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Flashcards in Biliary Diseases Deck (45)
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1

Cholelithiasis

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

2

Classic cholelithiasis pain presentation is

RUQ with radiation to the R shoulder and infra scapular area
(subscapular pain)

3

Gallstones are classified according to

chemical composition

-Majority are cholesterol stones in the US
-

4

Treatment for cholelithiasis

-NSAIDs

-Laparoscopic cholecystectomy for symptomatic disease
(Only done in asymptomatic if porcelain gallbladder, stones >3cm, or if a patient is a candidate for bariatric surgery or cardiac transplant)

5

What to give people who can't have cholecystectomy surgery

Ursodeoxycholic acid:

-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

-Gallstones usually reoccur by 5 years after medication is stopped
-Excess bile salts eliminates itching

6

How to screen before procedure or to see stones in asymptomatic pts

ultrasound

7

Clinical example: weight loss procedure, lost weight, right upper shoulder pain, think __________

cholecystitis issue

8

Porcelain Gallbladder

Chronic cholecystitis can cause hardening of the gallbladder

on XRAY seen as ring enhancing area

9

Case: A 45yo woman presents to the ER with a c/o steady RUQ tenderness and epigastric pain that began 30min after eating a burrito bowl at chipotle
She felt nauseated and vomited once on the way to the hospital. She has a low grade temp to 100F
She just saw in the news that there has been an e.coli outbreak and she is worried about food poisoning

-“Stabbing pain” in RUQ and upper back
-E. coli doesn’t make you sick right away- usually more than 24 hours to see s/s
-Has happened before after meals- fatty meals make it worse (think hamburger)

10

Acute Cholecystitis is associated with

gallstones 90% of the time

-Often precipitated by a fatty meal
-Vomiting may give temporary relief
*Physiologically – a stone becomes impacted in the cystic duct and inflammation develops around the obstruction

11

When acute cholecystitis is not caused by stones, could be caused by

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

12

During Acute Cholecystitis, labs will show

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

13

Physical exam sign you should see

-Murphy’s sign is 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
-Sonographic Murphy’s sign is positive when a patient reports maximum discomfort when the ultrasound probe is over the gallbladder

14

How to diagnose acute cholecystitis

-Ultrasound may show gallstones, biliary sludge, biliary ductal dilation, gallbladder wall thickening, pericholecystic fluid, and/or a positive sonographic Murphy’s sign

15

If ultrasound is not convincing of diagnosis, next step is

next step would be to do a hepatic iminodiacetic acid scan (HIDA)
-Test most reliable when bilirubin is under 5mg/dL
-HIDA scan is positive when the gallbladder does NOT light up and when the common bile duct DOES light up

16

Possible complication of acute cholecystitis

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

17

Another complication of acute cholecystitis is Acalculous cholecystitis, consider this if pt has

fever and RUQ pain 2-4 weeks after major surgery or in critically ill ICU patients- sitting, laying on backs, sludge in gallbladder

18

What can be done if patient too unstable for cholecystectomy?

Drain the gallbladder, go to interventional radiology and they put a drain in (drain stays in for a while)

19

Cholecystitis is very dangerous in elderly because

Can be life threatening- dangerous in elderly because they main not feel the pain (may only present with malaise)

20

Chronic Cholecystitis results from

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 (mucous filled)

21

Hydrops of the gallbladder can occur if

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

22

Acute cholecystitis can often improve with

gut rest, pain medications, and antibiotics

23

Antibiotics used for acute cholecystitis

-A cephalosporin + metronidazole (gram – coverage and anaerobe coverage, for all bacteria in gut)
-Fluoroquinolone + metronidazole
-Piperacillin/tazobactam
-Carbapenem (imipenem, meropenem, ertapenem)

-Given high risk for recurrence, interval cholecystectomy can be planned when symptoms improve

24

Case: A 38yo man presents to your office with a c/o yellow tinge to the whites of his eyes over the past 2 weeks. Patient does report some episodic nausea and vomiting which can be accompanied by epigastric pain.
-Has had more diarrhea recently, stool is greasy, worse with fatty food
-Yellow-green stool
-Urine color is darker than normal
-Itchy skin all over
-Ask about travel, see if they may have a liver fluke

Think Choledocholithiasis and Cholangitis

25

Choledocholithiasis and Cholangitis descrition

-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

TEST AND BOARDS

1. Frequently occurring attacks of RUQ abdominal pain
2. Jaundice associated with RUQ pain
3. Chills and fever

27

Reynold’s Pentad

TEST AND BOARDS

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

-Indicates probable supperative cholangitis and is an endoscopic emergency (when patient becomes septic or much sicker, they progress to reynold’s pentad)

28

CT and lab findings during Choledocholithiasis and Cholangitis

-Labs can demonstrated striking increases in LFTs and hyperbilirubinemia
-Serum amylase may be elevated indicating a secondary pancreatitis
-CT may show dilated bile ducts
-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- open sphincter and remove stone

29

What test provides the most accurate determination of the extent of the obstruction?

-ERCP, 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- open sphincter and remove stone

30

Treatment of Choledocholithiasis and Cholangitis

-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