Gi - 3-1 - Gallbladder And Biliary Tract Cases Only

Front 1

Jaundice

Back 1

Due to excess bilirubin.

Indirect or direct tells you if it is due to the liver, post-hepatic or prehepatic.

Front 2

RUQ/epigastric pain tells you...

Back 2

if there is organ injury, distention or inflammation.

Front 3

36 yo female, 3 months post partum
3 hours epigastric pain , 2 hours after a fried chicken family picnic
+ RUQ pain on palpation with inspiration
Murephy’s sign
Labs: WBC 12,000, Alk Phos 350, Bilirubin 0.2, ALT/AST 38/42

Back 3

Dx is acute cholecystitis.

2 hours is a little long for the biliary tree to get stimulated. But Murphy's sign is there and alk phos tells you there is inflammation and biliary/endothelial cell damage

Front 4

58 yo obese woman
2 months of intermittent epigastric pain
Usually after meals, lasts 1-3 hours

Normal labs

PPIs give some relief

Back 4

Not peptic ulcer because doesn't alleviate with meals.

Maybe spasm of the gall bladder neck due to biliary gall bladder stone without inflammation

Front 5

Severe pain with nausea an hour after a heavy meal.

fever, HR 105, RR 95/65
Scleric icterus
RUQ/epigastric tenderness, no Murphy’s

Back 5

Septic shock

Front 6

Labs:
WBC 16 (left shift)
Bili 7, ALP 350, AST 92, ALT 87

US: Gb stones, CBD 12mm

Back 6

this tells you that bilirubin is high and enzymes in gen are elevated.

common bile duct is dilated (should be a millimeter per decade of age).

most likely obstruction of the bile duct.

Front 7

Charcot's triad

Back 7

For cholangitis (infection of CBD often after obstruction).

pan emergency.

RUQ pain, fever, jaundice.

Must drain this.

Front 8

Raynold's pentad

Back 8

suggesting the diagnosis of septic or ascending cholangitis, a serious infection of the biliary system. It is a combination of Charcot's triad 2 (jaundice, fever, RUQ pain) with hypotension (low blood pressure) and an altered mental state.[1]

Front 9

ERCP

Back 9

endoscopic retrograde cholangiopancreatography

Infection that causes septic pressure.

This can dx and tx (decompress) it

Front 10

Cholecystitis vs. biliary obstruction

Back 10

Cholecystitis won't be a severe cramping pain while biliary obstruction will be.

Prior pain episodes makes you think of inflammation (cholecystitis) more than obstruction.

Front 11

73 yo M with painless jaundice x2-3 wks

Afebril, 115/85, 76
Jaundiced
Abd. nontender, no HSM
No signs of chronic liver disease

Labs:
Bili 15, AP 940, GGT 1040, AST/ALT 52/43
WBC normal

Back 11

Malignancy - Pancreatic or cholangial carcinoma.

Painless and age is a risk factor.

Normal transaminases tell us hepatocytes are not injured.

Alk phos and bili tells us that is it obstructive and ductal endothelial tissue is involved.

Front 12

Is there pain with hepatitis

Back 12

yes, usually.

Front 13

DDx for inflammatory biliary stricture (narrowing)

Back 13

PSC (primary sclerosing cholangitis)

postoperative strictures

ischemic

autoimmune

Front 14

DDx for tumor causing biliary stricture

Back 14

cholangiocarcinoma - dx by brushing and cholangioscopic biopsy

metastatic lesion

Front 15

cases at the end.

Back 15

Go through and think abt the next cases. He made it seem like we need to know this. He also said “slide 40” where it goes through the probabliilities of the diseases is a good one too…