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Flashcards in Pancreatic and Hepatic 1 Deck (23):
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24-year-old woman who has incidental finding of gallstones – when to perform cholecystectomy?

No cholecystectomy unless
1. immunocompromised (more prone to serious complications of gallstone disease)
2. porcelain gallbladder
3. gallstones larger than 3 cm (associated with gallbladder carcinoma)
4. Becomes symptomatic

1

24-year-old woman presents with 12 hour history of pain in RUQ, nausea, vomiting, anorexia. Guarding and tenderness in RUQ. differential? Diagnosed with?

1. Symptomatic cholelithiasis
2. Biliary colic
3. Acute cholecystitis (unlikely without a fever)

Ultrasound

2

Factors that predispose to gallstone formation?

Female, fertile (pregnant), forty, fat

3

24-year-old woman presents with 12 hour history of pain in RUQ, nausea, vomiting, anorexia. Guarding and tenderness in RUQ. Patient also notes long history of indigestion, tarry stools, and alcohol use - differential?

PUD or gastritis

4

What blood chemistries would be abnormal in cholelithiasis?

1. Mild leukocytosis (12-15)
2. Mild jaundice (Billirubin 2-3)
3. Elevated alkaline phosphatase and transaminases levels

5

Patient diagnosed with uncomplicated symptomatic cholelithiasis. Should the patient receive antibiotics at presentation? Perioperatively?

Who should always get antibiotics?

If uncomplicated, no antibiotics need the presentation

Single preoperative dose of first-generation cephalosporin

patients with high risk of developing septic complications (age over 70, acute cholecystitis, history of obstructive jaundice, current jaundice)

6

Major complications of a cholecystectomy?

1. Injury to the common duct – can result in biliary strictures, infection, cirrhosis
2. Injury to the hepatic artery – can lead to hepatic ischemic injury, bile duct ischemia

7

33-year-old woman presents with right upper quadrant pain, nausea, vomiting, and temperature of 102. Ultrasound shows gallstones and edematous gallbladder wall. WBC count of 19,000 and elevated alkaline phosphatase – likely diagnosis? Specific Causal organisms? Management?

Acute cholecystitis with cholelithiasis

E. coli, Enterobacter, Klebsiella, enterococcus

1. Obtain blood cultures
2. Second-generation cephalosporins (or antibiotics against gram-negative rods and anaerobes)
3. fluid resuscitation and NG tube if nausea/vomiting
4. Laparoscopic cholecystectomy within 2-3 days

8

Patient with symptomatic cholelithiasis. In addition to elevated alkaline phosphatase and gallstones on ultrasound, Bilirubin is at 4 mg/dL – likely diagnosis? management?

Common bile duct obstruction

1. Ultrasound to look for dilated bile ducts
2. ERCP followed by laparoscopic cholecystectomy OR laparoscopic cholecystectomy with intraoperative cholangiogram and common duct exploration OR laparoscopic cholecystectomy and postoperative ERCP

9

Removal of common duct stones is not always necessary if?

Smaller than 3 cm in diameter

10

Six-month pregnant patient admitted with symptomatic cholelithiasis – management plan? When to perform surgery? Timing of surgery?

Non-operative in majority of patients – just hydration and pain relief

If recurrent episodes of pain or episode of biliary colic, Acute cholecystitis, or peritonitis – perform surgery or ERCP

Cholecystectomy during second trimester

11

35-year-old woman admitted with symptomatic cholelithiasis. Ultrasound show gallstones and blood studies show elevated amylase. No other significant findings – suspected diagnosis? Management? Management would change with what findings? (How ?)

Mild pancreatitis

1. Usually patient's amylase improves by next day
2. Then perform cholecystectomy and operative cholangiography (Cholangiogram is mandatory with biliary pancreatitis)

If patient has complications from pancreatitis - high food requirement, hypocalcemia, oligoria, hypertension, pulmonary issues (delay cholecystectomy and if obstructive, do ERCP)

12

60-year-old man has RUQ pain and gallstones on ultrasound. Temperature of 104 and blood pressure of 100/60 – differential?

1. Acute cholecystitis
2. cholangitis
3. empyema of the gallbladder
4. pericholecystic abscess

13

60-year-old man has RUQ pain. Temperature of 104 and blood pressure of 100/60. Ultrasound shows gallbladder distention with fluid that has internal echoes and gallstones – suspected diagnosis? Management?

Empyema of the gallbladder

1. IV antibiotics
2. Emergent exploration with cholecystectomy
3. If in poor health, percutaneous cholecystectomy to drain gallbladder

14

60-year-old man has RUQ pain. Temperature of 104 and blood pressure of 100/60. Ultrasound shows previous removal of gallbladder, dilated common bile duct, air in biliary system – suspected diagnosis? Management? If fails? If that fails?

Suppurative cholangitis (Bacterial infection occurring with bile duct obstruction)

1. Quick stabilization with IV fluids and antibiotics
2. Emergent ERCP with sphincterotomy and decompression of bile ducts
3. If Unsuccessful, transhepatic cholangiogram with stone extraction by IR
4. If still not successful, cholecystectomy and common bile duct drainage

15

78 year old man who presents with 12 hour history of RUQ. Temperature of 104, BP of 90/60, and WBC of 20,000 – suspected diagnosis? Management?

Acute biliary sepsis

Urgent surgery and antibiotics

16

78 year old man who presents with 12 hour history of RUQ. Temperature of 96 and WBC count of 3900 – suspected diagnosis? Management?

Elderly patients may present with hypothermia and leukopenia

Acute biliary sepsis

Antibiotics and urgent surgery

17

78 year old man who presents with 12 hour history of RUQ. Tender 3 cm mass in RUQ, temperature of 103, and mental obtundation – suspected diagnosis? Management?

Inflamed gallbladder (palpable gallbladder) and sepsis

Emergent cholecystectomy

18

51-year-old man who presents with jaundice (bilirubin 9), fever, RUQ pain and tenderness – likely diagnosis? Management?

Acute cholangitis

1. Resuscitation
2. Antibiotics
3. Ultrasound of biliary tree (if obstruction or dilation of common bile duct is seen, then ERCP and biliary compression)

19

51-year-old man who presents with jaundice (bilirubin 9), fever, RUQ pain and tenderness. Previous cholecystectomy 1 year ago – suspected diagnosis?

Biliary stricture from cholecystectomy or Retained stone (Presents within two years after cholecystectomy) in common bile duct

Biliary stricture:
1. RUQ ultrasound
2. Positive, surgical exploration and bypass of stricture with choledochojejunostomy

Retained Stone:
1. RUQ ultrasound
2. If positive, ERCP or percutaneous transhepatic cholangiography with stone extraction
3. If fails, bile duct exploration

20

Complications of laparoscopic cholecystectomy? Tests?

1. Infections
2. Biliary leak

1. Abdominal ultrasound
2. hepatobiliary nucleide scan (HIDA)

21

HIDA scan?

Uses: ID injection of hepatoiminodiacetic acid

Dye is excreted into biliary tract and used to detect biliary leaks

22

51-year-old man who presents with jaundice (bilirubin 9), fever, RUQ pain and tenderness. HIDA scan shows cystic duct stump leak on ERCP – management?

1. Biliary drainage with temporary stent during ERCP
2. Surgical exploration if failure to rapidly improve