Gastroenterology
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| Biliary labs | bilirubin, alk phos, ALT, AST
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| Cholestatic vs hepatitis: labs | cholestasis: bili/alk phos high; hep: ALT/AST high
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| Firstline test in pt with RUQ pain, suspect cholecystitis: | US (not CT)
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| CT & MRI | X-section imaging of entire abd; eval liver parenchyma; MRI ID’s stones well; BUT: Cost; May miss stones;Radiation
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| EUS useful in: | large pt
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| 2 indications for HIDA | Cholecystitis when US is negative; leaks after cholecystectomy
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| Cholesterol stones: | GB; Large, yellow
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| Black pigment stones: | GB; Calcium bilirubinate; in pts with cirrhosis and chronic hemolysis (eg, sickle cell)
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| Brown pigment stones: | Ducts; Calcium salt of unconjugated bilirubin; assoc w/ infection; Form denovo in the ducts
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| Gold standard for GS | US; sensitivity > 95% for stones > 2mm (less sensitive for stones in CBD); GS best seen after 8hrs of fast; Stones seen as echogenic, mobile objects with acoustic shadow
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| Most common stone locations | 75% GB (Asx); cystic duct (20% intermittent: biliary colic; 10% impacted: cholecystitis)
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| Cholangitis | Stone in CBD; bile stasis, infection, bacteremia; Charcot’s triad/ Reynold’s Pentad; high WBC; Bili, ALP; pos blood cx; Emergent ERCP / PTC w/ Abx; Subsequent cholecystectomy
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| Charcot’s triad: | Pain, Fever, Jaundice
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| Reynold’s Pentad: | Charcot’s triad plus hypotension and mental confusion; suggests sepsis
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| Most effective procedure for detecting and removing cholangitis stones | ERCP; appear as filling defects; high rate of complications
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| Choledocholithiasis | Causes intermittent obstruction of CBD; indistinguishable from biliary pain; Predisposes to cholangitis and pancreatitis;
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| Choledocholithiasis: findings | Pain with jaundice; Elevated ALP, bili; ERCP / MRI / EUS / US
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| Choledocholithiasis: Tx | ERCP with stone removal and early lap cholecystectomy
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| EUS: | Highly accurate for CBD stones; invasive / expensive; No risk of pancreatitis compared to ERCP
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| Panc ca: most common sx | Pain, obstructive jaundice, weight loss; BUT classic hx = painless jaundice
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| Panc ca: RFs | smoking, chronic pancreatitis, obesity and family history; 5 year survival of 5%
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| Diffuse intra- and extrahepatic bile duct inflammation and fibrosis: | PSC
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| PSC: assoc with: | UC (most cases); leads to cirrhosis and portal HTN; elev alk phos, pruritus, fatigue; Cholangitis
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| Organisms complicating cholecystitis (found in GB or CBD: | E Coli (41%), Enterococcus (12%), Klebsiella (11%), Enterobacter (9%), B fragilis, Pseudomonas
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| Mirizzi syndrome = | a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
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| Cholecystitis abx: | Augmentin (2G TID), Zosyn, Rocephin + Flagyl, OR Levaquin + Flagyl
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| Biliary disease risk factors | 4Fs, Hispanic, rapid wt loss, insulin resistance/ CHO intake, high TG, IBD
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| Biliary colic | Referred pain to R shoulder
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| Elevated Alkaline phosphatase, urinary bilirubin | Cholecystitis
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| Hx IBD, progressive RUQ pain, wt loss, F, jaundice & pruritis. Elevated bilrubin & alkaline phosphate. ERCP with bile duct stenosis, dilatation | Primary sclerosing cholangitis (diffuse intra- and extrahepatic duct sclerosing and dilatation)
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| Bacterial agents of cholecystitis/biliary disease: | Enterobacteriaceae, Enterococcus, Bacteroides Clostridium species
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| Gall stones: Etiology related to: | increasing conc of cholesterol (chol stones: 80%) or bile salts (pigments stones: 15%)
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| Primary sclerosing cholangitis (PSC) = | stricture of biliary ducts; UC>CD; risk for CRC; refer to hepatologist
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| Whipple dz: Dx | arthralgias; GI sx; wt loss, chronic cough, low-grade fever, neuro sx (steady-state: wt loss & diarrhea); bx is confirmatory (villous atrophy, macrophage infiltration of lamina propria)
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| Black pigment gall stones: | GB; Calcium bilirubinate; in pts with cirrhosis and chronic hemolysis (eg, sickle cell)
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| Brown pigment gall stones: | Ducts; Calcium salt of unconjugated bilirubin; assoc w/ infection; Form denovo in the ducts
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| Most common stone locations | 75% GB (Asx); cystic duct (20% intermittent: biliary colic; 10% impacted: cholecystitis)
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| Diffuse intra- and extrahepatic bile duct inflammation and fibrosis: | Primary sclerosing cholangitis (PSC)
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| Primary sclerosing cholangitis (PSC): assoc with: | UC (most cases); leads to cirrhosis and portal HTN; elev alk phos, pruritus, fatigue; Cholangitis
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| Action of CCK on biliary system | causes contraction of gallbladder and relaxation of sphincter of Oddi
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| Hormones affecting gallbladder motility (3): | somatostatin & estrogen (decreased GB contraction); CCK (stimulates GB contraction)
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