PANCE Blueprint GI and Nutrition (9%)

Biliary Disorders (PEARLS + ReelDx)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint covers three topics associated with the gallbladder

Acute and chronic cholecystitis
Patient will present as → a 49-year-old female with a 2-day history of right-upper-quadrant, colicky abdominal pain, as well as nausea, and vomiting. Examination shows significant pain with palpation in the right upper quadrant. Laboratory findings include an elevated WBC count, alkaline phosphatase, and bilirubin level.

Inflammation of the gallbladder; usually associated with gallstones

Presentation:

  • 5 Fs: Female, Fat, Forty, Fertile, Fair
  • (+) Murphy's sign (RUQ pain with GB palpation on inspiration)
  • RUQ pain after a high-fat meal
  • Low-grade fever, leukocytosis, jaundice

Diagnosis:

  • Ultrasound is the preferred initial imaging - gallbladder wall >3 mm, pericholecystic fluid, gallstones
  • HIDA is the best test (Gold Standard) - when ultrasound is inconclusive
  • CT scan - alternative, more sensitive for perforation, abscess, pancreatitis
  • Labs: ↑ Alk-P and ↑ GGT, ↑ conjugated bilirubin
  • Porcelain gallbladder = chronic cholecystitis
  • Choledocholithiasis = stones in common bile duct - diagnosed with ERCP (gold standard)

Treatment: Cholecystectomy (first 24-48 hours)

Cholangitis
Patient will present as → a 58-year-old male with acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2 ° F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric and the skin is jaundiced

Infection of biliary tract secondary to obstruction, which leads to biliary stasis and bacterial overgrowth

  • Characterized by pain in the upper-right quadrant of the abdomen, fever, and jaundice
  • Choledocholithiasis accounts for 60% of cases
  • Other causes include pancreatic and biliary neoplasm, postoperative strictures, invasive procedures such as ERCP or PTC, and choledochal cysts
  • Organisms: E. coli, Enterococcus, Klebsiella, Enterobacter

Presentation:

  • Charcot’s triad: RUQ tenderness, jaundice, fever
  • Reynold’s pentad: Charcot’s triad + altered mental status and hypotension

Diagnostic studies:

  • Initial imaging: Ultrasound
  • Best: ERCP

Treatment: Cholangitis is potentially life-threatening and requires emergency treatment

  • Aggressive care and emergent removal of stones, Cipro + metronidazole
  • Antibiotics, fluids, and analgesia.
  • ERCP to remove stones, insert a stent, repair the sphincter
  • Cholecystectomy (performed post-acute)

Primary sclerosing cholangitis

  • Jaundice and pruritus
  • Associated with IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer
Cholelithiasis
ReelDx Virtual Rounds (acute cholelithiasis)
Patient will present as → a 43-year-old woman who comes to the emergency department with a 12-hour history of right upper quadrant (RUQ) abdominal pain. The pain is severe now but waxes and wanes and is associated with nausea and some episodes of vomiting. The pain sometimes radiates through to the back. She feels warm but has not checked her temperature. There is no diarrhea. Her last bowel movement was 1 day ago and was normal. The patient has no similar history in the past. On examination, the patient is an obese young woman in some discomfort. Her vital signs reveal a temperature of 100 ° F and pulse of 102 beats/ minute. Her blood pressure is 130/70 mmHg, and her respirations are 18 breaths/minute. There is no scleral icterus. The chest is clear, and the cardiovascular examination is normal. Abdominal examination reveals marked upper abdominal tenderness with guarding, especially in the RUQ. On palpation of the RUQ of the abdomen when the patient is asked to take a deep breath, there is a marked increase in pain. The bowel sounds are present but seem slightly sluggish. The patient has no drug allergies and is not taking any medications at present.

A precursor to cholecystitis, cholesterol stones account for > 85% of gallstones in the Western world

  • Stones in the gallbladder, pain secondary to contraction of gall against the obstructed cystic duct
  • Asymptomatic (most), symptoms only last a few hours
  • Biliary colic—RUQ pain or epigastric
  • Pain after eating and at night
  • Boas sign—referred right subscapular pain

DX: RUQ ultrasound - high sensitivity and specificity if  >2 mm. CT scan and MRI

TX: Asymptomatic—No treatment necessary

  • Elective cholecystectomy for recurrent bouts
GI/Nutrition Quick Cram Cards (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Diseases of the Gallbladder and Liver
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