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Spring Round II Exams > clin med- third set lectures > Flashcards

clin med- third set lectures Flashcards

1
Q

Cystic duct comes from:

A

gallbladder

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2
Q

Common hepatic duct comes from:

A

liver

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3
Q

Common bile duct consists of:

A

Cystic and Common Hepatic duct joining.

The Common bile duct then empties into duodenum thru sphincter of Oddi

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4
Q

What organ does the Common bile duct pass thru before it empties into duodenum?

A

Pancreas

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5
Q

Who makes bile?

A

Liver

then stored and concentrated in the Gallbladder

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6
Q

Function of bile

A

Digest/absorb fats

Vehicle to excrete: bilirubin, extra cholesterol, and met byproducts

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7
Q

inflammation of the BILE DUCTS

A

Cholangitis

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8
Q

Inflammation of the Gallbladder

A

Cholecystitis

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9
Q

Stones in the Gallbladder

A

Cholelithiasis

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10
Q

Stones in the Common Bile Duct

A

CholeDOCHOlithiasis

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11
Q

Disruption of bile flow

A

Cholestasis

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12
Q

The Four F’s of Cholelithiasis (Gallstones)

Risk factors

A

Female
Fluffy
Forty
Fertile

Also: Pregnant, Estrogen use, Rapid weight loss, Fam hx/genetics, DM

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13
Q

What type of stone is most common?

A

Cholesterol

other types: Pigment, Black pigment (underlying hemolytic anemia), Brown pigment (bacterial infection)

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14
Q

Do most gallstone pts have sx?

A

NO

If they do, Biliary colic and possibly leading to Gallstone related complications

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15
Q

Test of choice for Cholelithiasis (gallstones)

A

US

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16
Q

Do you have to treat Gallstones if you have no sx?

A

No, UNLESS:

  • increased risk of GB CA
  • Hemolytic disorder
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17
Q

Uncomplicated Gallstone dz

A

Biliary colic in the absence of complications

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18
Q

Biliary colic

NO gallbladder inflammation

A

Gallbladder contracts forcing stone/sludge against GB outlet or duct opening, increased pressure–> pain, pain slowly subsides as gallbladder relaxes

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19
Q

Biliary colic sx

A

RUG or epigastric pain radiates to R shoulder blade

constant and steady
at least 30 min, often peak at 1 hour

post-prandial

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20
Q

Other sx with Biliary colic

A

n/v
diaphoresis

unchanged by movement
Nocturnal pain common (awakes pt from sleep)

