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Flashcards in Biliary Tract Disorders Deck (27):

What is Cholelithiasis?

1 or more calculi (gallstones) in the gallbladder


Risk Factors: Cholelithiasis

Female gender
Native Indian ethnicity
Western diet
(+) FH


Pathophysiology: Cholelithiasis

Cholesterol stones account for 85% of gallstones
Form from bile that’s supersaturated (sludge) w/cholesterol produced by liver

Crystals or “microstones” are formed, then form into larger stones

Stone may be “silent” or become lodged in cystic duct or CBD, causing pain & cholecystitis

Stones can fill the entire gallbladder


Cholelithiasis: Black pigment stones

1. Small & hard
A. Ca bilirubinate & inorganic Ca salts
B. Form w/alcoholic liver disease, chronic hemolysis, & older age


Brown pigment stones

1. Soft & greasy
A. Bilirubinate & fatty acids
B. Form during infection, inflammation, and parasitic infestation


Signs & Symptoms: Cholelithiasis

1. 80% asymptomatic
2. +/- N/V
3. Biliary colic
A. Most common
B. Sudden onset RUQ pain w/radiation to back or right shoulder/arm, ↑ intensity w/in 15-60 min, steady intensity (not colicky) up to 12 h (usually < 6 h), then gradually disappears over 30-90 min, leaving dull ache


Diagnostic Studies: Cholelithiasis

1. Ultrasonography
A. Method of choice for detecting gallstones
B. 95% sensitivity & specificity

2. Cholescintigraphy (HIDA scan w/EF)
A. If needed


Prognosis: Cholelithiasis

Once biliary symptoms begin, they’re likely to recur

Pain returns in 20-40% of patients/year

1-2% of patients/yr develop complications
-Gallstone pancreatitis


Treatment: Cholelithiasis

1. Cholecystectomy for symptomatic stones
A. Laparoscopic or open laparotomy


Surgical Landmarks: What is Calot’s Triangle?

-Cystic Duct
-Common Hepatic Duct
-Margin of Liver


Surgical Landmarks: What is Mascagni’s (Lund’s) Lymph Node?

1. Sentinel lymph node of the gallbladder
2. ↑ in size in cholecystitis & cholangitis


Treatment: Cholelithiasis

1. Stone dissolution
A. Gallstones dissolved by oral bile acids over months

B. Candidates
-Pt who declines surgery
-High surgical risk
-Small, radiolucent stones (likely cholesterol)

C. Ursodeoxycholic acid (Ursodiol) 8-10 mg/kg/day po
-Dissolves 80% of tiny stones (< 0.5 cm) w/in 6 mo


What is Acute Cholecystitis?

1. Inflammation of gallbladder 2° to gallstone obstructing cystic duct
A. Develops over hours

2. Most common complication of cholelithiasis

3. 95% of patients w/acute cholecystitis have cholelithiasis


Signs & Symptoms: Acute Cholecystitis

1. Similar to biliary colic but lasts longer & more severe
2. Vomiting is common
3. Fever (low grade)
4. Right subcostal tenderness
5. (+) Murphy's sign
- Guarding

Sx’s begin to subside in 2-3 days & resolve w/in 1 wk in 85% of patients


Signs & Symptoms in Elderly: Acute Cholecystitis

1. Anorexia
2. Vomiting
3. Malaise
4. Weakness
5. +/- fever


Complications: Acute Cholecystitis

1. 10% perforate
A. Peritonitis

2. ↑ pain, high fever, rigors, & rebound tenderness or ileus suggest:
A. Empyema (pus in the gallbladder)
B. Gangrene
C. Perforation

3. When sx’s accompanied by jaundice, CBD obstruction is likely
A. Due to stones or inflammation

4. Mirizzi's syndrome
A. Rare
B. Gallstone impacted in cystic duct or Hartman's pouch, compresses & obstructs CBD → cholestasis (jaundice)

5. Gallstone pancreatitis
A. Gallstones pass from gallbladder into CBD block pancreatic duct

6. Cholecystoenteric fistula
A. Rare
B. Large stone erodes thru gallbladder wall, creating a fistula into small bowel


Diagnostic Studies: Acute Cholecystitis

1. Labs
A. Leukocytosis w/ L shift
B. Bilirubin up to 4 mg/dL & mildly elevated alkaline phos

2. Ultrasonography
A. Best test to detect gallstones
B. Pericholecystic fluid or thickening of the GB wall → acute inflammation

