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Flashcards in biliary disease Deck (42):
1

Cholelithiasis

pain presents where?

more in women or men??

Gallstones are usually asymptomatic in most patients and often found incidentally on imaging studies for other issues

Classic pain presentation is RUQ with radiation to the R shoulder and infrascapular area

-more common in women with 8.6% prevalence vs. men with 5.5% prevalence

2

Gallstones are classified according to ??

symptoms will develop in how many pts??

chemical composition

Majority are cholesterol stones in the US
less than 20% are composed of calcium bilirubinate

Symptoms will develop in 10-25% of patients over time

3

gallstone on US

opaque

4

Gallstone/pain tx

NSAIDs
Laparoscopic cholecystectomy for symptomatic disease
Ursodeoxycholic acid

5

Laparoscopic cholecystectomy for what pts??
Only done in asymptomatic if ??

symptomatic disease

-if porcelain gallbladder, stones >3cm, or if a patient is a candidate for bariatric surgery or cardiac transplant

6

what is Ursodeoxycholic acid ??


do gallstones recur?

A bile salt given orally for up to 2 years which can help dissolve some cholesterol stones in patients who are unable to have or refuse to have surgery (elderly, other risk factors)

Gallstones usually reoccur by 5 years after medication is stopped

also given to liver failure/transplant/cirrhotic pts, eliminates itching in skin

7

porcelain GB on XR

caused by ??

removed??

rim enhancing

continued insult to GB over time, pancreatic/GB/GI cancer

not all need to be removed, but indication for removal esp. with symptoms

8

case: N/V 30 min after eating, steady RUQ tenderness and epigastric pain, low grade temp 100F

probably not E.coli, too quick of presentation (usually takes 24 hrs)

S. aureus, B. cereus: more acute FBI

has this happened before?

9

?? is associated with gallstones 90% of the time

Cholecystitis

Often precipitated by a fatty meal (burger)
Vomiting may give temporary relief

10

Acute Cholecystitis: physiology

a stone becomes impacted in the cystic duct and inflammation develops around the obstruction

11

When not caused by stones acute cholecystitis could be caused by ??

CMV, cryptosporidiosis or microsporidiosis in advanced HIV patients; or by vasculitis

12

acute cholecystitis labs

WBCs often elevated, LFTs and bilirubin can be elevated, serum amylase may also be mildly elevated

13

other cholecystitis pain

stones may hang around, or stones may have caused hepatic problems so have pain even after removal

14

Murphy's sign

positive when you palpate the RUQ and ask the patient to breathe deeply
POSITIVE if patient develops pain that radiates to the R infrascapular area or if patient’s inspiration stops short

15

Sonographic Murphy's sign

positive when a patient reports maximum discomfort when the ultrasound probe is over the gallbladder

16

U/S may show ??

gallstones, biliary sludge, biliary ductal dilation, gallbladder wall thickening, pericholecystic fluid (around GB), and/or a positive sonographic Murphy’s sign

17

If ultrasound is not convincing, next step would be to do a ??

Test most reliable when ??

hepatic iminodiacetic acid scan (HIDA)

when bilirubin is under 5mg/dL

positive when GB does not light up but cystic bile duct does?? listen 15 min

18

Gangrene of the gallbladder

Symptoms of acute cholecystitis severe and lasting 24-48h
Due to ischemia from splanchnic vasoconstriction
Could lead to perforation, abscess
Obese, elderly, diabetics at higher risk (can't perceive pain as much)

19

Acalculous cholecystitis



What can be done if patient too unstable for cholecystectomy?

Should be considered if fever and RUQ pain 2-4 weeks after major surgery or in critically ill ICU patients

drain GB (loaded with sludge) cholecystotomy drain placed (can have in for a longer than year!)
to avoid sepsis
sometimes a bridge to sx

20

Chronic Cholecystitis Results from ??

repeated episodes of acute cholecystitis or from chronic irritation of the gallbladder due to stones
Occasionally chronic inflammation creates polypoid changes inside the gallbladder giving the gallbladder a strawberry appearance

21

chronic cholecystitis: Hydrops of the gallbladder can occur if ??

the cholecystitis subsides but the cystic duct obstruction persists generating a gallbladder filled with mucoid fuid

22

cholecystitis tx

Acute cholecystitis can often improve with gut rest, pain medications, and antibiotics

A cephalosporin + metronidazole
Fluoroquinolone + metronidazole
Piperacillin/tazobactam
Carbapenem (imipenem, meropenem, ertapenem)


23

chonic cholecystitis tx: Given high risk for recurrence, ?? can be planned when symptoms improve

interval cholecystectomy

don't want to do when acute, risk of perforation and infection

24

case 2: sclera icterus
some episodic N/V +/- epigastric pain

questions?

when N/V: sometimes after food
color: yellow/green stool
darker urine
itchy skin

recent travel?
some etOH

25

Choledocholithiasis and Cholangitis

Cholangitis suspected if ??

