1 Flashcards
RUQ pain radiating to the back after fatty meals, resolves within a few hours, female, multigravida, obese
Symptomatic cholilethiasis
RUQ pain; history of recent pelvic inflammatory disease (either Chlamydia trachomatis or Neisseria
gonorrhoeae), fever, “violin string” adhesions between liver and diaphragm
Fitz-Hugh- Curtis syndrome
Hepatitis A (recent foreign travel, IVDA, raw shellfish, fecal-oral)
Acute hepatitis
Costovertebral angle tenderness, dysuria, hematuria
Acute pyelonephritis
RUQ pain, high fever, hepatomegaly (bacterial or amoebic)
Hepatic abscess
Persistent RUQ pain, fever, jaundice (Charcot’s triad)
Acute cholangitis
(Charcot’s triad)
Persistent RUQ pain, fever, jaundice
Charcot’s triad)
Acute cholangitis
Severe RUQ pain radiating to back +/− scapular pain, persistent (>4–6 hours), fever, tachycardia, Murphy’s sign
Acute cholecystitis
Episodic RUQ pain aggravated by opioids
Sphincter of Oddi dysfunction
Intermittent burning epigastric pain that improves (duodenal ulcer) or worsens (gastric ulcer) with food
intake (secondary to H. pylori infection, NSAID, steroid use)
Peptic ulcer disease
severe persistent abdominal pain
following ingestion of fatty foods,
nausea and vomiting, and
associated right upper quadrant tenderness to palpation,
the etiology is most likely of
Biliary origin
a normal amylase and lipase ( wit symptoms of biliary origin ) rule out:
gallstone pancreatitis
Symptoms of biliary origin With a normal total bilirubin and alkaline phosphatase, …… and ……. Are less likely
choledocholithiasis , acute cholangitis
colic is a pain, usually …… or…… in nature
intestinal , urinary
لو كان الوجع من ال gallstones وقتها بكون ……
Constant
Distinguish Between Symptomatic Cholelithiasis and Acute Cholecystitis
من الهم افرق بينهم لأنه العلاج حيكون مختلف
Symptomatic cholelithiasis is usually managed as an outpatient, with eventual elective laparoscopic cholecystectomy.
Acute cholecystitis requires hospital admission, intravenous (IV) antibiotics, and urgent cholecystectomy..
Distinguish Between Symptomatic Cholelithiasis and Acute Cholecystitis
من الهم افرق بينهم لأنه العلاج حيكون مختلف
Symptomatic cholelithiasis is usually managed as an outpatient, with eventual elective laparoscopic cholecystectomy.
What Is the Significance of Abdominal Pain
After Eating Fatty Foods?
انه لما يتم تناول الطعام الدهني رح يتم انتاج cholecystokinin (CCK) وهذا مسؤول عن انقباض المرارة عشان تخرج العصارة منها ولكن وجود الحصوة بمنع ، وهذا مع الوقت رح يعمل :
ensuing distention of the gallbladder stretches the visceral peritoneum that surrounds it, leading to RUQ and/or epigastric pain that is vague and mild to moderate in severity (symptomatic cholelithiasis).
What Is the Significance of RUQ Pain
Combined with Scapular Pain?
طيب شو سبب بمنطقة الكتف ؟
انه الأصل الهم نفس المصدر :
The scapula is innervated by the supraclavicular nerves, and the soft tissue surrounding the gallbladder is innervated by the phrenic nerve. Since the same spinothalamic pathways ( pain and temperature) from both nerves travel to the same
cervical cord levels,
عشان هيك أي destination أو inflammation على ال gallbladder رح يؤدي إلى Scapular Pain
What Is the Significance of the Patient’s
Inspiration Stopping with RUQ Palpation?
الأصل انه عندي التهاب بال
It represents focal peritonitis of the anterior abdominal wall parietal peritoneum due to inflammation of the adjacent gallbladder.
