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17 Cards in this Set

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מטרת הבדיקה ERCP
הדגמה ויזואלית של דרכי מרה ולבלב
חולה בן 40 עם כאבי בטן ימנית עליונה וצמרמורת.בבדיקה חום 38,5 מעלותוכמו כן צהבת על פני העור ובלחמיות.
האבחנה?
ascending cholangitis
Charcot's triad
-jaundice
-fever usially with rigors
-pain in RUQ
Reynold's pentad
-jaundice
-fever usially with rigors
-pain in RUQ
-hypotension
-mental status changes
laparascopic cholecystectomy
dissection of gallblader
כולו
pain is a prominent feature of cholecystitis .

which agent is not given as an analgetic,why
MO
because of possibility of increasing tone at the sphincter of Oddi.

Meperidine(Demerol) is given instead (strong opoid)
Acetominophen(Acamol)
diclofenac(Voltaren)(COX1)
common ERCP complication
של דרכי מרה perforation
סיבוכים של אבנים בכיס המרה, הכל פרט ל:
-common bile duct stones
-billiary sepsis
-hepatitis
-gallstone pancreatitis
hepatitis
A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128.
Dx?
Diagnostic test if stable?
Diagnostic test if crashing?
Tx?
Dx: Ruptured spleen

Management if Stable: CT Scan
(if he responds promptly to fluid administration, and does not require blood; further management in that case may well be continued observation with serial CT scans)

Management if “crashing”: Peritoneal Lavage or Sonogram followed by (Tx)Exploratory Laparotomy
(2)
A 43-year-old white woman presents to the emergency department with 1 day of increasingly severe pain localized to the right upper quadrant and radiating to the right lower scapula. She has also been experiencing nausea and vomiting. The woman has had similar, but milder, episodes of pain in the past, which had resolved spontaneously in a few days. Physical examination demonstrates involuntary guarding of abdominal muscles on the right. The gallbladder is palpable. Which of the following is the most appropriate next step in diagnosis?

A. CT scan
B. Endoscopic retrograde cholangiography
C. Esophagogastroduodenoscopy
D. MRI scan
E. Ultrasound
The correct answer is E. The presentation is typical for acute cholecystitis, which occurs most frequently in the setting of holelithiasis (gallstones). Other common features include an initially low-grade fever with neutrophilia and painful splinting during deep breathing. Serum amylase is typically elevated in gallstone pancreatitis. Seriously ill patients with high fever, rigors, or significant rebound tenderness may require urgent surgical intervention; in less seriously ill patients, it is feasible to establish the diagnosis and defer surgical intervention until after the acute episode has resolved. In most hospitals, ultrasound is ordered first, since this relatively inexpensive, fast, and noninvasive study can usually establish the presence of gallstones. In atypical cases, when acute cholecystitis without stones is present, cholescintigraphy using radioactive technetium 99m may be used to sequentially visualize the liver, extrahepatic bile ducts, gallbladder, and duodenum.

CT (choice A) and MRI (choice D) scans are expensive and are usually not required for typical acute cholecystitis.

Endoscopic retrograde cholangiography (choice B) can be helpful in defining a small stone in the extrahepatic bile duct system, but it is not usually used as an initial test.