Often a h/o epigastric pain accompanied by jaundice
Sometimes patients present with painless jaundice as their chief complaint

Cholangitis suspected if there are signs of sepsis
Etiology is a stone in the bile duct which requires an ERCP for diagnosis and possible intervention

26

Charcot’s Triad

Frequently occurring attacks of RUQ abdominal pain
Jaundice associated with RUQ pain
Chills and fever

27

Reynold’s Pentad

The classic findings of Charcot’s triad for acute cholangitis PLUS:
Altered mental status
Hypotension

Indicates probable supperative cholangitis and is an endoscopic emergency

28

Cholangitis: labs can demonstrate ??

CT??

striking increases in LFTs and hyperbilirubinemia
Serum amylase may be elevated indicating a secondary pancreatitis

CT may demonstrate dilated bile ducts

29

ERCP ??

ERCP provides the most accurate determination of the extent of the obstruction especially when bile duct diameter is >6mm, when ductal stones are seen on ultrasound, or when bilirubin is >4mg/dL

Sphincterotomy with stone extraction or stenting can be done as needed during this procedure

30

cholangitis tx

Bile duct stones should be removed even in asymptomatic patients

If a patient has concurrent cholecystitis, cholecystectomy is generally performed during the same hospital stay
If no signs of cholecystitis, cholecystectomy can be done electively in 2 weeks

31

Cholangitis: Antibiotics targeted towards??

G- pathogens are often administered acutely via IV, and patients are sent home on ~2 weeks of p.o. agents
Ciprofloxacin/metronidazole, cefuroxime/metronidazole, amoxicillin/clavulanate

32

case 3: 3 weeks post liver transplant for hepC w/ cirrhosis
itching/yellowing

Biliary Stricture

33

Biliary Stricture

Benign biliary strictures are generally due to ??

what developments/common complications

injury around a surgical anastomosis ~95% of the time
5% of cases can be due to direct injury to the abdomen, pancreatitis, or prior endoscopic sphincterotomy

Jaundice can develop rapidly if complete occlusion occurs
Cholangitis is the most common complication of stricture
Biloma or infected fluid collection/abscess could also arise

34

biloma

backup of bile fluid

35

MRCP vs. ERCP

risk?

MRCP is valuable in demonstrating strictures
ERCP permits biopsy to evaluate for possible malignancy, sphincterotomy to allow closure of a bile leak, and dilation/stent placement

Risk of post-ERCP pancreatitis in challenging cases

36

ERCP

endoscope into mouth thru duodenum, up retrograde to GB

37

case 4: hx of UC, poor compliance with management
yellow skin/eyes
diffuse pruritis

yellow/green stools
dark urine

Upon further questioning, patient reports he hasn’t been eating well and had noticed the yellowing slowly over the past 2 months
Patient also with fatigue and loose stools
Labs reveal high direct and indirect bilirubin, elevated LFTs
MRCP is performed

38

MRCP shows punctuated strictures: "string of pearls"

Primary Sclerosing Cholangitis

39

Primary Sclerosing Cholangitis

Most common in men aged 20-50 years
*Often associated with ulcerative colitis*
Progressive jaundice over time, pruritus, labs consistent with cholestasis

Diagnosis on MRCP with classic cholangiographic findings
10-20% risk of cholangiocarcinoma

40

tx: Acute bacterial cholangitis component of Primary Sclerosing Cholangitis

Treated with antibiotics targeted towards gram negative pathogens (ciprofloxacin, 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems)

41

more Primary Sclerosing Cholangitis tx

Ursodeoxycholic acid can improve LFTs and decrease itching
Possible balloon intervention of some of the sclerosed areas
Possible stenting as a short term solution to relieve symptoms
Long-term stenting may increase complications
Liver transplantation for those with cirrhosis and clinical decompensation

42

Primary Sclerosing Cholangitis px

Average survival 9-17 years and up to 21 years in some studies
Survival may be less with a dominant bile duct stricture
Higher risk for colon cancer associated with longer survival
Survival rates with liver transplantation are as high as 85% at 3 years