Biliary Disease Clinical Flashcards
Cholelithiasis
Gallstones
- either cholesterol or pigmented/harden bile
- cholesterol is most common
- both types of gallstones contain calcium
- hemolytic disease always shows pigment gallstones
Know the 5 F’s of gallstones
- female
- forties
- fertile
- fat/obesity
- family history
- flatulence (can be 6th)
**CF, native Americans and medications (especially oral contraceptives) are other risk factors
Symptoms/and labs of cholelithiasis
1) biliary “colic” pain
- severe upper gastric pain that “comes and goes”
- caffeine and fatty foods increases pains and sometimes other foods alleviates it
- pain radiates to right side shoulder/scapula
2) right upper quad tenderness
3) No Murphy’s sign and shouldn’t show nausea/vomiting.
Labs:
- ALT/AST elevations
- alkaline phosphatase and bilirubin elevations** (specific)
- lipase and amylase elevation** (will only be elevated in pancreatitis gallstone blocking)
- EKG will show normal heart or sinus tachycardia
Imaging:
- ultrasound will show common bile duct >6mm and an anterior gallbladder wall >3mm
- DONT use MRI
In what lobe of what lung does pneumonia/PEs mimic cholelithiasis (right upper quad pain)?
Right lobe of right lung
What is fitz-Hugh-Curtis syndrome?
A rare complication from pelvic inflammatory disease from an STD or post surgery procedures
- the infection goes up and travels to the liver where liver capsule adhesions occurs
What lab value differentiates acute from chronic pancreatitis the best?
Amylase
- will be very high in acute, but chronic will either be minimally high or normal
***however, lipase elevation signals the pancreas is effected and is more sensitive to pancreatitis
Management of cholelithiasis
1) safety net (fluids/oxygen/pain meds/etc.)
2) surgery/lithotripsy
- * note the gallbladder must be functional to do lithotripsy
3) bile acids = dissolve stones
- takes months-years so not good for acute patients
4) medications
- anticholinergics, prescription dose NSAIDs or opioids for pain
Cholelithiasis in children
Children
- usually gallstones secondary to hemolytic diseases only
- however due to increasing obesity, gallstones are becoming more common
Cholecystitis
All are caused by inflammation of the gallbladder (can be infection or from blockage of the cystic duct only)
Chronic:
- low intensity pain and inflammation
- repeated attacks that come and go with asymptomatic in between (“colicky pain”)
- usually in elderly
- causes failure of gallbladder over time
Acute:
- Acute infection/inflammation
- pretty much always shows stones of some sort also
- often can be misdiagnosed as acalculus cholecystitis
- common infections include E. Coli (#1 by far) and other anaerobic organisms
Cholecystitis symtpoms
1) similar biliary colic pain as cholelithiasis
- except WILL show vomiting and nausea 90% of the time
2) There IS Murphys sign present
- extreme guarding and pain when you touch the gallbladder due to inflammation
3) also shows fever and tachycardia roughly 80% of the time (but can be absent)
Labs/imaging:
- WBC count is elevated
- AST/ALT, alkaline phosphatase and bilirubin are all mildly elevated
- lipase and amylase is normal
- ultrasound shows inflammation and diffuse stones in the gallbladder (anterior wall will be very thick >6mm usually)
- **you have to get a CT if Murphy sign/peritoneal signs are present just to be safe, but this is not needed to diagnosis cholecystits technically
- can get a HIDA scan after ultrasound as well to confirm, but ultrasound is always first
Treatment of cholecystits
1) safety net
2) diffuse antibiotics to kill infection (tazobactam, ampicillin, etc.)
- prevents sepsis and peritonitis
3) surgery afterwards if damage is too much
4) **can skip surgery or inpatient care and just give augmentin (amoxicillin and clavulonic acid) if they are young with no fever and has rather normal labs. Also NO peritoneal signs and NO comorbid diabetes
What happens if diabetic patients get cholecystitis
Increased risk of Emphysematous cholecystits occurs
- 15% mortitlity rate and only occurs in 1% of cases
- more common in males vs females
image will show air around the gallbladder (black circle/outline on MRI/CT, often will not show on ultrasound)
Need to treat for clostridium and C. Diff since this increase in air is often due to fermentation of gas from these or other fermenting bacteria
Treatment: emergency cholecystectomy
AIDS related Acalculous cholecystitis
Happens more commonly in older populations, patients with AIDS and post-op surgery patients.
Has a more malignant infectious corse and often kills if not caught
Need to treat for CMV and cryptosporidium plus other opportunistic pathogens since these are the most common infectious agents
- also shows air and inflammation, but often no stones. Also normal labs and cant use ultrasound to diagnosis (almost never works)
Tx: get emergent HIDA scan immediately and then cholecystectomy
Cholangitis
Blockage of the common bile duct
Present very ill appearing with charrcot’s triad
1) jaundice*** (cholecysistis and cholitheliasis doesnt show this)
2) RUQ pain
3) severe fever (>102.5)
Can be caused by cancers/stones/strictures/etc. (whatever can cause a blockage)
- often also shows infection with polymicrobes
Also can show Reynolds Pentad if chronic and untreated
- essential charcots triad + AMS and hypotension symptoms
Workup:
- ultrasound to rule out the other differential (everything will look dilated)
- HIDA scan to confirm (but wont tell cause)
Treatment
- ERCP treatment (confirms 100% and is the best treatment, but requires ultrasound first)
- removes stone and dilates sphincter to help clear blockage and can drain pus from abscess if present
- broad spectrum diffuse antibiotics (tazobactam, ampicillin, etc)
Sclerosing cholangitis
Frequently idiopathic but is highly correlated with IBD (especially UC)
Causes diffuse fibrosis of the intra and extrahepatic ducts of the biliary tree
Diagnosis:
- is challenging since ultrasound doesnt work
- NRCP and laparotomy is to confirm
- diagnosed initially with symptoms and clinical judgement for the most part
Symptoms: (looks kinda like cancer and all symptoms are chronic)
- weight loss
- malaise
- jaundice (chronic)
- pruritus
Treatment:
- antibiotics if needed
- bile acid sequential agents (cholestyramine)
AIDS cholangiopathy
A group of one of the following disorders that is commonly seen in AIDS/immunosupressed patients
1) bile duct strictures
2) papillary stenosis
3) sclerosing cholangitis
requires CD4 counts lower than 200 to diagnosis
Often infected with CMV/cryptosporidium
Labs:
- bilirubin is normal**
- ultrasound shows ductal dilation and possible strictures
Treatment
- ERCP (endoscopic retrograde cholangiopancreatography) is gold standard
