Disorders Of Biliary Tract

Front 1

What is in the Calot's triangle?

Back 1

Common Bile Duct

Cystic Duct

Cystic artery

Front 2

What is in the Hepatocystic triangle?

Back 2

Inferior liver margin

Common Bile Duct

Cystic Duct

Front 3

What is Cholelithiasis?

Back 3

Gallstones

Front 4

In which population is Cholelithiasis more common?

Back 4

Women>Men 2:1

Front 5

True or False

Cholelithiasis increases in incidence in both sexes and all races with age.

Back 5

True

Front 6

Most gallstone are

a. symptomatic

b. asymptomatic

Back 6

B. asymptomatic (only 1-2% have risk of developing symptoms/yr)

Front 7

What are the 3 main types of Cholelithiasis?

Back 7

• Cholesterol stones
• Brown pigment stones
• Black pigment stones

Front 8

What is the most common type of Cholelithiasis and in which population does it occur in?

Back 8

Cholesterol stones

4F's Female Forty Fat Febrile

Front 9

In what setting is Brown pigment stones usually occurring in?

Back 9

In the setting of biliary infections

Front 10

When does Black pigment stones occur?

Back 10

As a consequence of increase in bilirubin load, as occurs in hemolytic anemia

Front 11

What is the clinical finding of Cholelithiasis?

Back 11

It is asymptomatic

Front 12

What is the laboratory finding of Cholelithiasis?

Back 12

Normal

Front 13

What diagnostic test if performed for Cholelithiasis?

Back 13

Typically incidental finding on abdominal US

Front 14

What is the treatment for Cholelithiasis?

Back 14

None or

Prophylactic cholescystectomy

Front 15

What is the most common complication of gallstone and 1 of the most common causes of surgical emergencies?

Back 15

Acute cholelithiasis

Front 16

What is acute cholelithiasis?

Back 16

Impaction of a gallstone in the neck of the gallbladder- inhibits biliary drainage and distention and edema of the gallbladder wall ensue

Front 17

What are the clinical findings for acute cholelithiasis?

Back 17

RUQ abdominal pain

Murphy's sign (inhibition of inspiration by pain on palpation of RUQ)

Guarding

N/V

Fever-typical

Front 18

What are the laboratory findings of acute cholelithiasis?

Back 18

CBC (Leukocytosis)

LFT (Possible elevation of ALT, AST, Total bilirubin, ALK Phos), elevation of Amylase

Front 19

What imaging studies can be done to diagnose acute cholelithiasis?

Back 19

• Abdominal US (may show gallstones but is not sensitive for acute cholelithiasis)
• Cholescintigraphy (Hepatic Iminodiacetic Acid HIDA) Scan
• Paraisopropyl Iminodiacetic Acid (PIPIDA) scan (reveals obstructive cystic duct, Measures Ejection fraction Normal >35%)

Front 20

What is the treatment for acute cholelithiasis?

Back 20

• NPO
• IV Hydration
• IV Antibiotics (ciprofloxacin 500 mg IV qd, metronidazole (Flagyl) 500 mg IV q6h, ampicillin-sulbactam (Unasyn)
• IV analgesics
• Immediate cholecystectomy if mild symptoms
• For moderate to severe symptoms, cholecystectomy after 2-4 d of therapy

Front 21

Due to high risk of recurrence what should be performed first for acute cholelithiasis?

Back 21

Laproscopic cholecyestectomy is always attempted first (5-10% chance of becoming open procedure)

Front 22

What is acalculus cholecystitis?

Back 22

Acute necroinflammatory disease of the gallbladder with a multifactorial pathogenesis, without the presence of cholelithiasis-10% and occurs due to chronic stasis of bile in the gallbladder

Front 23

Which patients are more likely to get acalculus cholecystitis?

Back 23

Critically ill patients (trauma, burns, prolonged fasting) and Immunosuppressed patients (HIV/AIDS)

Front 24

What is Choledocholithiasis?

