incidence of gallstones
by age 75, 35% of women and 20% of men
30% of people will have symptomatic disease
what is acute cholecystitis
obstruction of the bile duct, usually a stone
leads to chronic inflammation
colicky epigastic pain or RUQ pain becoming steady and increases in intensity. often occurs after a high fat meal
*post prandial abdominal pain, assoc with N/V
acute cholelcystitis symptoms
right shoulder or subscapular pain may occur with what
acute cholecystitis
labs and imaging to order for acute cholecystitis
*HIDA scan initial and definitive test
bilirubin levels with increase after 24hrs and leukocytosis common
HIDA scan and ERCP for what
gallstone
HIDA to confirm
ERCP to identify cause, location, and extent of biliary obstruction
what is acute cholangitis
potentially deadly condition of common bile duct obstruction combined with ascending infection
charcots triad
RUQ tenderness, jaundice, fever. occurs in 50-70% of acute cholangitis
pt has charcots triad and also altered mental status and hypoTN
sepsis with acute cholangitis
elderly presentation of acute cholangitis
confusion, falls, and incontinence
how to dx acute cholangitis
initial test
labs
procedure
RUQ ultrasonography will show biliary dilation or stones *good initial test
leukocytosis with left shift along with increased bilirubin, elevated alk phos, and mildly increased transaminase levels support dx
ECRP(definitive) optimal procedure for dx and tx, should not be done until the pt is stable
initial tx for acute cholangitis (3)
antibx (FQ, cephalosporin, ampicillin, gentamycin with flagyl)
fluid and electrolyte replacement
analgesia
what is primary sclerosing cholangitis
chronic thickening of the bile duct walls of unknown etiology.
maybe stone or infection usually
80% of primary sclerosing cholangitis is associated with what
inflammatory bowel disease, generally UC
10% of pts with UC will develop PSC
gender and age of primary sclerosing cholangitis
male to female 7:3 age btw 21-67
sx of primary sclerosing cholangitis
jaundice and pruritis most common
hepatomegaly and/or splenomegaly on exam
fatigue, malaise, wt loss
primary sclerosing cholangitis
initial imaging
labs
2 other tests
RUQ ultrasonography
increased alk phos and bilirubin
leukocytosis with left shift
ERCP: “beading” mulitiple bile duct strictures
liver bx: “onion skinning” periductal sclerosis
tx for primary sclerosing cholangitis
localized strictures relieved with balloon dilation and stent placement
long term stenting increases risk of cholangitis
liver transplant is the only tx with a known survival benefit
complications of gallstones
cholecystitis
pancreatitis
acute cholangitis
common cause of acute cholecystitis
imaging
95% due to gallstones
20% radiopaque, remainder visible on sonography
* HIDA to confirm
ERCP
acute cholelcystitis symptoms
radiation
other mild symptoms
colicky epigastic pain or RUQ pain becoming steady and increases in intensity. often occurs after a high fat meal
radiation to rt shoulder or subscapular area
N/V, low fever are common
constipation and mild paralytic ileus may occur
acute cholangitis organisms
other causes
E coli, enterococcus, klebsiella, enterobacter
can lead to sepsis and death
most often caused by choledocholithiasis,
or neoplasms, post op strictures, other causes of obstruction
reynolds pentad
charcot triad
altered mental status
hypotension
all indicate sepsis!! fatal!!
think cholangitis
primary sclerosing cholangitis is strongly associated with what
cholangcarcinoma (10-30% of pts) as well as with an increased risk of pancreatic and colorectal carcinoma
secondary tx for acute cholangitis
[ECRP for drainage and cholecystectomy]
ECRP for drainage, sphincterotomy, stone removal, and stent placement when pt is stable
percutaneous transhepatic biliary drainage or surgical biliary drainage may be required
cholecystectomy should be performed after the acute syndrome is resolved when a stone is present
4 F’s for gallstones
female
fat
forty
fertile
additional risk factors:
OCP use, rapid wt loss, TPN,
chronic hemolysis(pigment stones in sickle cell disease),
small bowel resection(loss of enterohepatically circulated bile)
gallstones
acute cholecystitis
symptoms(3) and exam(1)
RUQ pain, N/V, low fever
murphy sign
murphy sign
inspiratory arrest with deep palpation of RUQ
acute cholecystitis
risk factors:
native american
DM
pregnancy
crohns
female
obesity
risk factors for cholecystitis
RUQ ultrasonography
increased alk phos and bilirubin
leukocytosis with left shift
ERCP: “beading” mulitiple bile duct strictures
liver bx: “onion skinning” periductal sclerosis
tests for primary sclerosing cholangitis
why are most gallstones not radiopaque
cholesterol
confusion, falls, and incontinence
elderly presentation of acute cholangitis