Biliary Popcorn

Question 1

• Elevated bilirubin
• Elevated bilirubin direct
• Elevated bilirubin indirect
• ALT & AST are elevated
• Protime (PT) – ordered w/ INR
• Labs indicative of liver infection (hepatitis labs)

Answer 1

LFT elevation due to Inflammation / Hepatocellular Damage

Question 2

• ↑Bilirubin elevated
• ↑Bilirubin Direct (conjugated)
• ↑Bilirubin Indirect (unconjugated)
• ↑Alkaline Phosphatase
• May see GGT
• ↓Urine Urobilinogen

Answer 2

LFT elevation due to Cholestasis (obstruction such as Choledocholithiasis)

Question 3

• ↓Albumin LOW
• ↓Total Protein LOW
• ↑PT prolonged/HIGH (ordered w/ INR)
• ↑INR increased

Answer 3

LFT elevation due to Reduced Liver Function

Question 4

Is urobilinogen normally in the urine?

Answer 4

YES

Question 5

Is Bilirubin normally in the urine?

Answer 5

NO

Question 6

Blood:

• ↑ bilirubin
• Normal ALP
• Normal ALT

Urine:

• Urobilinogen present +
• Bilirubin absent -

Answer 6

Pre-hepatic

Question 7

Blood:

• ↑ bilirubin
• Normal or ↑ ALP
• ↑↑↑ ALT

Urine:

• Urobilinogen: Present (normal)
• Bilirubin: Present (abnormal)

Answer 7

Hepatic

Question 8

Blood:

• ↑ bilirubin
• ↑↑↑ ALP
• Normal or ↑↑↑ ALP

Urine:

• Urobilinogen: absent - (abnormal)
• Bilirubin: present + (abnormal)

Answer 8

Post-hepatic

Question 9

stones in the gallbladder

Answer 9

Cholelithiasis

Question 10

inflammation of the GB

Answer 10

Cholecystitis

Question 11

stones in the CBD

Answer 11

Choledocholithiasis

Question 12

inflammation of the bile ducts

Answer 12

Cholangitis

Question 13

disruption of bile flow…regardless of cause

Answer 13

Cholestasis

Question 14

Which condition?

• Female, fluffy, forty, fertile
• Ethnicity: native americans, hispanics, caucasions
• Cholesterol stones are MC type!!!
• Initially order an US

Answer 14

Cholelithiasis

Question 15

CCY (cholecystectomy) is recommended in which patient w/ cholelithiasis??

Answer 15

Symptomatic! (biliary colic)

Question 16

Which condition?

• TEMPORARY obstruction (4-6 hrs)
• no inflammation
• “gallbladder attack” after fatty meal
• “symptomatic biliary disease”
• Dull RUQ pain

Answer 16

Biliary Colic

Question 17

4 conditions where US is intitial test of choice?

Answer 17

Cholelithiasis

Biliary Colic

Acute Cholecystitis

Choledocholithiasis (RUQ US)

(BACC)

Question 18

Which condition?

• Does not appear ill
• NO jaundice
• Negative murphy’s sign

Tx?

Answer 18

Biliary Colic

Tx: Prophylactic CCY

Question 19

Which condition?

• Functional GB disorder
• Motility disorder of GB
• NO gallstones, so can do HIDA w/ CCK –> EF <35-40%

Tx?

Answer 19

Biliary Dyskinesia

• Tx: CCY if HIDA w/ low EF
• ***Do not give CCK if pt has gallstones****

Question 20

Which condition?

• Sustained obstruction of cystic duct
• Acute inflammation of GB
• Prior hx of biliary colic
• SEVERE RUQ pain –> R shoulder/R flank
• PERSISTENT sxs (>6 hours)
• ↑ WBC w/ left shift
• Get US initially, HIDA to confirm

Tx?

Answer 20

Acute Cholecystitis

Tx:

• Admit, analgesics, IV abx (Piper Taco, Cef+Metro, Cipro+Metro)
• Early CCY
• Emergency CCY if severe complication (gangrene)

Question 21

Which condition?

• Gangrene
• Cholecystoenteric fistula
• Ill appearing
• Palpable/Tender GB
• ++ Murphy’s sign
• Guarding/Rebound
• NO jaundice

Answer 21

Acute Cholecystitis

Question 22

Tx for Acute Cholecystitis

ASA class 1 or 2

(healthy / low risk pt)

Answer 22

Early CCY (on initial hospitalization)

Question 23

Tx for Acute Cholecystitis

ASA class 3, 4, 5

(High risk pt)

Answer 23

• Supportive
• Consult specialist for surgery clearance
• Failure of therapy–> percutaneous CCY tube for decompression

Question 24

Which condition?

• Mechanical irritation from gallstones / repeated acute choleystitis
• Dx made upon reviewing histology s/p CCY

Answer 24

Chronic Cholecystitis

Question 25

**Which condition?** * Critically ill pts * Stasis/ischemia * Pt hospitalized / worse prognosis * Jaundice / No gallstones * Secondary infection of GB is COMMON! --\> broad abx **Tx?**

Answer 25

**Acalculous Cholecystitis** **Tx:** Prompt tx w/ CCY or Cholecystostomy

Question 26

**Which condition?** * Blocks flow of bile --\> jaundice * Hx of biliary colic * RUQ/Epi pain * Clay stool / Cola urine * Jaundice * Pruritis * RUQ US is intitial test **Tx?**

Answer 26

**Choledocholithiasis** **Tx:** 1. Remove stone (ERCP is preferred therapy test) 2. CCY 3. Prophylactic abx (piper-taco, Cef+Metro, Cipro+Metro)