Disorders of the gallbladder

Question 1

Cholelithiasis

Answer 1

Cholelithiasis is simply the presence of
gallstones, which form in the biliary tract,
usually in the gallbladder.

Question 2

_____ - the presence of 1 or
more gallstones in the common bile duct.

Answer 2

Choledocholithiasis

Question 3

Factors affecting Gallstone
formation:

Answer 3

● Stasis, change in bile concentration (high
cholesterol), and decreased gallbladder motility.
● CCK causes the gallbladder to contract and relaxes the sphincter of Oddi

Question 4

Cholelithiasis pathophysiology

Answer 4

○ Most gallstones are cholesterol based, which are most commonly radiolucent on X-ray
○ Patients with elevated risk of developing gallstones:
■ “The Four F’s.

Question 5

“Classic” risk factors for stone formation (the four F’s)

Answer 5

● Female- Estrogen increases risk of gallstones
● Forties- Premenopausal spikes in estrogen
● Fertile- Pregnant women have higher estrogen
● Fat- May be related to cholesterol levels in bile

Question 6

S/S of Cholelithiasis

Answer 6

● If symptoms develop, it is secondary to the lodging of gallstones, leading to
blockage of bile flow.
○ Sporadic and unpredictable episodes of biliary colic (sudden pain)
■ Pain often begins shortly after eating

Question 7

If the stone is in the ampulla of vater, _____

Answer 7

Gallstone Pancreatitis can develop.

Question 8

Pima indian tribe and gall stones

Answer 8

80% will have gallstones byy the age of 35

Question 9

Cholelithiasis diagnosis

Answer 9

Ultrasound is the diagnostic test of choice

Question 10

Other imaging If Choledocholithiasis is suspected

Answer 10

■ Endoscopic Retrograde Cholangiopancreatography (ERCP)
■ Magnetic Resonance Cholangiopancreatography (MRCP)

Question 11

Magnetic Resonance Cholangiopancreatography (MRCP)-

Answer 11

○ A non-invasive imaging technique that
allows for visualization of the biliary tree
and pancreatic ducts.

Question 12

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Answer 12

○ ERCP combines Endoscopy with
Fluoroscopy (X-ray with contrast dye)
to evaluate the biliary tree and
pancreatic ducts.
○ It is moderately invasive and does
administer radiation, so it is becoming
secondary to MRCP unless there is
high likelihood that treatment will be
needed during the study.
■ Ex: Choledocholithiasis

Question 13

If a gallstone is
immediately available, the
stone can be extracted
during this procedure

Answer 13

ERCP

Question 14

Cholelithiasis Management

Answer 14

As long as the patient is asymptomatic, treatment is essentially expectant and watchful.

Question 15

Cholecystectomy is usually the definitive treatment of choice for

Answer 15

Cholelithiasis

Question 16

Cholecystitis

Answer 16

Inflammation of the gallbladder that occurs most commonly secondary to
cystic duct blockage by a gallstone.
● Can be acute or chronic.
● Gallstones are present in 90-95% of
cases - “Calculous Cholecystitis.”

Question 17

Cholecystitis Pathophysiology (acute vs. chronic)

Answer 17

○ Acute Cholecystitis: Gallstone blockage in the cystic duct leads to
distended and tense gallbladder that may contain areas of ischemia with
necrosis, as well as possible purulent material.
○ Chronic Cholecystitis: Chronic irritation and inflammation of the gallbladder that continues over time, usually secondary to repetitive bouts of acute cholecystitis.

Question 18

Cholecystitis S/S

Answer 18

○ The most common symptom is upper abdominal pain.
■ With acute cholecystitis, the pain often beings in the epigastric region, then localizes to the RUQ.
○ Pain is often colicky, can become constant as it progresses.
■ Sometimes refers to the right scapula/shoulder
○ Nausea and vomiting are frequently present.
○ Often made worse by eating (especially greasy foods).

