Exam 2 CM3 Biliary dz Flashcards
(48 cards)
What is bile, it’s composition/function
500 mL secreted daily by liver, concentrated in GB
Composition: water, electrolytes, bile salts, phospholipids, bilirubin & cholesterol
Function: digestion and absorption of fats (bile salts); vehicle for excretion of bilirubin, excess chol and metab by products
Cholelithiasis
Stones in gallbladder
Cholecystitis
Inflammation of the GB
Choledocholithiasis
Stones in CBD
Cholangitis
Inflammation of the bile ducts
Cholestasis
Disruption of bile flow, regardless of cause
Risk factors for Cholelithiasis
Four F’s (female, fluffy/obese, Forty, Fertile/Estrogen) Female >40 Pregnancy (hormones change bile consistency) Obesity Rapid weight loss (bile not being used) Estrogen (birth control) Ethnicity (Native Americans)
What are the different types of gallbladder stones (Cholelithiasis)
- Cholesterol (most common) >80%
2. Pigment – bilirubin, calcium, proteins Black or Brown
What are the various outcomes/prognoses for Cholelithiasis
Asymptomatic (most) Symptomatic Biliary colic Complications Acute Cholecystitis (inflam of GB) Acute Choledocholithiasis (Stones in CBD) Ascending Cholangitis (inflam of bile duct) Acute Pancreatitis
How do you diagnose Cholelithiasis (initial study then others)
Initial study = UTZ
*UTZ is initial TOC in eval of biliary dz; inexpensive/noninvasive
*May show gallstones, wall thickening, pericholecystic fluid (fluid surrounding gallbladder)
Abdominal Plain film
Only + in ~10% pt’s with gallstones
CT abdomen
Will show majority of gallstones (50-80%) but higher cost, radiation exposure and less sensitive than UTZ
How do you treat Cholelithiasis
Asymptomatic Cholelithiasis incidental finding w/ no sx then Cholecystectomy (CCY) is NOT RECOMMENDED
Symptomatic Cholelithiasis sx biliary disease (biliary colic, cholecystitis, choledocholithiasis, ascending cholangitis) CCY recommended
What is Biliary Colic? Sx? Triggers?
Biliary Colic = TEMPORARY obstruction of cystic duct
Usually caused by gallstone (cholelithiasis); pressure rises in gallbladder causing pain
Colicky, dull constant RUQ pain, possibly radiating to R shoulder blade; assoc N/V, diaphoresis
As gallbladder relaxes, obstruction is relieved; no associated inflammation (thus NO FEVER, NO LEUKOCYTOSIS)
Triggers: fatty meal
Sx temporary, do not last more than 4-6 hr
Often initial presentation of sx gallbladder dz
In a pt with Biliary Colic, what PE findings would be present?
Gen: do not appear acutely ill
Skin: NO EVIDENCE of JAUNDICE (bc stone in cystic duct, NOT bile duct)
Eyes: anicteric (bc no jaundice)
Vitals: normal (no fever/tachy)
Abd exam: Fairly benign with possible RUQ tenderness, no evidence of peritonitis (rebound pain) and negative Murphy’s sign
What studies/results help dx BILIARY COLIC?
Lab: CBC, LFT, Amylase, Lipase ALL WNL!
UTZ: preferred initial test in eval of suspected biliary dz
Gallstones and/or sludge (bc temporary cystic duct obstruction)
How do you treat/manage BILIARY COLIC?
Considered sx biliary dz Prophylactic CCY (cholecystectomy) IS RECOMMENDED to prevent recurrent sx and complications
Be sure to r/o alternative dx
What is Biliary Dyskinesia and who should be considered for this dx?
Biliary dyskinesisa = functional gallbladder disorder, likely a motility disorder of gallbladder
Consider in pt presenting with typical biliary colic (dull constant RUQ pain that may radiate to R shoulder blade) who:
Has no evidence of Gallstones or sludge on UTZ
No CBC, LFT, amylase or lipase abnormalities
Other causes of sx r/o
Consider performing HIDA w CCK
What is a HIDA scan with CCK and what is it used to evaluate?
