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Flashcards in 8, 9, 10, 11, 12, 13, 14, 15, 16 Deck (26):

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?



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.


Complications of gallstone disease?

Involving GB: acute and chronic cholecystitis.
involving passage of stones from GB: Pancreatitis, choledocholithiasis, cholangitis, and gallstone ileus.


Define cholestasis.

Blockage of bile flow (intrahepatic or extrahepatic) with a resultant increase in conjugated bilirubin levels.


Clinical presentation of cholestasis.

Jaundice, gray stools, dark urine, pruritus (bile salt deposits on skin), and skin xanthomas (local cholesterol deposits).


Labs of Cholestasis.

elevated serum Alk phos and serum Cholesterol (can't excrete).


Major absorptive complication of cholestasis.

Malabsorption of fats and ADEK vitamins.


Define biliary colic.

Waxing and waning, poorly localized, post-prandial RUQ pain that may radiate to the back.


Labs of biliary colic.

Usually normal LFTs.


Cause of biliary colic.

CCK-stimulated GB contraction against obstructed (gallstone) cystic duct, following food ingestion.


Define Acute cholecystitis.

95% of pts, cause is gallstones obstructing cystic duct that allows bacterial infection via lymphatics.


Common organisms causing acute cholecystitis?

E. coli, Klebsiella, Proteus, Strep faecalis.


CP of acute cholecystisis?

PERSISTENT RUQ pain, w/ or w/o fever, GB tenderness, leukocytosis, and often mildly elevated LFTs.


Treatment of acute cholecystitis?

Admitted to hospital, get IV fluids, NPO, IV antibiotics, and cholecystectomy during the hospitalization.


Define Acalculous cholecystitis

GB inflammation caused by biliary stasis (5-10% pts w/ acute cholecystitis) leading to GB distention, venous congestion, and decreased perfusion.


Who usually presents w/ acalculous cholecystitis?

Patients with critical illness (ICU).


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.


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.


Define Cholangitis.

Infection within bile ducts!


Cause of cholangitis?

Most commonly b/c of complete or partial obstruction of bile ducts by gallstones or strictures.


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.


Management of cholangitis?

Blood cultures and then IV ABx
Decompress Common Bile Duct (CBD) when pt is stable endoscopically via PTC (drainage), ERCP (sphinterotomy), or laparotomy (T-tube insertion).


Most dreaded complication of acute cholagitis?

Hepatic abscess (high mortality).


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).


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.


ERCP (Endoscopic Retrograde Cholangio-Pancreatography)

Endoscopic CBD cannulation and direct injection of contrast material to visualize the duct. An endoscopic sphincterotomy in the duodenum during the prcedure may facilitate bile drainage and the clearance of bile duct stones, which is especially useful in tx cholangitis and CDCL. Procedure requires sedation and may be associated with complication rates of 8-10%.