Disorders of Gallbladder and Biliary Tree

Question 1

What is Cholelithiasis

Answer 1

aka gallstones
hardened deposits of digestive fluid that form in the galbladder

Question 2

what are complications of gallstones

Answer 2

cholecystitis
cholangitis
choledocholithiasis
gallstones pancreatitis
cholangiocarcinoma (rare)

Question 3

what are risk factors for cholelithiasis

Answer 3

female
obesity
increased age
pregnancy/OCPs
American Indian ethnicity
western diet, TPN
Rapid weight loss
family hx

Question 4

what are the pathways for gallstone formation

Answer 4

cholesterol supersaturation
excess bilirubin
gallbladder hypomotility or impaired contractility

Question 5

What patients have decreased bile salt secretion

Answer 5

cystic fibrosis

Question 6

what are black pigment stones

Answer 6

small, hard gallstones composed of calcium bilirubinate and inorganic CA salts
associated wtih alchol-related liver disease

Question 7

what are brown pigment stones

Answer 7

soft and greasy, consisting of bilirubinate and fatty acids
- infection, infalmation, parasitic - rare in US

Question 8

What is biliary sludge

Answer 8

precursor to cholelithiasis
consists of calcium bilirubinate, choesterol microcrystals and mucin
develops during gallbladder stasis

Question 9

what is the clinical presentation of cholelithiasis

Answer 9

most asymptomatic
Biliary colic most common symptom - RUQ pain radiating to scapula (or down right arm), sudden onset, intense in 15min to 1 hour, remains steady then gradually resolves over 30-90 minutes (temporary obstruction)

Question 10

What are the initial workup for cholelithiasis

Answer 10

CBC, CMP, PT/PTT< lipase, amylase, alk phos, tot bilirubin, UA (usually normal)
US first line and best imagine

Question 11

What is a HIDA scan

Answer 11

Evaluation of cholelithiasis with radioactive tracer

Question 12

what is the treatment of asymptomatic gallstones

Answer 12

counsel regarding symptoms and when to get medical tx
PO/Parenteral analgesia in ER/urgent care
diet changes to reduce chances of recurrent episodes

Question 13

what are stone dissolution treatments for cholelithiasis

Answer 13

Actigall/ursodiol

Question 14

what is the treatment of choice for symptomatic cholelithiasis

Answer 14

laparoscopic cholecystectomy

Question 15

what is inflammation of the gallbladder that develops over hours, usually because of obstructing gallstone in cystic duct

Answer 15

acute cholecystitis

Question 16

what are symptoms of acute cholecystitis

Answer 16

RUQ pain and tenderness; maybe fever, chills, n/v

Question 17

what is the treatment for acute cholecystitis

Answer 17

usually ABX and cholecystectomy

Question 18

what is the clinical presentation of acute cholecystitis

Answer 18

most with prior attacks of biliary colic or acute cholecystitis
severe RUQ pain > 6hours with bloating, foot intolerances, increased gas, n/v, pain in midback/shoulders
Murphys sign

Question 19

what is the first test in the ED for acute cholecystitis

Answer 19

CT scan; r/o GB perforation or pancreatitis

Question 20

what is the best test to detect gallstones and evaluate GB disease

Answer 20

Transabdominal gallbladder US

Question 21

What is Acute acalculous cholecystitis

Answer 21

cholecystitis without stones
risks: critical illness, prolonged fasting/TPN, Shock, immune deficiency, vasculitis, children

Question 22

what test is more helpful for acute acalculous cholecystitis

Answer 22

HIDA scan more helpful; failure to fill may indicate edematous cystic duct obstruction

Question 23

what are complications of acute acalculous cholecystitis

Answer 23

if untreated, rapid progression to GB gangrene and perforation, sepsis, shock, peritonitis, mortality 65%

Question 24

What is the treatment for acute cholecystitis

Answer 24

admit, iv analgesics, NPO, NG suction if vomiting, IV abx if concern for infection
cholecystectomy cures acute choecystitis and relieves biliary pain

Question 25

what is Mirizzi syndrome

Answer 25

rare; stone impacted in cystic duct, compresses and obstructs CBD, causing cholestasis

Question 26

What is cholecystoenteric fistula

Answer 26

rare; large stone erodes GB wall, creating fistula into small bowel; stone may pass freely or obstruct small bowel (gallstone ileus)

Question 27

What is chronic cholecystitis

Answer 27

prolonged, subacute condition; mechanical or functional dysfunction of GB emptying