Question 19

Clinical Clues of Cholecystitis

Answer 19

○ Acute calculous cholecystitis is commonly seen in patients with the 4 Fs
○ Murphy’s Sign
○ Abdominal guarding or rebound tenderness, are often present.

Question 20

Lab tests may suggests hepatobiliary disease, but are not reliable
for diagnosis of _____

Answer 20

cholecystitis.

Question 21

Cholecystitis diagnosis

Answer 21

○ Ultrasound is the preferred initial
imaging test
○ Hepatobiliary Iminodiacetic Acid (HIDA) Scan
○ CT abdomen with contrast or MRI with
contrast can identify cholecystitis, but are not recommended as initial studies

Question 22

What will you see on ultrasound for Cholecystitis

Answer 22

■ Gallbladder wall thickening and
pericholecystic fluid are sonographic
evidence of cholecystitis.
■ Presence of cholelithiasis in combination with the sonographic
Murphy’s Sign is a highly sensitive US
finding.

Question 23

Hepatobiliary Iminodiacetic Acid (HIDA) Scan

Answer 23

also known as Cholescintigraphy. Usually performed second, if the Gallbladder
Ultrasound is equivocal (IE, to confirm or clarify).
■ Nuclear imaging procedure to evaluate function of gallbladder.

Question 24

Management of cholecystitis

Answer 24

○ Initial treatment may involve bowel rest, IV hydration, analgesia,
antiemetics, and IV antibiotics.
○ Uncomplicated cholecystitis can be treated on outpatient basis, often
including Levofloxacin and Metronidazole, and antiemetics.
○ Surgical intervention is often performed, emergently if complications are
present- Laparoscopic Cholecystectomy is standard of surgical care.

Question 25

Cholecystectomy

Answer 25

surgical removal of the gallbladder

Question 26

T/F Laparoscopic Cholecystectomy is preferred over the open procedure

Answer 26

T

Question 27

When may a cholecystectomy need to convert from laproscopic to open?

Answer 27

○ Significant bleeding that is difficult to control laparoscopically ○ Rupture of the gallbladder ○ Difficulty due to size of liver ○ Unexpected pathology

Question 28

Outpatient vs. inpatient Cholecystectomy

Answer 28

● If the procedure was done as a planned, elective procedure, it’s generally done as an outpatient with discharge home the same day. ○ Generally regain normal level of life within 1 week ● If the procedure was performed emergently/urgently (and was not planned), the patient generally remains in the hospital for a few days for monitoring and IV antibiotics.

Question 29

Acute Cholangitis

Answer 29

Acute cholangitis is an acute infection of the biliary tree It is very dangerous and potentially deadly because it can lead to sepsis

Question 30

Acute Cholangitis pathophysiology

Answer 30

○ These bacteria are able to proliferate in the biliary tree when a significant obstruction occurs. ■ “Ascending cholangitis” ○ Most common cause of the obstruction is choledocholithiasis

Question 31

Acute Cholangitis S/S

Answer 31

○ Classic presentation is that of Charcot’s Triad (present in 50-70% of cases): ■ RUQ pain (90%) ■ Jaundice (80%) ■ Fever (95%) Reynold’s Pentad: ■ Altered Mental Status ■ Hypotension/shock

Question 32

Acute Cholangitis diagnosis

Answer 32

○ Although a clinical diagnosis for the most part, Ultrasound is the diagnostic tool that is most useful. ■ Biliary dilation or stones ○ Lab studies: ■ CBC will show leukocytosis ■ Elevated bilirubin levels ■ Elevated AST/ALT ○ ERCP can be diagnostic and therapeutic, but should be avoided until the patient medically stable.

Question 33

Management of acute cholangitis

Answer 33

○ Broad-spectrum IV antibiotics are necessary. ○ Correction of fluid and electrolyte disturbances. ○ With severe cholangitis with obstruction, Endoscopic Biliary Decompression may be necessary.

