Biliary Flashcards
RUQ pain radiating to the back after fatty meals resolves within a few hours female multigravida obese
Cholelithiasis
Gallstones
RUQ pain radiating to back +/− scapular pain,
persistent (4–6+ hours)
fever
Leukocytosis
tachycardia
Murphy’s sign (too painful to breath with palpation)
Acute cholecystitis (Gallbladder infection 2/2 cystic duct obstruction)
RUQ pain with jaundice but no systemic inflammatory signs
(no fever or leukocytosis)
Abnormal Bilirubin/ ALP levels
Choledocholithiasis
Episodic RUQ pain aggravated by opioids
Sphincter of Oddi dysfunction
Persistent RUQ pain
fever
jaundice
(Charcot’s triad)
Acute cholangitis
abnormal bili/ALP
Severe epigastric pain
radiating straight through to back
(2/2 cholelithiasis, alcohol abuse, CF)
Abnormal lipase/amylase
Acute Pancreatitis
a positive Murphy’s sign, fever, tachycardia, and elevated white blood cell (WBC) count,
Most likely diagnosis is:
acute cholecystitis
Symptomatic cholelithiasis (gallstones) is usually managed as an outpatient, with eventual elective
laparoscopic cholecystectomy
Acute cholecystitis requires hospital admission, intravenous (IV) antibiotics, and urgent
cholecystectomy
U/S reveals:
Gallstones
gallbladder wall thickening >4 mm
pericholecystic fluid
+ sonographic Murphy’s
acute cholecystitis
Fatty food ingestion triggers the release of ___, which leads to contraction of the gallbladder.
cholecystokinin (CCK)
Main Risk Factors for Developing Cholesterol Gallstones?
Lithogenic bile Obesity High-fat diet Hyperlipidemia Hispanic
(6-7)
Increased estrogen
(females, pregnancy, OCPs)
Crohn’s disease terminal ileal resection Rapid weight loss after gastric surgery Vagotomy (cutting vagal n. for PUD) Statins Total parenteral nutrition
Black stones are often associated with
Hemolytic diseases such as:
Hereditary spherocytosis
Sickle cell disease
G6PD deficiency
(2/2 increased unconjugated bilirubin)
Brown stones most often form within the bile ducts & are associated with
bacterial infection or parasites
ex: Chinese liver fluke
* brown stone common in asians
Transient obstruction of the cystic duct →
visceral peritoneal stretch →
RUQ pain
Symptomatic cholelithiasis
Persistent obstruction of the cystic duct → visceral peritoneal stretch → inflammation of the gallbladder → bacterial overgrowth → infection of the gallbladder → parietal peritoneum inflammation
Acute Cholecystitis
Obstruction of the common bile duct (CBD)
Choledocholithiasis
Obstruction of the CBD → bacterial overgrowth → infection of the entire biliary tree → ascends into the liver → cholestasis
Acute Cholangitis
Obstruction of the CBD and pancreatic duct (often at the ampulla of Vater) →
pancreatic enzyme release →
autodigestion/inflammation of pancreas →
cholestasis
Acute gallstone pancreatitis
Obstruction usually distal to pancreatic duct
Large stone erodes into the duodenum →
gallbladder-duodenal fistula →
stone travels down the GI tract →
small bowel obstruction (not ileus!)
Gallstone ileus
Large gallstone lodged in the cystic duct or in the neck of the gallbladder causing→
external compression of the common HEPATIC duct
Mirizzi’s syndrome
Gallstone ileus is a mechanical small bowel obstruction,
typically as a result of the gallstone trapped at the _____
Patients present with a tumbling obstruction with transient episodes of diffuse abdominal pain and nausea and air in the biliary tree (from the cholecystoduodenal fistula).
terminal ileum
near the ileocecal valve
A mechanical small bowel obstruction 2/2 gallstone trapped in the terminal ileum (near the ileocecal valve)
Gallstone ileus
Patients present with:
transient episodes of diffuse abdominal pain
nausea
air in the biliary tree (from the cholecystoduodenal fistula)
Gallstone ileus
Ultrasound Demonstrates Gas Bubbles in the Gallbladder Wall
emphysematous cholecystitis
Emphysematous cholecystitis, an infection due to gas-forming organisms.