3. Cholescintigraphy (HIDA scan)
A. If USN results are equivocal or (-) & ↑ suspicion
B. Failure of the radionuclide to fill GB → obstructed cystic duct
C. Low EF → GB dysfunction


Treatment: Acute Cholecystitis

1. Hospital admission, IV fluids, & analgesia w/ketorolac (Toradal) or opioid
2. NPO
3. NG tube to suction if vomiting or ileus present
4. IV antibiotics for possible infection
A. Empiric Tx [gram (-) enteric organisms]
- IV ceftriaxone (Rocephin) 2 g q 24h
-IV Metronidazole (Flagyl) 500 mg q 8h
-IV piperacillin/tazobactam (Zosyn) 4 g q 6h alone

5. Cholecystectomy
A. Early cholecystectomy preferred
- In 1st 24-48 h IF:
(Dx clear & low surgical risk,
Elderly or diabetic & higher risk of infectious complications,
Empyema, gangrene, perforation, or acalculous cholecystitis)


What is Cholangitis?

1. CBD blocked & infection occurs backing up into the liver
A. Can block the hepatic or common bile ducts & force bile into the circulation → jaundice
3. Defined by “CHARCOT’S TRIAD”
A. RUQ pain
B. Fever
C. Jaundice


Pathophysiology: Cholangitis

1. Choledocholithiasis
2. Biliary tract manipulations/interventions & stents more common cause
3. Hepatobiliary malignancies less common cause
4. Most common anaerobic organism- Bacteroides fragilis


Diagnostic Studies: Cholangitis

1. Ultrasonography
2. CBC w/diff
A. Leukocytosis w/L shift
3. LFT’s
A. Hyperbilirubinemia
B. ↑ alkaline phos
4. Blood cultures


Treatment: Cholangitis

1. IV antibiotic therapy
A. IV ceftriaxone (Rocephin) 2 g q 24h Gm (-)
B. IV metronidazole (Flagyl) 500 mg q 8h anearobes
C. IV ampicillin 4 g q 6h Gm (+)
D. IV Fluoroquinolone (Cipro or Levaquin)

2. If severe or toxic cholangitis
A. May require emergency biliary drainage

3. Diagnostic & therapeutic purposes (drainage)

4. Endoscopic retrograde cholangiopancreatography (ERCP)

5. Percutaneous transhepatic cholangiography (PTC)
A. Needle inserted through skin at R subcostal area, guide-wire passed through liver & into the blockage in the bile duct
B. Stent placed

6. Eventual cholecystectomy if candidate


Chronic Cholecystitis: Characteristics

1. Long-standing gallbladder inflammation almost always due to gallstones

2. Damage ranges from modest chronic inflammatory cells to a fibrotic, shrunken gallbladder

3. Extensive calcification due to fibrosis is called porcelain gallbladder


Signs & Symptoms: Chronic Cholecystitis

1. Gallstones intermittently obstruct cystic duct causing recurrent biliary colic
2. Generally mild sx’s
3. RUQ tenderness may be present, but no fever
4. Fever suggests acute cholecystitis
5. Once episodes begin, they are likely to recur


Diagnostic Studies: Chronic Cholecystitis

1. Ultrasonography
A. Suspected in patients w/recurrent biliary colic + gallstones
B. Shows gallstones and sometimes a shrunken, fibrotic gallbladder


Treatment: Chronic Cholecystitis

1. Laparoscopic cholecystectomy
2. Low fat diet until surgery


Characteristics: Gallbladder Cancer

-↑ risk in 6th-7th decades
-Female > Male (3:1)
-95% associated w/ gallstones
-6x more common in Native Americans
-22% increased risk if “porcelain GB” or calcified wall is seen on U/S
- >90% are Adenocarcinoma
- Symptoms same as cholecystitis
- Chemo has less than a 40% response rate
- 5 years survival is 5%
- Mean life expectancy 6-8 months