Esophagogastroduodenoscopy (choice C) would not be helpful in classic gallstone disease, but might demonstrate a duodenal cancer compressing the ampulla of Vater if a patient with what appeared clinically to be gallstone disease had a negative ultrasound.
A 32-year-old man presents complaining of severe pruritus over the past 2 weeks. He has a history of ulcerative colitis for the past 7 years, which has remained well controlled on sulfasalazine and cortisone enemas. His physical examination is unremarkable except for evidence of diffuse excoriations on his extremities and trunk. Laboratory studies reveal a mild iron deficiency anemia and normal electrolytes. Liver function tests are normal, except for an alkaline phosphatase that is 322 U/L (normal, <110 U/L). Which of the following is the most likely explanation for his symptoms?
A. Erythema nodosum
B. Hepatitis C
C. Primary biliary cirrhosis
D. Primary sclerosing cholangitis
E. Pyoderma gangrenosum
The correct answer is D. This patient has had longstanding ulcerative colitis and has now developed pruritus in the setting of an elevated alkaline phosphatase. This is consistent with a diagnosis of primary sclerosing cholangitis, whose activity is not related to the activity of the associated ulcerative colitis. This sclerosing process involves both the intra- and extrahepatic ducts and is diagnosed by endoscopic retrograde cholangiopancreatography (ERCP). Primary sclerosing cholangitis occurs most often in young men and is commonly associated with inflammatory bowel disease, particularly ulcerative colitis. Classically, primary sclerosing cholangitis produces a triad of progressive fatigue, pruritus, and jaundice, although some patients will present with upper quadrant pain, fever, hepatosplenomegaly, or cirrhosis. The condition is worrisome because it may eventually progress to decompensated cirrhosis, portal hypertension, ascites, and liver failure. Treatment is generally supportive, with more specific measures as needed including antibacterial treatment for superimposed bacterial cholangitis, dilation by endoscopy or a transhepatic route of significant strictures, and ursodeoxycholic acid to relieve the pruritus. A variety of anti-inflammatory therapies (e.g., corticosteroids, azathioprine, methotrexate) have been tried but appear to have more adverse than beneficial effects. Liver transplantation appears to be the only true cure.

Although erythema nodosum and pyoderma gangrenosum can be skin conditions seen in association with ulcerative colitis, they do not present with pruritus and, furthermore, have characteristic findings on physical examination. Erythema nodosum (choice A) presents as tender, red nodules, typically found on the lower extremities. Pyoderma gangrenosum (choice E) are pustular, ulcerating lesions, also generally found on the extremities, which can be very painful.

There is no evidence of hepatocellular dysfunction or transaminase elevation, nor any history of hepatitis risk factors, so hepatitis C is unlikely (choice B).

Primary biliary cirrhosis (choice C) does in fact present with pruritus and an elevated alkaline phosphatase; however, it is typically seen in middle-aged women and has no association with ulcerative colitis.
A 44-year-old obese woman presents to the emergency department complaining of 3 hours of severe abdominal pain. She has also had multiple episodes of vomiting during this time. She describes the pain as "worse than labor," and it radiates to the interscapular region. Her temperature is 38.9 C (102 F), and she has severe tenderness in her right upper quadrant. She reports that she has had multiple similar episodes in the past that have lasted approximately 30 minutes and then resolved spontaneously. Which of the following is most likely being obstructed by a gallstone?

A. Common bile duct
B. Common hepatic duct
C. Cystic duct
D. Pancreatic duct
E. Right hepatic duct
The correct answer is C. This patient with acute cholecystitis has multiple risk factors, including female gender, obesity, and a classic history of prolonged biliary colic in association with fevers. The presentation illustrated is typical and results from obstruction of the cystic duct, which drains the gallbladder.

Obstruction of the common bile duct (choice A) or the pancreatic duct (choice D) will produce acute bacterial cholangitis, which would be demonstrated by Charcot's triad, i.e., right upper quadrant pain, fever, and jaundice.

Obstruction of either the common hepatic duct (choice B) or the right hepatic duct (choice E) may give a limited episode of cholangitis but will not cause cholecystitis, since the obstruction occurs in the biliary tree above the level of the entry of the cystic duct.
A 51-year-old man presents to the emergency department with abdominal pain. He was well until 2 days ago, when he began to experience severe right upper quadrant pain, radiating to the epigastric region. He reports temperatures to 38.3 C (101 F) and some nausea and vomiting. His temperature is now 39.1 C (102.3 F), blood pressure is 130/70 mm Hg, and pulse is 90/min. Physical examination reveals tenderness in his right upper quadrant, with abrupt cessation of inspiration on deep palpation of his right upper quadrant. Which of the following is the most appropriate management for this patient?

