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Flashcards in Gallbladder Deck (58):
1

Pt presents with steady pain in the RUQ for the last 4 hours associated with N,V, and fever.

acute cholecystitis

2

if a pt presents with jaundice, light colored stools, and dark tea colored urine what do they have

extrahepatic biliary obstruction

3

how does a pt with biliary colic present vs acute cholecystitis

biliary colic-uncomfortable and restless

cholecystitis-still because pain is aggravated by movement

4

what is murphy's sign and what is it associated with

cessation of inspiration due to pain on deep palpation of the ruq when the visceral peritoneum overlying the gallbladder is inflamed

acute cholecystitis

5

courvoisier's sign

nontender palpable gallbladder w jaundice that suggests underlying malignant disease such as carcinoma of the pancreas

6

what lab tests should be obtained

LFTs
serum level of unconjugated bilirubin (hemolytic disorders);conjugated (extrahepatic obstruction)
alkaline phosphatase (ALP)- syn by biliary tract epithelium; differentiate it from bone by heat stability or elevation of GGT (ALP/GGT >AST/ALT)
INR- elev in pts w obstructive jaundice from malabsorption of vit K

7

what is the initial study of choice for pts w biliary disease

US

stones as small as 3mm in diameter

8

what does the finding of thickened gallbladder wall or pericholecystic fluid suggest

acute cholecystitis

9

how does the radionuclide biliary scan (HIDA scan) work

IV injection of 99techneitum derivative-> radionuclide excreted by the liver into bile in high concentrations --> enters gallbladder and duodenum

normal gallbladder begins to fill in 30m; if cant visualize common bile duct and duodenum wout filling of gallbladder in 4hr=cystic duct obstruction=acute cholecystitis

not useful for showing stones in either the gallbladder or common bile duct

10

leukocytosis,left shift, mild inc in AST/ALT/ALP, mild hyperbilirubinemia

acute cholecystitis

11

what is the initial management of acute cholecystitis

withholding oral intake
administering iv fluids
abx therapy

12

what bacteria is commonly assoc w acute cholecystitis

e choli
klebsiella
streptococcus faecalis

13

what is the tx for pts w acute cholecystitis who are poor surgical candidates

cholecystostomy- percutaneous placement of a tube under us guidance through the liver into the gallbladder to drain its contents

14

what is acute emphysematous cholecystitis

result from gas forming bacteria

will see air on xray

15

biliary colic, n, v, intolerance to fatty foods, flatulence, belching and indigestion; no fever or chills

chronic cholecystitis

16

management of an episode of biliary colic

analgesics and observations

after cholelithiasis is confirmed, the optimum tx is elective cholecystectomy

17

oral dissolution therapy

ursodeoxycholic acid taken for 6m-1yr

18

gallstones that pass through the cystic duct and enter common bile duct

choledocholithiasis

19

pt presents with jaundice, light colored stools and dark tea colored urine

obstruction of the bile duct

20

characterized y charcots triad

acute cholangitis

charcots- jaundice, ruq pain, fever

21

acute suppurative cholangitis

infx accompanying acute cholangitis that progresses to presence of pus in biliary ducts

22

presents with reynolds pentad

acute suppurative cholangitis

reynolds- ruq pain, jaundice, fever, hypotension, mental confusion

23

mirizzi's syndrome

large stone in the gallbladder compresses the common hepatic duct that can lead to obstructive jaundice

24

lab results for cholangitis

leukocyte count elev
total bili elev
serum ALP/GGT marked elev
AST/ALT mild elevations

25

management of acute cholangitis

urgent intervention
hydrated w IV fluids
abx
bowel rest
blood cx

26

why are gallstones a common cause of pancreatitis

transient or persistent obstruction of the ampulla of Vater by a large stone or passage of small stones and biliary sludge

27

management of pts w acute biliary pancreatitis

resuscitation
supportive care
correction of any fluid deficits

28

when can a laparoscopic cholecystectomy be safely performed with mild/moderate pancreatitis

within the first 48-72hrs of admission

29

what is performed if someone with gallstone pancreatitis is a poor surgical candidate

endoscopic sphincterotomy

30

when should a cholecystectomy be performed if pt has severe pancreatitis

delayed until pancreatitis has resolved some weeks or months later but make sure pt is placed on abx

