GI: Biliary Diseases

Question 1

The Four Fs of cholelithiasis…

Answer 1

female
fluffy
forty
fertile

Question 2

MC presentation of cholelithiasis…

Answer 2

asymptomatic

Question 3

Initial test of choice for cholelithiasis

Answer 3

US

Question 4

What causes the pain in biliary colic?

Answer 4

pressure forcing stone against gallbladder

Question 5

what disorder?

Intense RUQ, Epigastric Pain

+/- Radiation to Right Shoulder Blade

Constant and steady, lasts < 5-6 hours

Postprandial
N/V
Diaphoresis
Nocturnal pain

Answer 5

biliary colic

Question 6

does movement make biliary colic worse?

Answer 6

no

Question 7

is there jaundice, peritoneal signs, or murphy’s sign with biliary colic?

Answer 7

no

Question 8

For biliary colic, US should show…

Answer 8

gallstones/sludge

Question 9

When should tx be considered with asymptomatic gallstones?

Answer 9

when sxs develop, cholecystectomy

Question 10

patient p/w…

Biliary colic
Normal PE
Normal CBC, LFTs, Amylase, Lipase

Answer 10

uncomplicated gallstone disease

Question 11

gallbladder dysmotility…

Answer 11

functional gallbladder d/o

Question 12

how is functional gallbladder d/o diagnosed?

Answer 12

exclusion + Rome IV criteria

Question 13

What diagnostic should be ordered for suspected functional gallbladder d/o if no other causes can be considered…

Answer 13

CCK + HIDA scan

GBEF < 35%

Question 14

Rome IV Criteria for functional gallbladder d/o…

Answer 14

Biliary pain
No stones
Low EF
Normal Labs

Question 15

the below describes…

Lasts 30+ min
Not relieved w. BM, posture, antacids
Variable occurrence
Severe, interrupts daily life

Answer 15

biliary pain

Question 16

When is cholecystectomy indicated in functional gallbladder d/o?

Answer 16

Biliary pain + GBEF < 40%

Question 17

This is an acute inflammation of the GB +/- cystic duct obstruction

Answer 17

acute cholecystitis

Question 18

Hx of:

Attack of worsening biliary pain ( > 4-6 hours steady, severe, RUQ/epigastric pain)

Fever

N/V, anorexia

Hx of fatty food

Answer 18

Acute cholecystitis

Question 19

On PE…

laying still
(+) Murphy’s
(+) guarding
(+) RUQ TTP

Answer 19

acute cholecystitis

Question 20

Labs should show ______ in acute cholecystitis

Answer 20

leukocytosis w/ left shift

+/- elevated AST/ALT

Question 21

US shows + hx of biliary pain

Gallstones
Wall thickening
Pericholecystic fluid
Sonographic murphy’s sign

Answer 21

acute cholecystitis

Question 22

When to order HIDA w. suspected acute cholecystitis

Answer 22

if dx uncertain

Question 23

what is a POS for acute cholecystitis on HIDA scan?

Answer 23

failed gallbladder visualization

Question 24

MC complication of acute cholecystitis (20%)

Answer 24

gangrene

Question 25

What is a serious, but rare, complication of acute cholecystitis that can cause jaundice?

Answer 25

Mirizzi Syndrome (impaction)

Question 26

Management of acute cholecystitis

Answer 26

admission for cholecystectomy + NPO, IV Fluids, IV pain meds (opioids), IV abx

Question 27

What disorder? A/w gallstones Minimal sxs

Answer 27

chronic cholecystitis

Question 28

What biliary disorder? Acute inflammation w/o stones High morbidity/mortality Common w. Critically ill patients