Back 24

Choledocholithiasis is the common bile duct stones which is the most common cause of cholangitis

Front 25

What is Cholangitis?

Back 25

Oobstruction of the bile duct by choledocholithiasis complicated with bacterial infection (originates from intestinal flora)

Front 26

What are the clinical findings of Choledocholithiasis/Cholangitis?

Back 26

Charcot triad (right upper quadrant abdominal pain, fever, jaundice)

Mental status changes

Hypotension

Front 27

What is Reynolds pentad?

Back 27

It is a combination of Charcot's triad (jaundice, fever, abdominal pain (usually RUQ)) with shock and an altered mental status that diagnoses obstructive ascending cholangitis

Front 28

What are the laboratory findings of Choledocholithiasis/Cholangitis?

Back 28

Leukocytosis

LFTs Alk Phos very high, Bilirubin > 3 mg/dL, Trasaminase very high >1000 unit/L , PT/INR elevated

Front 29

Which imaging studies will show dilated bile duct?

Back 29

US and CT

Front 30

Which imaging studies will show an accurate demonstrating bile stone and can be used in pots thought to be at intermediate risk for choledocholithiasis?

Back 30

MRCP

Front 31

Which imaging study is the most accurate and can be therapeutic?

Back 31

ERCP

Front 32

What is the treatment for Choledocholithiasis/Cholangitis??

Back 32

Endoscopic sphincterotomy and stone extraction followed by laparoscopic cholecystectomy (2-5% chance of postoperative pancreatitis)

Front 33

What is Mirizzi Syndrome?

Back 33

External compression of the common hepatic duct from a large stone lodged in the cystic duct

Front 34

True or False

Mirizzi Syndrome is an uncommon disorder with 0.1% of all patients with gallstones.

Back 34

True

Front 35

What are the clinical findings for a patient with Mirizzi Syndrome?

Back 35

Cholestasis, pain, jaundice

Front 36

What imaging studies can be done to diagnose Mirizzi Syndrome?

Back 36

US, CT, MRCP

Front 37

What is the most common biliary tract malignancy?

Back 37

Gallbladder cancer

Front 38

What is the prognosis for gallbladder cancer?

Back 38

Very poor prognosis because usually diagnosed at advanced stage

5 yr survival rate 0-10%

Present in 2% of elective cholecystectomy pts.

Front 39

What are the risk factors for gallbladder cancer?

Back 39

Gallstones (65-90% of cancer pts have gallstones and 1-3% of pts with known gallstones develop g. cancer)

Calcified gallbladder

Gallbladder polyps >1cm=cholecystectomy

Anomalous pancreticobiliary duct anatomy

Obesity

Estrogen

Front 40

What imaging studies are done to show polypoid lesion without acoustic shadowing for gallbladder cancer?

Back 40

US

Front 41

What imaging studies are done to diagnose and stage gallbladder cancer?

Back 41

EUS

Front 42

What imaging studies are done to confirm extent of spread and involvement of vessels and lymph nodes gallbladder cancer?

Back 42

CT, MRI

Front 43

How do you treat gallbladder cancer?

Back 43

Surgical resection

Adjuvant radiation and chemotherapy

Front 44

What is cholangiocarcinoma?

Back 44

Tumors that arise from the biliary tract (low incidence and poor prognosis 5 yr survival rate 20-35% with successful resection)

Front 45

What are risk factors for cholangiocarcinoma?

Back 45

Primary Sclerosing cholangitis

Ulcerative colitis

Intrahepatic bile duct stones

Liver flue infestation

Front 46

What are the clinical findings of cholangiocarcinoma?

Back 46

Painless jaundice

Pruritis

Weight loss

Front 47

What laboratory findings are seen in pt with cholangiocarcinoma?

Back 47

CA19-9 may be elevated, but not specific (pancreatic, colorectal, esophageal, hepatocellular cancer)

Front 48

What imaging studies are done to diagnose cholangiocarcinoma?

Back 48

The modality of choice is MRCP