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Flashcards in Gastro - Online MedEd - gallbladder Deck (23):

Cholelithiasis - what is it?

Bunch of stones in gallbladder
3 types of gallstones
Won't know which type until take out gall bladder


Gallstones are what types

Cholesterol - green, from Five F's: fat, female, forty, fertile, Native American
Pigmented stones - black, from hemolysis
Mixed of both - is most common


Cholelithiasis - presentation

Colicky, RUQ pain radiate to shoulder
Worse with fatty foods
Fatty foods cause more contraction of gall bladder


Cholelithiasis - dx?

US --> see gallstones
US is first diagnostic imaging for all gallstone disease!


Treatment - cholelithiasis

Elective cholecystectomy (not emergent)
Not surgical candidate: ursodeoxycholic acid (i.e. very old patient)
But generally curative


Gall stone pops out and ends up in duct gets...

Cholecystitis =
Obstruction of cystic duct --> gall bladder gets big inflamed and angry
Gallstone stuck in cystic duct


US of cholecystitis

This is first set of imaging
Pericholecystic fluid
Thickened gallbladder wall
Gallstones - others in the gall bladder, but rarely see obstructing stone


Cholecystitis - presentation

Constant RUQ pain
Positive Murphy's sign - jab thumb into gallbladder with inspiration
Due to inflammation - mild fever and mild leukocytosis


Dx of cholecystitis

1) US - rarely see obstructing stone
2) HIDA scan - get radio tracer --> fill gall bladder into biliary tree = normal; if there is cholecystitis --> biliary tree will fill, but gallbladder won't
HIDA scan positive = no radioactive tracer in gall bladder!


Treatment of cholecystitis

IV antibiotics
-Start with above, but do surgery
Cholecystectomy - urgent, within 72-96 hours (not emergent)
-If not a surgical candidate, can do a cholecystotomy --> put in a tube to drain away the inflammation


Choledocholithiasis - what is it?

Stone comes out of cystic duct --> common bile duct
-If down to ampulla of vater --> can get inflammation of liver (hepatitis, elevated bilirubin), pancreas (gall stone pancreatitis, elevated amylase)
*Will certainly have obstructive jaundice


Painful jaundice is...

Stone stuck in common bile duct cause painful obstructive jaundice


Presentation - choledocholithiasis

Inflammation - mild fever/leukocytosis


Dx choledocholithiasis

US - may see dilated ducts/obstruction, if don't see dilated ducts then there is unlikely to be a stone in the common bile duct
*If think there is choledocholithiasis because there is painful jaundice (direct hyperbilirubinemia) BUT US is negative --> get the MRCP (do not use HIDA)


When to use MRCP?

When there is painful jaundice (indicating choledocholithiasis) but there is negative US


Treatment of choledocholithiasis

ERCP urgent!
NPO, give fluids and IV antibiotics initially with goal to ERCP
Then do cholecystectomy (elective)
-Why give IV antibiotics --> in case it becomes cholangitis

In reality...
1) Gen Surg: cholecystectomy, then intraoperative cholangiogram to remove the stones from the back
2) Gastro: scope down esophagus --> ampulla of vater/ERCP --> sphincterotomy --> pull out stones --> then surgeon removes gall bladder in the future


Sometimes... can dx choledocholithiasis... but next day...

Patient is better
Enzymes have removed etc.
What has happened? stone moved out of the way, may not need to do ERCP
Then enzymes go up again --> means stone is moving up and down! Ball-valve effect
-Still need ERCP!


Cholangitis - is the most serious of all gall bladder diseases!
What is it?

Dilated ducts!
Gallstones in common bile duct + obstructing stone = like choledocholithiasis
Now there is Stagnant fluid --> nidus of infection --> bacteria grow and cause ascending infection up the tree!


What type of infection of cholangitis?

Gram negative rods


Presentation of cholangitis

RUQ abdominal pain
Painful jaundice
= Charcot's triad for cholangitis
Might also have hypotension and altered mental status
= Reynaud's pentad


Dx of cholangitis

RUQ US - obstruction, dilated ducts, but won't see obstructed stone
Don't do MRCP, HIDA


Treatment of cholangitis

If have infection, will need surgery right away!
No amount of antibiotics will clear the infection
Therapeutic and diagnostic step: ERCP emergent!!
Then do cholecystectomy (usually urgent, sometime elective)
Need initial resuscitation: IVF, NPO, IV antibiotics while waiting for surgery
In real life will be emergency ERCP


Which IV Antibiotics for cholangitis?

GNR and anaerobes
Same bugs of GI tract
1) Ciprofloxacin and Metronidazole
2) Ampicillin, gentamycin, metronidazole
-Pip/Tazo - do not pick, it does cover this, but also covers Gram positive (over-covering for Strep and Pseudomonas), not antibiotics stewardship - easily done in hospital