscopy every 1-2 yrs (high UC risk)

Question 6

Pain control for cholelithiasis

Answer 6

ketorolac 30 mg IV

Question 7

Utility of GGT

Answer 7

confirming biliary source of elevated ALP

Question 8

Types of gallstones (2)

Answer 8

cholesterol (most common)
pigment (hemolysis, cirrhosis)

Question 9

Causes of pigmented gallstones (2)

Answer 9

hemolysis
cirrhosis

Question 10

Gold standard diagnosis for cholelithiasis

Answer 10

ultrasound

Question 11

PBC pathophysiology

Answer 11

progressive destruction of intrahepatic ducts - leads to fibrosis and cholestasis

Question 12

Antibody associated w/ PBC

Answer 12

anti-mitochondrial (AMA)

Question 13

Liver enzyme primarily elevated in PBC

Answer 13

alk phos

Question 14

PBC first-line treatment

Answer 14

ursodeoxycholic acid 13-15 mg/kd/day divided into 2 doses

Question 15

Chemotherapy for cholangiocarcinoma (2)

Answer 15

gemcitabine
cisplatin

Question 16

PSC pathophysiology

Answer 16

inflammation and fibrosis of the bile ducts, both intrahepatic AND extrahepatic

Question 17

Timeframe for surgery in acute cholecystitis

Answer 17

72 hours

Question 18

Typical GGT level in cholestasis

Answer 18

elevated

Question 19

Gallbladder polyp size where cholecystectomy is indicated

Answer 19

> 1 cm or symptomatic

Question 20

Causes of GGT elevation (4)

Answer 20

hepatitis
alcohol use disorder
cirrhosis
biliary disease

Question 21

Mutation in Gilbert’s syndrome

Answer 21

UGT1A1 gene

Question 22

Yearly monitoring for PSC (2)

Answer 22

MRCP
CA 19-9

Question 23

Acute cholecystitis treatment (2)

Answer 23

ceftriaxone 2g q12h +
flagyl 500mg q8hr

Question 24

PBC pathophysiology

Answer 24

destruction of INTRAhepatic ducts

Question 25

Diagnosis of PBC (2)

Answer 25

AMA biopsy

Question 26

Biopsy findings for PBC (3)

Answer 26

ductal destruction fibrosis cirrhosis

Question 27

Treatment for PBC refractory to UDCA

Answer 27

obeticholic acid 25mg qday - can increase to 50mg after 3 months

Question 28

Obeticholic acid MOA

Answer 28

farnesoid X receptor agonist

Question 29

Most common presentation of PSC

Answer 29

asymptomatic

Question 30

Timing of surgery for acute cholecystitis

Answer 30

< 72 hrs

Question 31

Iron supplementation dose for Celiac (men and women)

Answer 31

men: 8mg/day women: 18mg/day

Question 32

Calcium supplementation dose for Celiac

Answer 32

1000mg

Question 33

Vitamin D supplementation dose for Celiac

Answer 33

600 IU

Question 34

Folate supplementation dose for Celiac

Answer 34

400 mcg/day

Question 35

ALP level indicative of cholestasis

Answer 35

3x ULN

Question 36

Bile malabsorption diagnosis (2)

Answer 36

SeHCAT 75Se-cholyltaurine

Question 37

Gallbladder polyp characteristics indicating need for cholecystectomy

Answer 37

> 1cm symptomatic

Question 38

uSEMS description

Answer 38

Structure: Bare metal mesh without any covering. Main uses: 1) Malignant biliary obstruction (e.g., pancreatic or cholangiocarcinoma) 2) Malignant esophageal strictures Advantages: Lower risk of stent migration (because tissue grows into it) Disadvantages: 1) Tumor ingrowth can cause stent occlusion 2) Difficult to remove once placed

Question 39

uSEMS main uses (2)

Answer 39

malignant biliary obstruction malignant esophageal strictures

Question 40

Advantage of uSEMS

Answer 40

lower risk of stent migration b/c tissue grows into it

Question 41

Disadvantages of uSEMS (2)

Answer 41

difficult to remove tumor ingrowth can cause occlusion

Question 42

fcSEMS description

Answer 42

Structure: Covered with a polymer membrane (like silicone) to prevent tissue ingrowth. Main uses: 1) Benign biliary strictures 2) Post-surgical bile leaks 3) Refractory esophageal strictures or leaks Advantages: 1) Prevents tissue ingrowth → Easier to remove 2) Useful in benign disease or situations where temporary stenting is needed Disadvantages: 1) Higher risk of migration 2) Can occlude cystic duct → risk of cholecystitis in biliary stenting

Question 43

fcSEMS main uses (3)

Answer 43

benign biliary strictures post-surgical bile leaks refractory esophageal strictures or leaks

Question 44

fcSEMS advantages (2)

Answer 44

prevents tissue ingrowth - easier to remove useful in benign disease where temporary scenting is needed