Answer 28

acute acalculous cholecystitis

Question 29

Patient p/w critically ill sepsis w/o clear source biliary pain jaundice

Answer 29

Acute acalculous cholecystitis

Question 30

workup for biliary pain

Answer 30

``` US LFTs CBC CMP Amylase Lipase UA Urine Preg ```

Question 31

tx for acute acalculous cholecystitis

Answer 31

prompt Abx + blood Cx

Question 32

Patient p/w... Prolonged Biliary Pain Jaundice Courvoisier Sign normal vitals

Answer 32

choledocolithiasis

Question 33

What elevated LFTs indicate cholestasis?

Answer 33

serum bili alk phos GGt

Question 34

Labs in choledocolithiasis

Answer 34

cholestasis LFTs

Question 35

Management of choledocolithiasis

Answer 35

ERCP (therapeutic & Dx) ID/tx of complications (acute cholangitis)

Question 36

what biliary d/o? Bacterial infection in pt w. biliary obstruction Ascent of bacteria from duodenum “Pus under pressure” = surgical emergency

Answer 36

acute cholangitis

Question 37

Lab results suggesting acute cholangitis... (4)

Answer 37

leukocytosis w. left shift elevated CRP/ESR cholestatic LFTs 3x normal pancreatic enzymes

Question 38

What 2 things can be seen on MRCP/EUS in acute cholangitis?

Answer 38

CBD dilation, stone

Question 39

Charcot's Triad for acute cholangitis...

Answer 39

fever abd. pain jaundice

Question 40

Reynolds pentad for acute cholangitis

Answer 40

``` fever abd. pain jaundice AMS hypotension ```

Question 41

Tx for acute cholangitis

Answer 41

911 admit/surg consult | biliary drainage via ERCP

Question 42

which biliary d/o? Women 30-65 yo Autoimmune destruction of intrahepatic bile ducts → cholestasis Can lead to liver failure/cirrhosis

Answer 42

primary biliary cholangitis

Question 43

Patient presents with... ``` Fatigue + Pruritus Jaundice RUQ discomfort Xanthomas Hepatomegaly Hx of autoimmune conditions ```

Answer 43

PBC

Question 44

Labs for PBC

Answer 44

(+) AMA (hallmark) cholestatic LFTs (+) ANA Hyperlipidemia

Question 45

To Dx PBC... ``` No extrahepatic biliary obstruction + no liver comorbidities + 2 of... (3) ```

Answer 45

elevated Alk Phos (+) AMA Histologic evidence

Question 46

Which biliary d/o? MC in men Assoc. w. UC Leads to cholestasis, end-stage liver disease

Answer 46

PSC

Question 47

Male patient presents with... Fatigue Pruritus Jaundice Hepatomegaly

Answer 47

PSC

Question 48

Lab results for PSC

Answer 48

AMA NEG | cholestatic LFTs

Question 49

2 diagnostics helpful for PSC

Answer 49

cholangiography/MRCP/ERCP/PTC Liver Bx

Question 50

3 complications of PSC...

Answer 50

End-stage liver disease Hepatobiliary CA Colon CA

Question 51

Which biliary d/o? Inherited deficiency in biliary glucuronidation enzymes more common in men Elevated UCB w/o hemolysis

Answer 51

Gilbert Syndrome

Question 52

Does Gilbert Syndrome require Tx?

Answer 52

no

Question 53

Male patient p/w: mild intermittent jaundice triggered by dehydration, fasting

Answer 53

Gilbert Syndrome

Question 54

Which biliary neoplasm? MC CA of biliary tract Uncommon but fatal Incidental finding

Answer 54

gallbladder CA

Question 55

RF for gallbladder CA?

Answer 55

procelain gallbladder

Question 56

Which biliary neoplasm? Arise from epithelial bile duct cells Rare, but more common in men Associated with PSC and choledochal cysts

Answer 56

cholangiocarcinoma

Question 57

Patient p/w... ``` Jaundice Pruritus Abd. pain Wt. loss Fever (+) Courvoisier sign cholestatic LFTs ```

Answer 57

cholangiocarcinoma

Question 58

which biliary neoplasm? Near ampulla of vater Associated with FAP and HNPCC

Answer 58

ampullary carcinoma

Question 59

Patient p/w Obstructive Jaundice Occult GI bleed + microcytic anemia Abd. pain hx FAP or HNPCC

Answer 59

ampullary carcinoma