A. IV fluids and observation
B. IV antibiotics and observation
C. Admission to a surgical service for next day surgery
D. Urgent surgical evaluation for immediate surgery
E. Urgent percutaneous drainage
The correct answer is C. This patient has symptomatic cholecystitis. This complication is most commonly associated with long-standing gallstones and less frequently with severe illness (so-called acalculous cholecystitis). The therapy for such patients is usually prompt surgical removal of the inflamed gallbladder. If left in place, there is an increased risk of infection, abscess formation, or sepsis. All such patients should receive IV fluids, resuscitation, and, if very ill appearing, coverage with broad-spectrum antibiotics.

IV fluids and observation (choice A) and IV antibiotics and observation (choice B) are inappropriate since the patient requires surgery. Failure to recognize this fact will result in serious morbidity. Once the patient is appropriately referred, then fluids and possibly antibiotics are crucial components of therapy.

Urgent surgical evaluation for immediate surgery (choice D) is not appropriate since the patient appears stable, although febrile and uncomfortable.

Urgent percutaneous drainage (choice E) is an interventional radiology procedure that allows for drainage of the gallbladder. These procedures are usually reserved for very ill patients who could not tolerate surgery and general anesthesia.
A 44-year-old woman with a history of recurrent biliary colic presents with 18 hours of very severe right upper quadrant pain, fever, and jaundice. An abdominal ultrasound reveals a markedly dilated common bile duct. Multiple gallstones are seen in the gallbladder. Which of the following would best determine whether there is cystic duct obstruction?

A. Abdominal CT scan
B. Abdominal MRI
C. Abdominal ultrasound with Doppler flow studies
D. Endoscopic retrograde cholangiopancreatograph (ERCP)
E. HIDA scan
The correct answer is E. This patient has evidence of a prolonged episode of biliary colic, which may progress to acute cholecystitis. An abdominal ultrasound has revealed a markedly dilated common bile duct, as well as gallstones within the gallbladder. Acute cholecystitis is the result of cystic duct obstruction, and this would be best demonstrated by a HIDA scan. A HIDA scan measures flow of iminodiacetic acid, which follows the flow of bile, i.e., from the blood stream into the liver, into the gallbladder, and then through the cystic duct into the common bile duct. If there is cystic duct obstruction, the common bile duct is not visualized on the HIDA scan.

An abdominal CT scan (choice A) may reveal gallstones and pericholecystic changes but does not demonstrate good visualization of the cystic duct.

Abdominal MRI (choice B) is not effective in the demonstration of cystic duct obstructions.

An abdominal ultrasound (choice C) is not as effective in revealing cystic duct obstructions, and Doppler flow studies are useful for blood flow patterns but would not assist in the diagnosis of acute cholecystitis.

An endoscopic retrograde cholangiopancreatograph (ERCP) (choice D) is more effective in demonstrating the intra- and extrahepatic biliary trees but is not as effective in demonstrating the cystic duct.
A 44-year-old school bus driver presents to the emergency department complaining of severe abdominal pain. She reports that the pain began approximately 8 hours ago, after eating lunch at a fast-food restaurant. The pain has become increasingly severe and radiates to her back. She recalls a similar episode, lasting 3 hours, 2 months earlier and another episode, lasting 12 hours, during her last pregnancy. She is febrile, with a temperature of 38.1 C (100.5 F), and has right upper quadrant tenderness with deep palpation of this area. A rectal examination reveals brown, guaiac-negative stool. Her WBC is 12,900/mm3, and her hematocrit is 39%. Her total bilirubin is 2.1 mg/dL. Which of the following is the most appropriate diagnostic test?

A. CT scan of the abdomen and pelvis
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. HIDA scan
D. Percutaneous transhepatic cholangiogram (PTC)
E. Upper gastrointestinal barium study
The correct answer is C. This patient has the classic presentation of acute cholecystitis. The episodes she had several months ago and during pregnancy suggest a prior history of biliary colic. A HIDA scan is a noninvasive nuclear medicine test that will reveal obstruction of the cystic duct, which is caused by an impacted gallstone and is the cause of acute cholecystitis.