فلما اعمل palpation على هاي المنطقة وهو ماخد نفس عميق ( الأعضاء نازلة لتحت ) ، رح يلمس ال جدار الملتهب وبعمل irritation فبسبب وجع شديد
McMurray’s sign
A positive McMurray’s sign indicates a medial
meniscal tear.
systemic inflammatory response, such as
fever, tachycardia, and leukocytosis,
Systemic inflammatory response such fevers; tachycardia; leuokocytosis suggest:
a more severe biliary disease such as acute cholecystitis or acute cholangitis.
Symptomatic cholelithiasis ( biliary colic) does not typically present with a systemic
response.
Symptomatic cholelithiasis (biliary colic) ………typically present with a systemic response.
does not
Acute cholecystitis is caused by
sustained obstruction (impaction) of the cystic duct, most often by a gallstone
sustained obstruction (impaction) of the cystic duct, most often by a gallstone. This obstruction leads to
inflammation and edema of the gallbladder wall and then eventually bacterial overgrowth and invasion of the gallbladder wall.
Acute Cholecystitis / ( obstruction leads to inflammation and edema of the gallbladder wall and then eventually bacterial overgrowth and invasion of the gallbladder wall.)
ischemia,
necrosis (gangrenous cholecystitis),
and rarely gallbladder perforation
What Is Hydrops of the Gallbladder? mucocele of the gallbladder
the ( gallbladder mucosa )continues to secrete mucus, and the bile in the gallbladder eventually gets reabsorbed, leaving a glycoprotein rich white fluid, sometimes called “white bile.”
بتكون كبيرة وملانة عصارة بيضا
The most common organisms found in biliary cultures from patients with acute cholecystitis are, in order,
E.coli
Klebsiella
Bacteroides fragility
Enterobacter
Enterococcus
Pseudomonius species
What Are the Components of Bile?
The three main components of bile are
1- bile salts, 2- cholesterol, 3- lecithin (a phospholipid).
Bile also contains :
water, electrolytes, proteins, and bile pigments.
Patients with biliary disease often have the 4 “Fs”
(female,fat, forty, fertile)
Lithogenic bile
Stone producing bile
Oral contraceptives increase incidence of cholesterol stone due to
Increased estrogen
Increase estrogen will cause
1- increases cholesterol in bile
2- decreases gallbladder motility
Obesity, Crohn’s disease, and terminal ileal resection Increase the risk of Developing Cholesterol Gallstone due to :
decreases bile salts
High-fat diet, hyperlipidemia:
increases bile cholesterol
بالتالي بزيد خطر ال Cholesterol Gallstones
hereditary predisposition to biliary disease
Hispanic, Pima Indians:
How Do Cholesterol Gallstones Form?
High concentrations of cholesterol or
lower concentrations of bile salts or lecithin lead to precipitation of cholesterol stones.
The dark coloration of pegmented gallstone is a result of
the presence of calcium bilirubinate within the stones.
Black stones are often associated with
hemolytic diseases such as
1- hereditary spherocytosis .
2- sickle cell disease
3- G6PD deficiency.
Brown stones form from……., while Black stones form from the …….
Bacteria , Blood
Brown stones, in comparison, with black stone are
larger and softer and most often form within the bile ducts.
Transient obstruction of the cystic duct
→ visceral peritoneal stretch → RUQ pain
Symptomatic
cholelithiasis
Acute
cholecystitis
Persistent obstruction of the cystic duct
→ visceral peritoneal stretch → inflammation
of the gallbladder → bacterial overgrowth
→ infection of the gallbladder → parietal
peritoneum inflammation
Choledocholithiasis
Obstruction of the common bile duct (CBD)
Cholangitis
Obstruction of the CBD → bacterial
overgrowth → infection of the entire biliary
tree → ascends into the liver
Acute gallstone pancreatitis
Obstruction of the CBD and pancreatic duct
→ pancreatic enzyme release
Gallstone ileus
Very large stone erodes into the duodenum
→ gallbladder-duodenal fistula → stone
travels down the GI tract → small bowel
obstruction (not ileus!)