31

what is a gallstone ileus

mechanical obstruction of the intestine caused by a large gallstone that erodes through the gallbladder into the duodenum; may be assoc w pneumobilia; point of obstruction is often in the distal ileum

32

what do plain abd xray show for gallstone ileus

findings of small intestinal obstruction and may show air in the biliary tree

33

what is the preferred dx test for gallstone ileus

ct with oral contrast

34

tx for gallstone ileus

NG tube for decompression of the obstruction
IV hydration
surgical exploration of the abd and an enterolithotomy

35

why does gallbladder cancer occur

chronic inflammation MC from cholesterol gallstones

36

Pt with ruq pain, weight loss, malaise and jaundice

gallbladder cancer

37

what are the majority of bile duct strictures a result from and why

iatrogenic injury during an operative procedure because of limited blood supply and no redundancy

38

procedure for open common bile duct exploration

1. mobilize the duodenum w Kocher maneuver
2. id the duct and make small longitudinal incision in common bile duct
3. irrigate lumen w saline using flexible catheters to flush out stones and debris
4. inflatable balloon catheters passed prox/dist to extract stones
5. small endoscope (choledochoscope)
6. all stones and debri removed, duct is irrigated with saline
7. T tube placed in lumen of duct and opening of duct is closed around it

39

when there are multiple stones or if stones left in bile duct what is important to be done during surgery

anastomosis between bile duct and GI tract (choledochoduodenostomy or choledochojejunostomy) so that residual stones may pass easily from duct into intestine

40

when is the peritoneal drainage catheter removed after T tube has been clamped during bile duct exploration

24-48hr

41

when are T tubes removed

3-6wks

42

how are MC bile duct stones removed

ERCP and sphincterotomy

43

how is a sphincterotomy of the sphincter of Oddi performed

special cautery wire passed through the duodenoscope into the sphincter and then the common duct is cleared using special balloon catheters or wire baskets

44

41yo F w 18hrs of N, ruq pain and fever. Ate heavy meal night before. Elev WBC, normal bilirubin, slightly elev AST/ALT. Most appropriate study?

US

most likely acute cholecystitis

45

51yo fever and abd pain, Temp 38.4C. tender w guarding of ruq. WBC 17000. LFs and lipase normal. US ids gallstones, gallbladder wall of 5mm, fluid surround gallbladder. what abx?

Cefoxitin

MC gram neg (e coli and klebsiella) want 2/3 cephalosporin

46

83yo 2d hx n/v. abd slightly distended and nontender. norm WBC and metabolic alkalosis. abd xray show small bowel obstruction and air in biliary tree. dx?

gallstone ileus

47

54yo abd pain for 8hrs. mid abd getting worse. elev wbc, amylase 792, normal lfts. US gallstones. Management?

admit, hold intake by mouth, schedule for cholecystectomy before discharge

48

72yo yellow eyes, dark urine, light stool. diminished appetite. afebrile. jaundiced. nontender smooth globular mass consistent w enlarged gallbladder in ruq. dx?

pancreatic cancer

49

what regulates bile flow into duodenum

sphincter of Oddi which encircles the common channel

50

what makes triangle of calot

inferior margin of liver, common hepatic duct, cystic duct

51

where does most bile acid reabsorption happen

level of terminal ileum

52

what makes bile more prone to stone formation

greater losses=diminished pool= dec concentration

53

what is responsible for the green brown color of bile and brown of stool

conjugated bilirubin

direct=water soluble=excreted in urine
indirect=fat soluble=no urine

54

ways to prevent gallstone formation

avoid obesity, high fiber diet, eat meals at regular intervals, foods w low levels of sat fatty acids

55

MC type of gallstones

cholesterol, bile acids, lecithin (phospholipid)= cholesterol crystals

56

where is the source of most stones found in the biliary ducts (choledocholithiasis)

gallbladder

57

how is biliary colic described

steady visceral dull/aching pain lasting 1-4hrs postprandial lg/fatty meal

58

what is acute cholecystitis

acute inflammation and infection of the gallbladder