A CT scan (choice A) may show a distended gallbladder, but it is not as accurate as a HIDA scan for evaluating the cystic duct.

Endoscopic retrograde cholangiopancreatography (ERCP) (choice B) is useful for evaluation of the common bile duct but is of a less value in evaluation of the cystic duct and, furthermore, is a far more invasive test than a HIDA scan.

Percutaneous transhepatic cholangiography (PTC) (choice D) is an examination that is performed by the interventional radiologist by injecting the intrahepatic biliary tree percutaneously. This is rarely done since ERCP is a more accurate evaluation of the biliary of tree. PTC is of limited value in evaluating the cystic duct and it is an invasive procedure.

An upper gastrointestinal barium study (choice E) may be useful for the evaluations of peptic ulcer disease but the symptoms here are far more suggestive of acute cholecystitis. Furthermore, if the patient has been vomiting she is unlikely to tolerate this examination.
A 28-year-old man with a 15-year history of ulcerative colitis and primary sclerosing cholangitis has recent worsening of his jaundice. His symptoms of ulcerative colitis have been in remission for the past year. He now complains of the onset of steatorrhea approximately 3 months ago and a 12-pound weight loss during that time. Which of the following would most likely account for this patient's recent symptoms?

A. Bacterial overgrowth
B. Bile salt deficiency
C. Celiac sprue
D. Tropical sprue
E. Whipple disease
The correct answer is B. This patient has a history of ulcerative colitis and primary sclerosing cholangitis. He has developed steatorrhea as the result of poor delivery of bile salts into the small intestine. This occurs because of intra- and extrahepatic duct stricturing of the biliary tree, which prevent adequate delivery of bile salts to the small bowel. In the absence of adequate bile salt, maldigestion of fats occurs, since micelle formation does not occur.

Bacterial overgrowth (choice A) does not occur specifically in patients with ulcerative colitis or primary sclerosing cholangitis. It typically results from an underlying anatomic or motility disturbance, such as a blind loop, hypomotility, a fistula, or a stricture.

Celiac sprue (choice C) is not associated with ulcerative colitis or primary sclerosing cholangitis.

Similarly, tropical sprue (choice D) is not associated with this patient's symptoms of colitis or primary sclerosing cholangitis. Furthermore, there is no travel history to suggest exposure.

Whipple disease (choice E) is a multi-systemic disease that causes characteristic small bowel biopsy findings and results in malabsorption. It is also associated with hyperpigmentation, lymphadenopathy, cardiac disease, and rheumatologic disturbances.
A 40-year-old, obese, white woman, mother of five children, gives a history of repeated episodes of right upper quadrant abdominal pain. The pain is brought about by the ingestion of fatty foods and is relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. The patient has no pain at this time, but is anxious to avoid further episodes. She is afebrile, and physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A. Sonogram of the biliary tract and gallbladder
B. Upper gastrointestinal series with barium
C. Antibiotics, IV fluids, and nothing by mouth
D. Endoscopic retrograde cholangiopancreatogram (ERCP)
E. Exploratory surgery
The correct answer is A. The clinical description is classic for biliary colic, due to gallstones that are intermittently impacted at the cystic duct. The diagnostic study of choice to confirm the presence of gallstones is a sonogram.

An upper gastrointestinal series (choice B) will miss the diagnosis. This woman does not have a problem in her stomach or duodenum. She has to be suspected of having gallstones, and the study has to target that area.

Antibiotics and IV fluids (choice C) are required to "cool down" an episode of acute cholecystitis. However, this woman does not have fever, leukocytosis, and a tender right upper quadrant. She does not have acute cholecystitis.

Endoscopic retrograde cholangiopancreatogram (ERCP) (choice D) would be an expensive, invasive, and totally unjustifiable way to take a look at the gallbladder.

Exploratory surgery (choice E) would be even worse. This woman will need surgery, but it should be directed at the gallbladder and done laparoscopically as an elective procedure (i.e., at a convenient time) after a diagnosis has been confirmed.