Question 34

Primary Sclerosing Cholangitis

Answer 34

● PSC is a chronic, progressive thickening of the walls of the bile ducts. ● The etiology is essentially unknown (autoimmune?), although there is a very strong correlation to Inflammatory Bowel Disease, especially Ulcerative Colitis (UC).

Question 35

Primary Sclerosing Cholangitis pathophysiology

Answer 35

○ A continual underlying inflammation of the walls of the ducts is the likely explanation for the development of fibrosis and strictures. ● The disease generally progresses until it eventually culminates in portal hypertension, cirrhosis with complications, and liver failure. ● PSC patients are high risk for development of cholangiocarcinoma.

Question 36

Primary Sclerosing Cholangitis s/s

Answer 36

○ Jaundice and pruritus are the most common presenting features. ○ Other signs and symptoms include: ■ Fatigue/malaise ■ Weight loss ■ Dull right upper quadrant pain ■ Hepatomegaly and/or splenomegaly are common ○ Recurrent febrile bacterial cholangitis occur in about 10-15% of patients.

Question 37

Primary Sclerosing Cholangitis Diagnosis

Answer 37

○ ERCP (or MRCP) demonstrate sclerotic appearing biliary ducts.

Question 38

Although not necessary for diagnosis, liver biopsy may reveal “onion skin” fibrosis of the bile ducts with

Answer 38

Primary Sclerosing Cholangitis

Question 39

Primary Sclerosing Cholangitis managment

Answer 39

No great options ■ Ursodiol is a PO medication that can be used in combination with ERCP (endoscopic duct dilation). ○ The median length of survival after diagnosis is 12 years. ○ Liver transplantation is the only treatment that appears to extend life or change the prognosis.

Question 40

Gallbladder Cancer

Answer 40

Gallbladder Cancer is a rare malignancy that develops in patients with a long history of chronic gallbladder inflammation

Question 41

The average age of diagnosis for gallbladder cancer in the US is between ____

Answer 41

62 and 66 years.

Question 42

Gallbladder Cancer S/S

Answer 42

○ Signs and symptoms may not develop until late stage gallbladder cancer ○ Typical symptoms include: (Seem familiar?) ■ Jaundice ■ RUQ aching abdominal pain ■ Low-grade fever ■ Nausea with vomiting ■ Bloating ■ Small percentage may have RUQ mass

Question 43

Gallbladder Cancer diagnosis

Answer 43

○ Ultrasound is the standard for initial study of choice; may show mass in 50-75% of cases. ○ CT with contrast may show the tumor better and will shed light on any mets. ○ ERCP may establish the diagnosis by obtaining cytology samples of the bile.

Question 44

Gallbladder cancer and surgery

Answer 44

Complete surgical resection is the only chance for a cure, however, most have metastasized to the local or distant nodes early

Question 45

Cholangiocarcinoma

Answer 45

A malignancy of the biliary ducts that may occur anywhere from the small upper ducts down to the Ampulla

Question 46

There are essentially two anatomic regions for cholangiocarcinoma

Answer 46

○ Intrahepatic tumor ○ Extrahepatic tumor

Question 47

More than 90% of cholangiocarcinoma are _____

Answer 47

adenocarcinomas

Question 48

Cholangiocarcinoma etiology

Answer 48

largely unknown, but likely attributable to chronic ductal inflammation. ○ Association with Primary Sclerosing Cholangitis

Question 49

Cholangiocarcinoma S/S

Answer 49

○ Significant Jaundice is the most common manifestation. ○ Clay-colored stools (Acholic) and bilirubinuria (dark urine). ○ Pruritus is common with the jaundice. ○ Weight loss or abdominal pain are variable

Question 50

Cholangiocarcinoma tumor marker

Answer 50

CA 19-9

Question 51

ERCP with brush cytology provides tissue to make the definitive diagnosis of

Answer 51

Cholangiocarcinoma

Question 52

Overall survival of Cholangiocarcinoma

Answer 52

6 months after diagnosis