Mirizzi’s
syndrome
Large gallstone impacted in the cystic duct
→ compresses the common hepatic duct
Gallstone ileus is a
mechanical small bowel obstruction, typically as a result of the gallstone trapped at the terminal ileum near the ileocecal valve as this is the narrowest part of the gastrointestinal tract.
Patients present with a tumbling obstruction with transient episodes of diffuse abdominal pain and nausea and air in the biliary tree
Diagnosis of these conditions
A RUQ ultrasound is the diagnostic test of choice
The ultrasound should also note
the thickness of the gallbladder wall and whether there is any fluid surrounding the gallbladder.
The ultrasound should make note of the diameter of the CBD as well as whether a stone is visualized within it.
These two findings, gallbladder wall thickening (>4 mm) and pericholecystic fluid, are diagnostic for…………..
acute cholecystitis
Most gallstones are……… , so a CT scan of the
abdomen may be negative.
radiolucent
What Is the Normal CBD Diameter,
A normal CBD ranges from 4–5 mm
In most patients a CBD >6 mm is considered abnormally dilated
In most patients a CBD >6 mm is considered abnormally dilated. This suggests……
obstruction from either a
gallstone or a tumor.
How Accurate Is Ultrasonography
in Detecting Gallstones Within
the Gallbladder? Within the CBD?
Ultrasound is very sensitive (95%) and specific (97%) for
gallstones (even as small as 1–2 mm) within the gallbladder.
Conversely, it is very poor for detecting gallstones within the
CBD (sensitivity of about 50%) as bowel gas interferes with
the ultrasound waves.
What If the Ultrasound Demonstrates Gas Bubbles in the Gallbladder Wall?
This would be concerning for emphysematous cholecystitis
emphysematous cholecystitis
an infection due to gas-forming organisms.
an infection due to gas-forming organisms.
emphysematous cholecystitis,
This diagnosis is
common in older men, often with diabetes mellitus. Bile cul-
tures will often grow Clostridium or E. coli.
emphysematous cholecystitis
emphysematous cholecystitis can progress to
1- gallbladder perforation
2- intra-abdominal abscess,
3- sepsis
4- death if cholecystectomy is not performed emergently
along with administration of broad-spectrum antibiotics
(that must also cover Clostridia).
A liver panel should include
1- Total and direct bilirubin,
2- aspartate (AST) and alanine (ALT) amino transferase
3- alkaline phosphatase (AP)
4- gamma-glutamyl transferase (GGT).
In a patient who only had symptomatic cholelithiasis, all of
these ( liver panel ) should be……
normal
Mild elevations in liver panel can be seen in
acute
cholecystitis.
Significantly elevated AP and GGT out of proportion to AST and ALT suggest
1- cholestasis or biliary obstruction 2- are often related to choledocholithiasis
marked elevations in AST or ALT, out of proportion to the
AP and GGT, indicate
1- hepatocellular damage
2- a primary hepatic pathology such as viral or alcoholic hepatitis
2- any other condition in which hepatocyte necrosis is occurring.
……. is the test of choice to rule out pancreatitis.
Lipase
Better tests of the liver’s
synthetic function include
albumin,
prothrombin time (PT),
international normalized ratio (INR)
as the liver synthesizes albumin and clotting factors.
One possible explanation of is the rare false-negative ultrasound
……. . This may occur if gallstones are very small (≤ …. mm) or if there are very few gallstones.
Another possibility is acalculous cholecystitis.
(<5%) , 1,
If abdominal ultrasound is negative for gallstones, a …… scan is done.
a hepatobiliary iminodiacetic acid (HIDA) scan
HIDA has a sensitivity of…% and a specificity of…..%.
97 , 90
One possible explanation of is the rare false-negative ultrasound
<5%. This may occur if gallstones are very small (≤1 mm) or if there are very few gallstones.
Another possibility is ……
acalculous cholecystitis.
Can You Develop Acute Cholecystitis Without Gallstones?
