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Biliary Tract Dz

Clinical Medicine I

Cholelithiasis the presence of gallstones in the gallbladder
Cholecystitis gallstone obstruction of the cystic duct, causing inflammation and infection
Choledocholithiasis gallstones in commone bile duct
cholangitis gallstone obstruction of biliary or hepatic ducts: inflammation and infection
Formation of a gallstone cholesterol or calcium bilirubinate in bile above solubility
Risk Factors of Cholesteral gallstones Female, European/NA ancestry, Age, Obesity, pregnancy, gallbladder stasis, drugs, heredity
RF pigment gallstones associated w/ disorders of hemolysis (sickle cell, hereditary spherocytosis, beta-thalassmia
Cholelithiasis sxs Biliary colic, RUQ, radiation to R scapular tip (Collins sign, post fatty meal, last 1-5 hrs, N/V, sporadic and unpredictable
Collins Sign Pain radiating to R scapulalr tip
Cholelithiasis Signs asymptomatic in PE
Causes of fever, tachy, hypotension, jaundice w/cholelithiasis cholecystitis, cholangitis, pancreatitis,
Diagnosis of Cholethiasis US is gold standard,
Tx of Cholelithiasis Removal of gallbladder w/ complications and repeated episodes, Ursodiol
Ursodiol Med to help dissolve gallstones
Complications of stones in gallbladder Acute cholecystitis, chronic cholecystitis, gallbladder empyema, gallbladder cancer, gallstone ileus
Complications of stones in bile duct ascending cholangitis, acute pancreatitis
Alarming sxs d/t cholelithiasis epigastric pain>20 mins, N/V or fever with it, pain>1hr seek medical attention
Types of cholecytitis acute calculous (90%) and Acute acalculous (10%)
Etiology of calculous cholecystis Female, ethnic groups, obesity or rapid wt loss, drugs, pregnancy, increasing age (MC in Females)
Etiology of acalculous cholecytitis critical illness, major surgery, sepsis, long-term parenteral nutrition, prolonged fasting (Biliary stasis)(Males)
Signs of cholecystitis Fever, tachy, tenderness in RUQ w/guarding or rebound, jaundice, pain diffuse >6hrs
Lab tests for cholecystitis Leukocytosis, ALT, AST, bilirubin, alk phose elevation, amylase/lipasse r/o pancreatitis, urinalysis r/o pylonephritis, pregnancy test
Gold standard to dx cholecystitis Ultrasound, CT for extrabiliary disorders
Tx Cholecystitis Initial: Bowel rest, IV hydration, IV abx, analgesia, Complicated: cholecystectomy
Criteria for uncomplicated cholecystitis nl vitals, labs, US, underlying medical problems, proper at home care and analgesics
Complications of Cholecystitis Usually rare, but w/ surgery, perforation/gangrene can occur
Lab Dx of Choledocholithiasis Elevated AST, ALT, bili, alk phos,
Imaging Dx choledocholithiasis EUS, MRCP
Tx ERCP, endoscopic retrograde cholangiopancreatography
Etiology of Cholangitis Choledocholithiasis, biliary tract manipulations/intervations, stents
Clinical Presentation of Cholangitis Charcot's triad, mental confusion, bacteremia, septic shock
Dx Cholangitis Leukocytosis, ^ bilirubin, alk phos leves, + blood cultures, Ultrasoud will confirm
Tx Cholangitis Nonsuppurative: abx, Suppurative ~100% death unless obstruction is relieved and drained (ERCP)
Etiology of Gallbladder Cancer Chronic inflammation, unusual: sclerosing cholangitis, ulcerative colitis, exposures and bacterial infections (62066yo)Females
Clinical presentations of gallbladder cancer similar to biliary colic, abd pain, more diffuse, anorexia, wt loss
GB cancer signs Jaundice, palpable GB (Courvoiser's sign) palbable nodes into umbilicus, Virchow node papable, palpable mass in digital rectal exam
Virchow node left supraclavicular adenopathy
Sister Mary Joseph nodes Palpable nodules buldging into the umbilicus
