Flashcards in 8, 9, 10, 11, 12, 13, 14, 15, 16 Deck (26):
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Case 8
46-year-old woman presents with a one-day history of right upper quadrant abdominal pain at a physical exam and lab findings suggest the vault gallstone disease. One of the most likely diagnosis?
Cholecystitis.
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What is the best therapy for cholecystitis?
Admit to hospital, IVF, IV ABx, and Laparoscopic cholecystectomy is the preferred treatment for all patients with a reasonable life expectancy and no prohibitive risks for general anesthesia and abdominal surgery.
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Complications of gallstone disease?
Involving GB: acute and chronic cholecystitis.
involving passage of stones from GB: Pancreatitis, choledocholithiasis, cholangitis, and gallstone ileus.
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Define cholestasis.
Blockage of bile flow (intrahepatic or extrahepatic) with a resultant increase in conjugated bilirubin levels.
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Clinical presentation of cholestasis.
Jaundice, gray stools, dark urine, pruritus (bile salt deposits on skin), and skin xanthomas (local cholesterol deposits).
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Labs of Cholestasis.
elevated serum Alk phos and serum Cholesterol (can't excrete).
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Major absorptive complication of cholestasis.
Malabsorption of fats and ADEK vitamins.
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Define biliary colic.
Waxing and waning, poorly localized, post-prandial RUQ pain that may radiate to the back.
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Labs of biliary colic.
Usually normal LFTs.
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Cause of biliary colic.
CCK-stimulated GB contraction against obstructed (gallstone) cystic duct, following food ingestion.
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Define Acute cholecystitis.
95% of pts, cause is gallstones obstructing cystic duct that allows bacterial infection via lymphatics.
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Common organisms causing acute cholecystitis?
E. coli, Klebsiella, Proteus, Strep faecalis.
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CP of acute cholecystisis?
PERSISTENT RUQ pain, w/ or w/o fever, GB tenderness, leukocytosis, and often mildly elevated LFTs.
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Treatment of acute cholecystitis?
Admitted to hospital, get IV fluids, NPO, IV antibiotics, and cholecystectomy during the hospitalization.
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Define Acalculous cholecystitis
GB inflammation caused by biliary stasis (5-10% pts w/ acute cholecystitis) leading to GB distention, venous congestion, and decreased perfusion.
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Who usually presents w/ acalculous cholecystitis?
Patients with critical illness (ICU).
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Tx of acalculous cholecystitis?
Emergent cholecystectomy is best Tx, but if cannot be done (too ill for surgery), then perform perQ drainage of GB w/ cholecystostomy.
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Define chronic cholecystitis.
Results from repeated bouts of biliary colic and/or acute cholecystitis leading to GB wall inflammation and fibrosis. Pt may present w/ RUQ pain w/o fever or leukocytosis. U/S: thickened GB wall or a contracted GB.
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Define Cholangitis.
Infection within bile ducts!
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Cause of cholangitis?
Most commonly b/c of complete or partial obstruction of bile ducts by gallstones or strictures.
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CP of cholangitis?
70% with Charcot's triad: FAJ = Fever, RUQ Adbominal pain, and Jaundice.
Worse, w/ Reynold's Pentad: FAJ ASS+ Altered mental status + Septic Shock.
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Management of cholangitis?
Blood cultures and then IV ABx
IVF
Decompress Common Bile Duct (CBD) when pt is stable endoscopically via PTC (drainage), ERCP (sphinterotomy), or laparotomy (T-tube insertion).
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Most dreaded complication of acute cholagitis?
Hepatic abscess (high mortality).
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Define RUQ U/S.
98-99% Sn in identifying gallstones in GB. <50% in CBD.
Useful in measuring diameter of CBD, which can indicate the possible presence of stones in CBD (Choledocholithiasis).
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Biliary Scintigraphy
study of GB function and biliary patency using IV radiotracer. Normally, liver is visualized, followed by GB, followed by emptying of radiotracer into duodenum. Non-visualization of GB in pt w/ RUQ pain indicated GB dysfxn caused by cholecystitis.
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