HIDA: inject 99 technetium labeled derivative or hepatic iminodiacetic acid (HIDA) dye which is excreted in bile and taken up by gallbladder if cystic duct is patent. Normal gallbladder fills in 30 min, radioactivity measured in gallbladder. CCK given to stim contraction, EF calculated to see how well gallbladder is functioning. Want at least 35-40% ejection fraction upon stimulation or CCK, less than 35-45% EF may indicate Biliary Dyskinesia)
Used to eval BILIARY DYSKINESIA
*NOTE: do NOT given CCK if pt has gallstones (contractions stimulate attack)
How should you manage/treat biliary dyskinesia
CCY if…
Typical biliary sx (RUQ pain, may radiate to R shoulder)
HIDA w/ CCK <35-40%
R/o other dx (PUD, gastritis, GERD, cardiac ischemia etc) need good H&P
What is ACUTE CHOLECYSTITIS and what is the cause? Sx?
Etiology: acute inflammation of the gall bladder secondary to sustained obstruction of the cystic duct
Most commonly caused by cholesterol stones (Overall mortality: 3%)
Often prior hx of biliary colic
Sx: Steady severe RUQ pain +/- radiation to R shoulder/flank;
Assoc N,V, diaphoresis, FEVER!!
Sx are PERSISTENT, often longer than 4-6 hr (unlike Biliary colic with sx <4-6hr)
Trigger: fatty meal
PE findings associated with Acute Cholecystitis
Gen: ILL appearance
Vitals: FEVER, tachy (biliary colic, no fever or tachy)
Eyes: Anicteric (in cystic duct)
Skin: No jaundice (in cystic duct)
Abd exam: RUQ tender, Palpable tender gall bladder in 30-40%, possible guarding and rebound, +MURPHYS (unlike biliary colic)
What complications are associated with acute cholecystitis?
Gangrene (up to 20%): often in elderly, immunosuppressed, people who get delayed tx
Look for signs of sepsis
Perforation
Generalized Peritonitis
Cholcystoenteric fistula (bw small bowel and gallbladder)
Gallstone ileus
What lab/imaging studies are helpful to dx acute cholecystitis?
CBC (elevated WBC with LEFT shift)
LFT: usually normal
Possible mild increase in AST/ALT, alk phos, bilirubin
If significant elevations in alk phosbilirubin, r/o CHOLANGITIS (CBD obstruction)
UA: elevated uroblinogen
Pancreatic Enzymes
Possible mild elevation of amylase
UTZ (preferred) gallstones, wall thickening (>4-5mm), Pericholescystic fluid, + sonographic Murphys
HIDA: used to confirm dx if in question
Failure to fill gallbladder in setting of cystic duct obstruction
How do you manage/tx acute cholecystitis?
Admit All
Analgesia (Ketorolac, morphine, meperidine or NSAID)
NPO (don’t want to stim gallbladder)
IV fluids w/ electrolyte
IV ABX (similar as diverticulitis)
Monotx: Zosyn, Unasyn, Timentin IV or Combo (Rocephin & Flagyl or Cipro & Flagyl)
Early CCY (most laparoscopic)
Recommended during initial hospitalization in healthy low risk ASA I or II pt
Emergent CCY if severe complication (gangrene, perf, peritonitis etc) or clinical deterioration despite supportive tx
IF HIGH RISK (ASA III-V) continue supportive tx, weight risk vs. benefit via specialist
if med tx fails then possible percutaneous CCY tube for decompression
What is chroniccholecystitis and how is it dx?
Chronic inflammation of the gallbladder
Associated with mechanical irritation from gallstones or repeated episodes of acute cholecystistis
Typically dx made upon review of histology ie post CCY
