BILIARY DISEASE Flashcards
DDx
Biliary Colic
Choledocholithiasis
Cholecystitis
Ascending Cholangitis
Hepatitis
Pancreatitis
Peptic Ulcer Disease
Gastritis
Dyspepsia
Pneumonia
ACS
Clinical Features: Biliary Colic
Usually resolves within 6 h.
Associated with: radiation to the right shoulder (60%).
urgency to walk (66%).
Associated jaundice should raise concern for choledocholithiasis.
No systemic inflammatory signs.
Clinical Features: Acute Cholecystitis
Unremitting RUQ pain and fever.
The absence of RUQ tenderness has a negative likelihood ratio of 0.4.
Murphy’s sign: low sn and a high sp (+LR of 14)
Murphy’s sign is less reliable in the elderly.
Elevated inflammatory markers.
Normal liver function tests
Clinical Features: Choledocholithiasis
Biliary colic and jaundice
elevated bilirubin (≥2 mg/dL [≥34 µmol/L]).
Concomitant elevation of gamma-glutamyl transferase and alkaline phosphatase (90% sensitive).
Elevated LFTs >1.5× the upper limit of normal (94% sensitive).
Clinical Features: Cholangits
Abdominal pain (60%-70%) plus signs of cholestasis plus fever (>90%).
Charcot’s triad (abdominal pain, fever, jaundice) has a low sensitivity (26.4%) but a high specificity (95.9%).
Reynolds’ pentad (Charcot’s triad + altered mental status + shock) is observed in fewer than 10% of patients.
Elevated inflammatory markers and leukocytosis (>80%).
Positive blood cultures (70%).
Tokyo Diagnostic Criteria:
Evidence of systemic inflammation
Fever >38°C or rigors
Lab abnormalities
WBC count <4 or >10 (×10 × 109/L)
CRP ≥1 mg/L [9.5 nmol/L]
B
Evidence of cholestasis
Jaundice
T-Bili ≥2 mg/dL [34 µmol/L]
Abnormal LFTs
ALP >1.5 ULN
GGT >1.5 ULN
AST >1.5 ULN
ALT >1.5 ULN
C
Imaging findings
Biliary dilatation
Evidence of stricture, stone or stent
Labs / Imaging
CBC
Lytes
LFTs
Coags
Lipase
Ultrasound Abdomen
Cholelithiasis: >95% sn and sp.
Acute Cholecystitis: 81% sn and 83% sp.
Low sn high sp for choledocholithiasis
CT Abdomen w/ IV Contrast if acute cholangitis is suspected
Sn 85%-97%
Sp of 88%-96%
MRCP
ERCP
HIDA
Diagnostic Criteria Acute Cholecystitis - Tokyo Guidelines
A. Local Signs of Inflammation:
-Murphy’s Sign
-RUQ mass, pain, tenderness
B. Signs of Inflammation:
Fever > 38 C
CRP > 28.5
WBC > 10
C. Imaging Findings:
Ultrasound
Other imaging modalities are acceptable.
A+B = Suspected
A+B+C = Definite Diagnosis
Ultrasound Finding
Sonographic Murphy’s Sign
Gallbladder wall thickening (>4mm)
Pericholecystic fluid
Gallbladder distension (> 4 cm short axis view)
Gallstones present and are usually
impacted.
RED FLAGS
Charcot’s Triad:
High Fever
Jaundice
RUQ Pain
High sp but low sn
Reynold’s Pentad
AMS
Hypotension
Vomiting
Weight Loss
Acholic Stool
Dark Urine
Diagnostic Criteria for Acute Cholangitis - Tokyo Guidelines 2018
A. Evidence of Inflammation:
Fever >38°C or rigors
WBC count <4 or >10
CRP ≥9.5 nmol/L
B. Evidence of Cholestasis:
Jaundice
Abnormal LFTs
ALP >1.5 ULN
GGT >1.5 ULN
AST >1.5 ULN
ALT >1.5 ULN
C. Imaging Findings
Biliary dilatation
Evidence of stricture, stone or stent
A + one item in either B OR C = Suspected diagnosis
One item in A, B AND C = Definite diagnosis
Management of Biliary Colic
Antiemetics
Analgesia:
NSAIDS = OPIOIDS
Referral to General Surgery
Management of Cholecystitis
NPO
IVF
+/- NG
Analgesia
Antiemetics
Broad spectrum antibiotics based on severity
Early surgical consult
Management: Cholangitis
NPO
IVF
Analgesia
Ceftriaxone 1 g IV q12h +/− metronidazole 500 mg IV q8h
piperacillin-tazobactam 3.375 g IV q6h
Consult surgery for ERCP
Antibiotics: Indications & Dosing - Tokyo Guidelines
Mild: ceftriaxone 1 g IV q12h +/− metronidazole 500 mg IV q8h (if biliary enteric anastomosis present)
Moderate: piperacillin-tazobactam 3.375 g IV q6h*
Severe: piperacillin-tazobactam 3.375 g IV q6h plus a vancomycin loading dose of 25-30 mg/kg IV followed by 15-20 mg/kg q8-12h*
Complications
Gangrenous Cholecystitis
Emphysematous Cholecystitis
Gallbaldder perforation
Choledocholithiasis
Ascending Cholangitis
Gallstone Pancreatitis