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21
Q

Biliary colic PE

A

NO FEVER or tachy
vitals normal
no jaundice
Negative murphys

Basically, everything is normal besides

POSSIBLE RUQ or EPIGASTRIC tenderness

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22
Q

Biliary colic

order labs and US

A

labs: normal
US: expect Gallstones or Sludge

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23
Q

If pt has Stones and Biliary colic

A

Cholecystectomy recommended

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24
Q

Functional Gallbladder disorder

gallbladder DYSMOTILITY

A

Biliary type pain but NO stones, sludge, or dz

Normal labs, Normal imaging

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25
Functional Gallbladder disorder dx look at Ejection Fraction via HIDA scan
Diagnosis of exclusion
26
HIDA scan tells Ejection Fraction CCK given to stimulate gallbladder contraction, if ejection fraction is <35-40%
Considered LOW | Supports dx of Functional gallbladder dz
27
Rome 4 Criteria required for Functional GB dz
Biliary Pain Absence of stones or other structural path Supportive: Low EF, Normal liver enzymes
28
Biliary colic type pain must last at least
30 minutes
29
Tx for Functional gallbladder dz if EF <40
Cholecystectomy
30
Complicated gallstone dz
Cholecystitis CholeDOCHOlithiasis Acute cholangitis
31
Acute calculous cholecystitis
acute inflammation of gallbladder usually a COMPLICATION from a STONE
32
What does Acalculous vs Calculous cholecystitis mean?
Acalculous: no obstruction Calclous: occurs in the setting of Cystic duct obstruction
33
Starts with biliary pain that prog worsens Prolonged >4-6 hours, steady, severe, RUQ or epigastric pain FEVER
sx of Acute calculous Cholecystitis | can also have n/v, anorexia, radiating to r shoulder, often hx of fatty food eating
34
PE of Acute calculous cholecystitis
``` FEVER, tachy Ill appearing Lying still Guarding + Murphy's sign ```
35
Acute calculous Cholecystitis labs
+Leukocytosis w left shift anytime we see "itis", have an elevated WBC
36
Elevated AMYLASE usually associated w
Pancreatitis
37
If Total Bili and Alk Phos (ALP) are elevated, we should be concerned about
Cholangitis Choledocholithiasis both of which can result in Biliary obstruction
38
Dx Acute calculous cholecystitis
US preferred initial Can progress to HIDA if above not helpful
39
+ "Sonographic Murphy's sign"
US tech produced Murphy's pain while obtaining the US
40
Most common Complication of acute calculous cholecystitis
Gangrene
41
Acute calculous cholecystitis tx
Admit, NPO, IVF, Pain meds, IV empiric Abx Mainstay: CHOLECYSTECTOMY
42
Gallbladder inflammation Leukocytosis RUQ pain Fever
Acute Cholecystitis
43
Acute ACALCULOUS Cholecystitis
Acute necro-inflammatory dz of gallbladder in ABSENCE of stones High morbidity/mortality
44
Pathogenesis of Acute ACALCULOUS cholecystitis
gallbladder stasis/ischemia --> local inf response secondary bacterial infection is common perforation in severe cases
45
Acute ACALCULOUS cholecystisi
Hospitalized and Critically ill people may have sepsis or jaundice
46
Suspect Acalculous cholecystitis in
Critically ill, sepsis without clear source of jaundice Post op jaundice
47
Acalculous Cholecystitis tx
Start Abx | Cholecystectomy vs Gallbladder drainage
48
Choledocholithiasis
Gallstones in Common bile duct incidence increases w age JAUNDICE if blocking flow of bile
49
Biliary type pain and JAUNDICE Vitals normal RUQ /epigastric pain Courvoiser sign (palpable gallbladder)
be thinking CholeDOCHOlithiasis | stone in common bile duct
50
Choledocholithiasis labs early vs late dz
early: elevated ALT and AST late: elevated Bili, ALP, and GGT
51
for Choledocholithiasis, if US is not helpful, next consider
MRCP or Endoscopic US
52
What is the test to CONFIRM Choledocholithiasis (common bile duct stone)
MRCP
53
Tx of Choledocholithiasis
ERCP is therapeutic and diagnostic !! Cholecystectomy to follow if appropriate
54
Acute cholangitis
Charcot's triad: Fever RUQ pain Jaundice
55
Bacteria ascending from duodenum can cause
Acute cholangitis "pus under pressure" surgical emergency
56
Reynold's Pentad | like Charcot triad, but more
+ AMS and Hypotension
57
Reynold's Pentad
``` Fever RUQ pain Jaundice AMS Hypotension (low BP) ``` High morbidity and mortality
58
Acute cholangitis Labs
Leuk w/ left shift Elev CRP/ESR Evidence of cholestasis: elevated Bili, ALP, GGT, maybe AST/ALT Serum amylase/lipase can be 3-4x elevated (associated pancreatitis)
59
Acute cholangitis tx
Admit Monitor/tx for Sepsis (EMPIRIC ABX) Emergent consult w GI and Surgery ERCP !!!
60
Acute cholangitis procedural tx
ERCP w/Sphincterotomy and stone extraction Cholecystectomy after prn
61
Progression of gallbladder dz, increasing severity
``` A-sx gallstones Sx gallstones Acute cholecystitis Chole-docholithiasis Acute Cholangitis ```
62
Tx for Gallstones and Acute cholecystitis
Cholecystectomy with cholecystitis, add abx
63
Tx for Choledocho and Acute cholangitis
ERCP w/stone extraction For acute cholangitis, add Abx
64
PBC: Primary Biliary Cholangitis
Women 30-65 YO | AUTOIMMUNE destruction of bile ducts in the Liver which cause Cholestasis
65
Sx of PBC
Fatigue and Pruritis most common Also, RUQ discomfort, skin hyperpigmentation, hepatomegaly, xanthomas, jaundice Assoc w other autoimmune dz
66
Autoimmune dz
be thinking of PBC- Primary Biliary Cholangitis
67
PRURITIS and FATIGUE
PBC and PSC
68
Elevated ALP AMA !!!*** Hyperlipidemia may be strikingly elevated
Primary Biliary Cholangitis AMA is a serologic hallmark of PBC
69
Tx of PBC Primary Biliary Cholangitis
Refer to GI Meds Treat complications
70
PSC Primary Sclerosing Cholangitis
Sclerosing, inflammatory, obliterative process involving Biliary tree Chronic, progressive disorder unknown etiology
71
Higher incidence in MEN age ~40 Strong association with IBD (specifically ulcerative colitis)
Primary Sclerosing Cholangitis
72
PSC
Men 40 YO | assoc w IBD (Ulcerative colitis)
73
Complications of Primary Sclerosing Cholangitis
Cholestasis End stage liver dz Hepatobiliary CA Colon CA
74
Cholestatic pattern of liver labs
Elevated ALP, GGT, and Bili
75
PSC primary sclerosing cholangitis labs
Elevated ALP, GGT, and Bili (cholestatic pattern) but negative AMA
76
What will you see on ERCP or MRCP with Primary sclerosing cholangitis?
Multifocal strictures and dilation of bile ducts
77
Tx of PSC
Meds | Treat complications
78
Gilbert syndrome
``` Teen men (post puberty) Unconjugated hyperbilirubinemia ``` Intermittent jaundice
79
Gilbert syndrome
Deficiency in enzyme for Glucuronidation NO hemolysis (CBC and other blood labs are normal)
80
Presentation of Gilbert syndrome
Teen males INTERMITTENT jaundice Triggers: dehydration, fasting, menses No specific tx
81
Gallbladder CA
Most common CA of biliary tract HIGHLY FATAL often found incidentally
82
Risk factors for GB CA
Porcelain bladder
83
Cholangiocarcinoma (bile duct CA)
Arise from Epithelial cells of bile ducts
84
CA that has jaundice, pruritis, Courvoiser sign Cholestatic pattern labs
Cholangiocarcinoma
85
Ampullary CA
Ampulla of Vater (right where it empties into duodenum) Increased inc w FAP and HNPCC
86
CA with these sx: Obstructive jaundice, occult GI bleed, microcytic anemia, abd pain
Ampullary CA blocking where the GB usually empties into duodenum

Spring Round II Exams (10 decks)

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