Colecistitis Aguda y Coledocolitiasis Flashcards
(29 cards)
Criterios de colecistitis moderada
Grade II (moderate) acute cholecystitis “Grade II” acute cholecystitis is associated with any one of the following conditions:
- Elevated WBC count (>18,000/mm 3 )
- Palpable tender mass in the right upper abdominal quadrant
- Duration of complaints >72 h a
- Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)
Criterios de colecistitis grave
Grade III (severe) acute cholecystitis “Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems:
- Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 lg/kg per min, or any dose of norepinephrine
- Neurological dysfunction: decreased level of consciousness
- Respiratory dysfunction: PaO 2 /FiO 2 ratio <300
- Renal dysfunction: oliguria, creatinine >2.0 mg/dl
- Hepatic dysfunction: PT-INR >1.5
- Hematological dysfunction: platelet count <100,000/mm 3
Criterios diagnósticos de colecistitis aguda
A. Local signs of inflammation etc.
(1) Murphy’s sign, (2) RUQ mass/pain/tenderness
B. Systemic signs of inflammation etc.
(1) Fever, (2) elevated CRP, (3) elevated WBC count
C. Imaging findings Imaging findings characteristic of acute cholecystitis
Suspected diagnosis: one item in A + one item in B
Definite diagnosis: one item in A + one item in B + C
Hallazgos en imagen de colecistitis aguda
The generally accepted imaging findings of acute cholecystitis are:
Thickening of the gallbladder wall (≥4 mm)
Enlargement of the gallbladder (long axis ≥8 cm, short axis ≥4 cm)
Gallstones or retained debris
Fluid accumulation around the gallbladder
Linear shadows in the fatty tissue around the gallbladder
Estudio recomendado para colecistitis gangrenosa
TC o RMN contrastadas
Hallazgos en imagen de colecistitis gangrenosa
Gangrenous cholecystitis exhibits specific findings on dynamic CT, including:
Irregular thickening of the gallbladder wall
Poor contrast enhancement of the gallbladder wall (interrupted rim sign)
Increased density of fatty tissue around the gallbladder
Gas in the gallbladder lumen or wall
Membranous structures within the lumen (intraluminal flap or intraluminal membrane)
Peri-gallbladder abscess
El signo del borde interrumpido tiene valor predictivo negativo de 95%. V/F/NS
Verdadero pero tiene sensibilidad de 73%
El US tiene alta sensibilidad para identificar gas en la pared de la vesícula biliar. V/F/NS
Falso. Es difícil distinguirlo de la vesícula de porcelana o del aire intraluminal. Se requiere TC para diagnóstico de colecistitis enfisematosa la cual tiene alta sensibilidad.
Coledocolitiasis: valor predictivo negativo de PFH normales es…
97%
US de HVB, tiene sensibilidad de 22-55% para coledocolitiasis. V/F/NS
Verdadero, es muy baja. Pero su sensibilidad para dilatación del colédoco es 77-87%
En paciente con vesícula biliar intacta, la presencia de dilatación de vía biliar sugiere altamente probable coledocolitiasis cuando es mayor a cuantos milímetros:
> 8 mm
Litos biliares que tienen mayor riesgo de coledocolitiasis
A. <5 mm
B. 5-10 mm
C. >10 mm
Múltiples litos <5 mm son los de mayor riesgo
Predictor más fuerte de la existencia confirmada de coledocolitiasis:
Presencia de coledocolitiasis en US
Predictores MUY FUERTES de coledocolitiasis:
Very strong
CBD stone on transabdominal US
Clinical ascending cholangitis
Bilirubin >4 mg/dL
Predictores FUERTES de coledocolitiasis
Dilated CBD on US (>6 mm with gallbladder in situ)
Bilirubin level 1.8-4 mg/dL
Predictores MODERADOS de coledocolitiasis
Abnormal liver biochemical test other than bilirubin
Age older than 55 y
Clinical gallstone pancreatitis
Como se define un paciente con alta probabilidad de coledocolitiasis?
1 predictor muy fuerte o 2 predictores fuertes
Cuando no tienen ningún predictor es bajo
Cuando tienen 1 fuerte o algún moderado solamente es intermedio
Paciente con alto riesgo de coledocolitiasis, que estudio requiere?
CPRE prequirúrgica
Paciente con riesgo intermedio de coledocolitiasis, qué opciones de estudio tiene a continuación?
- Colangiografía intraoperatoria, US intraoperatorio
2. US endoscópico pre quirúrgico o colangiorresonancia pre quirúrgica
Paciente con colecistitis aguda y riesgo moderado de coledocolitiasis. Le hicieron colangiorresonancia y tiene coledocolitiasis. Qué le toca?
CPRE pre quirúrgica
Qué estudio tiene mejor sensibilidad para coledocolitiasis? TC o US?
TC. Conventional (nonhelical) CT has historically demonstrated better sensitivity for choledocholithiasis than transabdominal US when composite diagnostic criteria are used (eg, the inclusion of indirect signs such as ductal dilation), although direct visualization of stones has not exceeded 75%. 45 Helical CT has shown improved performance over conventional CT for choledocholithiasis, with 65% to 88% sensitivity and 73% to 97% specificity.
La sensibilidad de la colangiorresonancia es mayor que otros estudios (USE o CPRE) para litos <5 mm en coledocolitiasis. V/F/NS
Falso. MRC has 85% to 92% sensitivity and 93% to 97% specificity for choledocholithiasis detection, as assessed in 2 recent systematic reviews. However, the sensitivity of MRC seems to diminish in the setting of small (<6 mm) stones and has been reported as 33% to 71% in this clinical subset
La sensibilidad del US endoscópico sigue siendo alta para coledocolitiasis a pesar del tamaño pequeño de los litos del colédoco. V/F/NS
Verdadero. Two meta-analyses, each composed of more than 25 trials and more than 2500 patients, reported an 89% to 94% sensitivity and 94% to 95% specificity of EUS for detecting choledocholithiasis, with ERC, IOC, or surgical exploration used as criterion standards. EUS remains highly sensitive for stones smaller than 5 mm, and its performance does not seem adversely affected by decreasing stone size
Complicación más común de CPRE:
Pancreatitis. The risks of ERC include pancreatitis (1.3%-6.7%), infection (0.6%-5.0%), hemorrhage (0.3%-2.0%), and perforation (0.1%-1.1%) in prospective series of unselected patients. However, several patient variables (eg, young age, female sex) have been identified that serve as risk factors for pancreatitis; similarly, coagulopathy increases bleeding risk and immunosuppression increases the risk of infection at ERC. Thus, risk estimates must be individualized to the patient.