This diagnosis is common in
older men, often with diabetes mellitus
Emphysematous cholecystitis complications
gallbladder needs to be SAPeD off
Sepsis
Abscess (intra-abdominal)
Perforation (gallbladder)
Death
Bile cultures will often grow:
Clostridium or E. coli
Treat with: IV ABx & cholecystectomy
Pneumobilia (air in biliary tree)
MCC (2)
recent instrumentation
gallstone ileus
(NOT emphysematous cholecystitis that is GAS not AIR)
__ may be negative for gallstones due to radiolucent. stones
CT
get an U/S
Significantly elevated ALP and GGT out of proportion to AST and ALT
suggest what primary pathology?
Biliary
*Gamma-glutamyl transferase (GGT)
Significantly elevated AST and ALT out of proportion
to ALP and GGT suggest what primary pathology?
Hepatocellular
like hepatitis
__ (lab) is the test of choice to rule out pancreatitis.
Lipase
Lipase = higher sensitivity for pancreatitis than amylase
RUQ pain in critically ill patients who are:
hospitalized (for other reasons)
or
fasting for prolonged periods (on total peripheral nutrition)
Acalculous cholecystitis
Ultrasound will typically demonstrate a thickened gallbladder wall or pericholecystic fluid without stones.
Acalculous cholecystitis
If U/S is negative, a HIDA scan is obtained
Acalculous cholecystitis
Treatment: IV antibiotics & emergent cholecystectomy
If the patient is UNSTABLE:
______ is performed followed by cholecystectomy
once the patient is medically stable.
Percutaneous cholecystostomy
tube to drain the gallbladder
Post- cholecystectomy
cystic duct stump leak is treated with:
_____ & stenting of the sphincter of Oddi.
Endoscopic-retrograde cholangiopancreatography
(ERCP)
HIDA scan is obtained to r/o a bile leak and/or a bile duct injury
Suspected Common Bile Duct injury s/p cholecystectomy management:
- HIDA scan
(obtained to r/o a bile leak or a bile duct injury) - Hepatico-jejunostomy
(if injury is present)
Gallbladder infection antibiotic of choice:
1st line:
Cefoxitin (2º ceph; covers anaerobes)
Alternatives:
(piperacillin/ tazobactam)
(ampicillin/sulbactam)
In severe cases:
3rd & 4th gen cephalosporins
Calcified gallbladder (porcelain) = increased risk of \_\_\_\_\_
Tx: _____
malignancy
cholecystectomy
Postcholecystectomy syndrome is persistent abdominal pain or dyspepsia either postoperatively (early) or months to years (late) after cholecystectomy.
U/S followed by ______
is the next best step
direct visualization via
endoscopic retrograde cholangiopancreatography (ERCP)
or
magnetic resonance cholangiopancreatography (MRCP)
Biliary cyst presents with: RUQ-pain Fever Juandice elevated LFTs & WBCs
Treatment:
Treatment:
Cyst resection (to ↓ risk of malignancy)
± Roux-en-Y hepaticojejunostomy (percutaneous drainage)
Diagnosis: Ultrasound ± CT scan or MRCP
Complications: Cholangiocarcinoma (malignancy) Acute cholangitis (infection) Pancreatitis Stone formation
Cholangiocarcinoma is a biliary tract epithelial malignancy.
Most often occurs in those who have:
fibropolycystic liver disease
or
____ 2/2 ____
primary sclerosing cholangitis
2/2
ulcerative colitis
(↑CEA & ↑CA 19-9)
Porcelain gallbladder usually shows a calcified rim in the gallbladder wall with a central bile-filled dark area.
It is associated with an increased risk for ____ and requires cholecystectomy.
gallbladder adenocarcinoma
gallstone pancreatitis complicated by acute cholangitis in a hypotensive pt w/ altered mental status ( aka unstable)
Next best step in management:
Endoscopic retrograde cholangiopancreatography
(ERCP)
(to relieve the biliary obstruction/stone)
A HIDA scan is used to diagnose____ in patients with equivocal ultrasound findings
Acute Cholecystitis
______________________
HIDA INTERPRETATION
HIDA scan used to assess function or integrity of biliary tract.
acute cholecystitis: No GB visualization in 1hr
acute acalculous cholecystitis: no GB in 1hr visualization w/o stones or partial filling of GB
chronic cholecystitis: ↓ GB ejection fraction + stones
chronic acalculous cholecystitis (GB dyskinesia) : ↓ GBEF w/o stones
Biliary dilation suggests ____
cholangitis
Infection/Obstruction of the common bile duct
A ___ is used to diagnose cholecystitis in patients with equivocal ultrasound findings
HIDA scan
A rare complication of hepatic or bilio-pancreatic procedures.