Yes, acalculous cholecystitis (cholecystitis in the absence of
gallstones) can occur, though very rare
Ultrasound in acalculus Cholecystitis will typically demonstrate ……. , If ultrasound is completely negative, a……. scan is obtained.
a thickened gallbladder wall or pericholecystic fluid without stones. , HIDA
Treatment of acalculas Cholecystitis includes
1- IV antibiotics and emergent intervention.
2- If the patient is
- stable : emergent cholecystectomy is performed.
- is unstable, percutaneous cholecystostomy (tube
to drain the gallbladder) is performed followed by cholecystectomy once the patient is medically stable.
Common settings for acalculous cholecystitis include
critically ill patients on ventilators and post cardiopulmonary bypass.
The low-flow state leads to gallbladder ischemia, stasis, and in!ammation.
acalculous cholecystitis
What Is the Difference Between an Urgent and Emergent Case?
An urgent case can be booked during the next available oper-
ating room (OR) time slot (6–24 hours), while an emergent
case requires a patient to be rushed to the OR immediately.
…… is now the gold standard for managing acute cholecystitis in most patients.
Early laparoscopic cholecystectomy
What Is the Next Step in the Management
of a Patient with an Ultrasound
Demonstrating Gallstones, Pericholecystic
Fluid, Gallbladder Wall Thickening of 5 mm,
and a Positive Sonographic Murphy’s Sign?
1- admitted to the hospital
2- made NPO, and given IV fluids and IV antibiotics with gram negative and anaerobic coverage.
3 - laparoscopic cholecystectomy
(provided the patient is not medically considered high risk) within 48–72 hours of presentation leads to fewer surgical complications and decreases length of stay
What Is the Ideal Choice of Antibiotics? In acute Cholecystitis
1- Second-generation cephalosporins (e.g., cefoxitin)
are considered first line
2- An alternative would be broad spectrum penicillin/β-lactamase inhibitors such as ( piperacillin/tazobactam or ampicillin/sulbactam.)
3- In severe cases,
third- and fourth-generation cephalosporins may be used.
asymptomatic gallstones require cholecystectomy ?
There is no benefit for cholecystectomy for asymptomatic gallstones.
Up to 20% of Americans >60 years old have
asymptomatic gallstones.
For patients with symptomatic cholelithiasis and that are poor surgical candidates, medical management with…….. is a viable
option.
ursodeoxycholic acid
What Is a Major Complication
of Laparoscopic Cholecystectomy
CBD injury is one of the most feared complications of laparo-
scopic cholecystectomy.
Bile duct injuries can lead to
strictures, resulting in recurrent cholangitis and eventually
cirrhosis and liver failure requiring transplantation.
…… is a rare functional biliary disorder due to either stenosis
or dyskinesia of the sphincter of Oddi.
SOD
Ultrasonography of SOD in patients with intact gallbladders
generally shows
moderate distension of the gallbladder and common bile duct.
It is most commonly
recognized in patients who have recently undergone laparo-
scopic cholecystectomy and continue to have episodic RUQ
pain, particularly when they receive opioids (e.g., morphine)
SOD
management of SOD
sphincter of Oddi manometry or
endoscopic sphincterotomy.
KUB not helpful: only …..% of gallstones are radiopaque.
10
Management of Symptomatic cholelithiasis (biliary colic)
elective lap cholecystectomy
Management of Acute cholecystitis:
prompt (within 48–72 hours) lap
cholecystectomy
Management of Emphysematous cholecystitis:
emergent cholecystectomy
Management of Gallstone ileus
remove large impacted gallstone from terminal ileum (leave gallbladder alone)
If a patient presents within the first week after cholecytectomy with abdominal pain, distention, and anorexia, consider a
biloma (cystic duct stump leak, CBD injury).
Cystic duct stump leak readily treated with
- ERCP
- stenting of the sphincter of Oddi.
CBD injury may require.
hepaticojejunostomy
Calcified gallbladder (porcelain) increased risk of
1- malignancy
2- perform cholecystectomy
are congenital dilations of the biliary tree
Choledochal cysts
Choledochal cysts prone to
cholangitis, risk of associated malignancy,
need to excise
……. associated with gallstones (always
check final path)
Gallbladder cancer
