This or That

Presentation

100

RUQ pain/tenderness lasting less than 6 hours 

Normal LFTs, amylase/lipase

Uncomplicated Cholelithiasis 

200

What is the diagnosis: RUQ (typically post prandial with radiation to epigastrium, right shoulder, back) lasting > 6 hours. Signs of extrahepatic cholestasis 

Choledocholithasis 

300

Severe epigastric pain with radiation to the back. 

Acute pancreatitis

400

List possible clinical signs of extrahepatic cholestasis 

jaundice, pale stools, dark urine, pruritus  

500

Differential the Cullen sign, Grey Turner Sign, and Fox Sign's associated with underlying pancreatitis 

Cullen sign = periumbillical ecchymosis with discoloration 

Grey turner sign = flank ecchymosis with discoloration 

Fox sign = ecchymosis over inguinal ligament 

Labs

100

Which is more specific for pancreatic etiology: lipase or amylase? 

Lipase 

(Salivary amylase can also be elevated)  

200

If ALP is elevated, how can you differentiate if biliary in nature? What additional lab can you order? 

GGT 

A gamma-glutamyl transpeptidase (GGT) 

- GGT is especially concentrated in the liver, but it's also found in the kidney, pancreas, heart, and brain 

300

Where in the cell is AST located? ALT? 

AST = mitochondrial (alcohol is a mitochondrial poison, this is why you see an increase in AST with alcoholics) 

ALT = cytoplasm 

400

In choledocholithasis, is there an increase in conjugated or unconjugated bilirubin? 

Conjugated (liver is still able to convert UCB --> CB) 

500

In Ranson's Criteria of acute pancreatitis, what is the WBC on admission that adds one point to the patients score? 

> 16,0000

Imaging

100

In cholelithiasis, what do you expect to see on POCUS? 

• Intraluminal highly echogenic foci

• Strong posterior acoustic shadowing

200

If biliary sludge is present, what findings do you expect to see on POCUS? 

• Low-level echogenic material in the dependent portion of the GB

• No posterior acoustic shadowing

• Slow movement with the changing of patient posture

300

Name 2 imaging studies used in diagnosis of cholelithiasis 

Biliary POCUS 

Transabdominal US 

400

When imaging patient's with suspected cholelithiasis, what are the main goals? 

Rule out complications --> acute cholecystitis +/- choledocholithasis 

500

What are 2 findings you may see on ultrasound with acute pancreatitis/biliary pancreatitis? 

• Enlarged hypoechoic pancreas 

• Peripancreatic fluid or ascites 

Mix

100

Why can patients present with pruritus when there is extrahepatic biliary obstruction? 

Deposition of bile salts in the skin 

200

Blockade of (........) in choledocholithasis can result in progression to acute biliary pancreatitis 

Ampulla of Vater 

300

Explain why patients can present with pale stool if they have extrahepatic cholestasis.

Lack of conjugated bilirubin entering the digestive tract --> decreased production of sterobillinogen --> pale stool color 

400

What is the enzyme used to convert UCB --> CB? 

Uridine diphosphate (UDP)–glucuronyl transferase (UGT) conjugates bilirubin with glucuronic acid in the hepatocyte

500

If acute pancreatitis progresses to chronic pancreatitis, what are the two types of necrosis that can be seen? 

Liquefactive Necrosis 

Fat necrosis