Gallbladder and biliary disorders

Question 1

What is cholelithiasis

Answer 1

Hardened deposits of digestive fluid that form in the gallbladder

Question 2

What are the complications with cholelithiasis

Answer 2

most disorders of the biliary tract

Question 3

Who is at increased risk for cholelithiasis

Answer 3

those with crohns disease with ileum resection

Question 4

What are common risk factors for cholelithiasis

Answer 4

Female
obesiry
increased age
pregnancy
western diet
American indian ethnicity
+fh

Question 5

What are the 3 main pathways that gallstones can form

Answer 5

cholesterol supersaturation
Excessive bilirubin
impaired contractility

Question 6

What is cholesterol supersaturation

Answer 6

liver produces more cholesterol than bile can dissolve and the excess cholesterol can crystallize

Question 7

How does excess bilirubin lead to gallstones

Answer 7

liver makes too much bilirubin processing breakdown of hemoglobin

Question 8

Why does gallbladder hypo motility lead to stones

Answer 8

gallbladder does not empty effectively causing bile to concentrate

Question 9

What are the properties of black pigment gallstones

Answer 9

small, hard gallstones composed of calcium bilirubinate and inorganic salts

Question 10

What are the risk factors for black pigmented gallstones

Answer 10

ETOH related liver disease, sickle cell, ill disease, chronic hemolysis

Question 11

What are the properties of brown pigmented gallstones

Answer 11

soft and greasy, consisting of bilirubinate and fatty acids

Question 12

What are the causes of brown pigmented gallstones

Answer 12

infection, inflammation, parasitic infection

Question 13

What is the precursor to cholelithiasis

Answer 13

biliary sludge

Question 14

When does biliary sludge develop

Answer 14

during gallbladder stasis (TPN)

Question 15

What is the most common symptom of cholelithiasis

Answer 15

biliary colic

Question 16

What is biliary colic

Answer 16

Temporary obstruction that cause sudden onset of RUQ pain, radiating to scapula (15min-hour) and will gradually resolve in 30-90min.

*generally a nocturnal issue

Question 17

What is the first line and best imaging modality for cholelithiasis

Answer 17

US

Question 18

If US of gallbladder is equivocal, what is the next line of imaging that can be done

Answer 18

nuc med cholescintigraphy scan (HIDA scan)

Question 19

How do you treat asymptomatic gallstones

Answer 19

Diet changes to reduce the chance of recurrent episodes

refer to general surgeon for cholecystectomy

Question 20

When can stone dissolution be preformed

Answer 20

small, radiolucent stones in functioning non-obstructed gallbladder

Question 21

What can be used for stone dissolution

Answer 21

ursodeoxycholic

Question 22

What is the treatment of choice for cholelithiasis

Answer 22

laparoscopic cholecystectomy

Question 23

If a patient is at risk for cholelithiasis, what else are they at a risk for

Answer 23

cholecystitis

Question 24

How will acute cholecystitis present

Answer 24

RUQ pain and tenderness
N/V
Fever / chills

Question 25

What is the treatment for acute cholecystitis

Answer 25

antibiotics and cholecystectomy

Question 26

What is the most common complication of cholelithiasis

Answer 26

acute cholecystitis

Question 27

What is cute emphysematous cholecystitis

Answer 27

GB wall infected with gas forming organisms

Question 28

When will Murphys sign be present

Answer 28

with acute cholecystitis

Question 29

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

Answer 29

US

Question 30

Which type of cholecystitis is a HIDA scan more useful to diagnose

Answer 30

acute acalculous cholecystitis

Question 31

What is gallstone pancreatitis

Answer 31

stones pass into the biliary tract and block pancreatic duct

Question 32

What is a cholecystoenteric fistula

Answer 32

large stone erodes GB wall, creating a fistula into the small bowel may pass freely but could cause ileus

Question 33

What is the classic mantra for cholecystitis

Answer 33

fat, forty, fertile, female, flatulent

Question 34

What is a porcelain gallbladder

Answer 34

Extensive calcification due to fibrosis

Question 35

What is the classic PE findings with chronic cholecystitis

Answer 35

+murphys sign uncomfortable but not acutely ill vitals WNL

Question 36

What is the test of choice for chronic cholecystitis

Answer 36

US unless aclculous

Question 37

What is the preferred treatment for chronic cholecystitis

Answer 37

laparoscopic cholecystectomy

Question 38

What is choledocholithiasis

Answer 38

Stone in the CBD

Question 39

What is the treatment for choledocholithiasis

Answer 39

ERCP *possible cholecystectomy

Question 40

What is the clinical presentation of choledocholithiasis

Answer 40

Colicky, RUQ pain, clay colored stools, episodic icterus (jaundice)

Question 41

What is courvoisers sign

Answer 41

presence of palpable GB

Question 42

What T.bili level is strongly associated with choledocholithiasis

Answer 42

>3-4 mg/dL

Question 43

What bloodwork should be drawn when working up choledocholithiasis

Answer 43

WBC, Hb/Hct, platelets, T. bili, D. bili, Alk phos, ALT, AST

Question 44

What is the first test to be done if there is any suspicion of biliary disease

Answer 44

abdominal ultrasound

Question 45

What is an ERCP

Answer 45

Endoscopic stone fragmentation may be considered for stones not easily removed

Question 46

What is charcots triad

Answer 46

abd pain jaundice fever / chills

Question 47

What is Reynolds pentad

Answer 47

confusion, hypotension, abdpain, jaundice, fever/chills

Question 48

What is acute cholangitis

Answer 48

CBD obstruction allows bacteria to ascend from the duodenum

Question 49

What are common organisms that cause cholangitis

Answer 49

E.coli Enterobacter Klebseilla

Question 50

What is recurrent pyogenic cholangitis

Answer 50

oriental cholangiohepatitis *intrahepatic brown stone formation that occurs in Southeast Asia

Question 51

How do you treat acute cholangitis

Answer 51

agressive supportive care w/ urgent stone removal endoscopically or surgically

Question 52

What is primary sclerosis cholangitis

Answer 52

chronic and progressive patchy inflammation, fibrosis, and strictures of bile ducts w/ no known cause

Question 53

What do most people with primary sclerosing cholangitis already have

Answer 53

inflammatory bowel disease *ulcerative colitis

Question 54

How do you diagnose primary sclerosing cholangitis

Answer 54

ERCP

Question 55

How do you treat advanced primary sclerosing cholangitis

Answer 55

liver transplant

Question 56

What gender is at highest risk for primary sclerosing cholangitis

Answer 56

men

Question 57

What are the different types of primary sclerosing cholangitis

Answer 57

classic small-duct association with autoimmune hepatitis

Question 58

What is primary sclerosing cholangitis

Answer 58

progressive fibrosis around intrahepatic bile ducts that lead to concentric and circumferential lamination *onion skin fibrosis

Question 59

What will be seen on physical exam with primary sclerosing cholangitis

Answer 59

hepatomegaly splenomegaly jaundice excoriations from pruritis

Question 60

What is indicative of the terminal phase of primary sclerosing cholangitis

Answer 60

decompensated cirrhosis portal HTN ascites liver failure

Question 61

How do you diagnose primary sclerosing cholangitis

Answer 61

cholangiography showing multiple strictures and dilations in intrahepatic and extra hepatic bile ducts

Question 62

What is the only treatment that improves life expectancy with primary sclerosing cholangitis

Answer 62

liver transplant

Question 63

If a patient has +PSC and IBD, what are they at an increased risk for

Answer 63

colorectal cancer

Question 64

What is a TIPS procedure

Answer 64

Transjugular Intrahepatic portosystemic shunt