Question 28

what is porcelain gallbladder

Answer 28

extensive calcification due to fibrosis

Question 29

What is the classic montra for cholecystitis

Answer 29

fat, forty, fertile, female, (flatulant)

Question 30

What is the clinical presentation of chronic cholecystitis

Answer 30

dull RUQ pain, radiate mid back/right scapula; usually associated with fatty food ingestion c/o N/v, bloating, flatulence; usually later evenin

Question 31

what is the classic physical exam of chronic cholecystitis

Answer 31

+ murphys sign not acutely ill but uncomfortable vitals usually WNL

Question 32

What is the test of choice for the diagnosis of chronic cholecystitis

Answer 32

US HIDA best to confirm acalculous cholecystitis

Question 33

what is the treatment for chronic chollecystitis

Answer 33

laparoscopic cholecystectomy milder/poor surgical candidates: strict low fat and low spice diets or Actigall (ursodiol)

Question 34

what is choledocholithiasis

Answer 34

presence of stones within the common bile duct (CBD) primary: form in bile duct secondary: form in GB but migrate to bile duct

Question 35

What is the clinical presentation of CBD stones

Answer 35

pain: colicky, RUQ, mod severity: intermittent and recurrent episodic hx epigastric, RUQ pain may have episodic icterus/jaundice; pruritis, n/v, clay-colored stools, tea-colored urine

Question 36

What is Courvoisier's sign

Answer 36

presence of palpable GB (GB dilation due to obstruction of CBD)

Question 37

What bloodwork is done for choledocholithiasis

Answer 37

CMC/CMP Lipase INR/PT

Question 38

what is the diagnostic test of choice for choledocholithiasis

Answer 38

abdominal US

Question 39

what is the treatment for choledocholithiasis

Answer 39

ERCP (with spincterotomy to remove stone/s)

Question 40

What is acute cholangitis

Answer 40

CBD obstruction allows bacteria to ascent from duodenum

Question 41

what is charcot triad

Answer 41

abdominal pain, jaundice, fever or chills (cholangitis)

Question 42

what is reynolds pentad

Answer 42

confusion, hypotension, abdominal pain, jaundice, fever and chills (cholangitis)

Question 43

What is recurrent pyogenic cholangitis

Answer 43

characterized by intrahepatic brown pigment stone formation occurs in southeast asia sludge and bacterial debris in bile ducts

Question 44

what is the treatment of acute cholangitis

Answer 44

emergency requiring aggressive supportive care and urgent removal of stones, endoscopically or sugically abx likely acute alternative for very ill: meropenem, ciprofloxacin plus metrinidazole

Question 45

what is the treatment of recurrent pyogenic cholangitis

Answer 45

supportive care (broad-spectrum abx), eradicate any parasites and mechanically clear ducts of sotnes and debris via ERCP or surgically

Question 46

what are the common organisms associated with acute cholangitis

Answer 46

gram negative (e.coli, klebsiella, enterobacter)

Question 47

what is primary sclerosing cholangitis

Answer 47

chronic and progressive patchy inflammation, fibrosis, and strictures of bile ducts that has no known cause 80% have IBD, most often ulceratlive colitis

Question 48

what procedure is indicated with primary sclerosing cholangitis

Answer 48

liver transplant

Question 49

what is the pathophysiology of primary sclerosing cholangitis

Answer 49

progressive fibrosis around intrahepatic bile ducts lead to concentric and circumferential laminations "onion skin" fibrosis

Question 50

what is the clinical presentation of PSC

Answer 50

50% asymptompatic- dx after abnormal LFTs found when tested for other reasons c/o RUQ pain, pruritis, fatigue, jaundice development of symptomatic gallstoens and choledocholithiasiss

Question 51

what are the subtypes of PSC

Answer 51

classic small duct associated with autoimmune hepatitis

Question 52

what is seen on PE with PSC

Answer 52

hepatomegally, splenomegally, jaundice, excoriations from prurutis fever, chills, RUQ pain, +/- jaundice; onset bacterial cholangitis

Question 53

what is rerquired for diagnosis of PSC

Answer 53

US cholangiography- multiple strictures and dilations in intrahepatic and extrahepatic bile ducts - ERCP

Question 54

what is acute cholecystitis

Answer 54

stone lodged in cystic duct causes GB to become distended and inflamed; fever, RUQ pain and murphys sign