Courvoisier's Sign Palpable gallbladder
Dx of GB cancer CA 19-9 may be elevated, anemia, ^alk phos, bilirubin, US and CT to identify masses
Tx of GB cancer Complete resection, adjuvant radiation and chemo, survival 10-20% 5yr survival, advanced 2-4months
Patho of acute pancreatitis Injury to pancreas causes an inflammatory response, ^pancreatic vascular permeablity=hemorrhage, edema, eventually necrosis
Etiology of acute pancreatitis Gallstones, alcohol, post ERCP, hypertriglyceridemia, drug-related, apolipoprotein CII deficiency
causes in M/F Males: usually alcohol (39yo), Females: biliary tract related (69yo)
Sxs acute pancreatitis abd pain, steady and boring, usually >1day, epigastric and periumbilical regions, radiate to back, bhest, flanks N/V/D
When is pain worse for acute pancreatitis in supine position
Signs of acute pancreatitis Fever, tachy, hypotension, abd tenderness, guarding, distention, hypoactive bowel sounds
Signs of necrotizing pancreatitis Cullen's sign & turner's sign
Cullens sign bluish discoloration around the umbilicus
Turner sign bursing of the flanks
Dx labs of acute pancreatitis ^amylase or lipase-more specefic to pancrease) Leukocytosis, Hemoconcentration (>44)& azotemia (>22)
Suggests gallstone pancreatitis ^AST, ALT, alk phos, total biliary rased
Dx of choice of acute pancreatitis CT, US only to detect gallstones
Dx requires 2/3 for Acute pancreatitis -typical abd pain, -^amalase/lipase -radiology findings
Ransons Criteria If score >= 3 severe pancreatitis is likely
Tx acute pancreatitis bowel rest, NPO, IV fluids, oral intake once pain-free, no N/V nl bowel sounds and hungry (cholecystectomy if appropriate)
Complications of acute pancreatitis acute fluid collection, pseudocyst, pancreatic necrosis, intra-abdominal infections
Fluid encolsed by granulation tissue (develops 4-6 weeks) pseudocyst
Chronic inflammatory proccess that leads to IRREVERSIBLE fibrosis, w/ calcification Chronic Pancreatitis
Etiology of chronic pancreatitis alcohol and CF in kids (25% idiopathic)
What can happens w/ Chronic pancreatitis? obstruction, toxinn or toxic metabolites, oxidative stress, necrosis-fibrosis, ischemia, autoimmune?
Epidemiology chronic panreatitis 3X higher in African americans, alchol-induced dx~46yo
Sxs of chronic pancreatitis abd pain varying location,severity, frequency, maldigestion,
Signs of chronic pancreatitis mild tenderness, inconsistent w/ sevarity of pain the pt reports
Dx C. pancreatitis secretin stimulation test* ^amylase/lipase, blood glucose, bilirubin and alk phose
Tx of C. pancreatitis Cessation of alcohol consumption, pancreatic enzymes, acid supression, analgesics, Maybe surgical intervention
Complications of chronic pancreatitis pseudocyts, obstruction, narcotic addiction, impared glucose tolerence, GI bleeding, jaunidce, 10%^ pancreatic cancer, cholangitis/bliary cirrhosis
4th leading cause of cancer death Pancreatic Cancer
Etiology of pancreatic cancer Smoking, Obesity and dietary factors, DM, Chronic pancreatitis, Genetic features
Sxs pancreatic cancer gradual onset, anorexia, malaise, nausea, fatigue, wt loss, mid-epigastric pain, jaundice w/ pruritis of head of pancreatis, depression, DM recent diagnosis
Signs of Pancreatic Cancer Jaundice/cachexia, Courvoiser's sign, signs of metastases, miratory thrombophlebitis
Dx Pancreatic Cancer CT: if doubt, EUS, CA 19-9 low sensitivity and specificty
Tx Pancreatic cancer Surgery resection, chemo or chemo/rad
Median survival of pt's 4-6m very deadly, w/ chemo about 9m, metastasis ~6m
Created by: becker15
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