Presents with:
RUQ pain
Jaundice &
Upper gastrointestinal bleeding (aka Melena)
Hemobilia
bleeding into the biliary tract
Dyskinesia or stenosis of the sphincter leading to cholestasis
worsened with opioids
Sphincter of Oddi dysfunction
Most likely diagnosis: RUQ pain jaundice fever, hypotension leukocytosis hyperbilirubinemia elevated alkaline phosphatase (ALP) \+/- altered mental status
acute cholangitis
2/2 gallstone impaction (CBD)
Pale/white (acholic) poop is due to:
prolonged biliary obstruction
would not be expected in patients with acute gallstone cholangitis
Acute biliary obstruction can lead to an increased level of _____ which may cause dark (Coca-Cola-colored) urine.
conjugated bilirubinemia
Acute biliary obstruction can lead to an increased level of conjugated bilirubinemia which may cause ___ urine.
dark (Coca-Cola-colored)
Charcot’s triad consists of _____
Classically associated with Cholangitis
fever
RUQ pain
jaundice (not always seen on PE)
Reynold’s pentad implies cholangitis with septic shock.
It includes Charcot’s triad plus ______ & ______.
hypotension
&
altered mental status
Reynold’s pentad implies cholangitis with ____.
septic shock
Fever, RUQ pain, Juandice (Charcot’s triad) + AMS, Hypotension
Once the Patient is Fluid resuscitated, started on Antibiotics, and the diagnosis of Cholangitis is established via U/S & blood cultures
What is the next step in treatment:
ERCP
(drain the infected bile/ biliary decompression)
If ERCP is unsuccessful → PTC
ERCP
a scope is inserted through the mouth to the sphincter of Oddi → sphincterotomy → wire is
passed through ampulla → stone removed/bile drained into duodenum → place stent.
Percutaneous Transhepatic drainage (PTC)
The bile is drained via a catheter inserted directly into the liver.
Once the patient’s sepsis 2/2 cholangitis has completely RESOLVED
Next, step in management
Cholecystectomy
Bloody diarrhea in a patient who presents with
cholangitis is suggestive of ulcerative colitis with
primary sclerosing cholangitis (PSC)
Characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts.
Cholangiography shows multifocal areas of alternating stricturing and dilation of intrahepatic and/or extrahepatic bile ducts
(“pearls on a string”)
primary sclerosing cholangitis (PSC)
2/2 ulcerative colitis (IBD)
If a patient (generally a middle-aged woman) presents with: pruritus, fatigue, mildly elevated ALP, normal AST/ALT, normal RUQ U/S
then suspect a diagnosis of
primary biliary cholangitis (PBC)
Patients test positive for the anti-mitochondrial antibody (AMA).
Complications:
cirrhosis, hepatobiliary cancers, malabsorption, &
osteopenia.
Suppurative cholangitis
aka
acute cholangitis complicated by septic shock
Think ____ if pt also having symptoms of IBD (bloody diarrhea)
sclerosing cholangitis
Suspect \_\_\_\_\_\_ if there is: pruritis elevated ALP no duct dilatation (+) Anti Mito-Ab
primary biliary cholangitis
Epigastric pain radiating straight through to the back
bilious vomiting/ nausea
hypoactive bowel sounds
imaging = gas in the small & large bowel.
Focal dilated loop of proximal small bowel w/o air fluid levels.
Acute pancreatitis
MCC 2/2 cholelithiasis (gallstones)
*Treatment is supportive if not 2/2 to gallstones
Criteria for the diagnosis of acute pancreatitis:
Require 2 of 3:
- Sudden/Persistent epigastric pain radiating to
the back - Elevated Lipase or Amylase 3x> normal
3. Characteristic findings of acute pancreatitis on imaging such as (3-4)
enlarged pancreas
sentinel loops
[dilated loops of proximal small bowel in the
LUQ on XR]
colon cutoff sign
[distended proximal colon with abrupt collapse in the LUQ at the splenic flexure]
Criteria for the diagnosis of acute pancreatitis:
Require 2 of 3:
- Epigastric pain radiating to the back
- Elevated Lipase or Amylase (3x normal)
- sentinel loops [dilated small bowel] or gas
on imaging
Main Pulmonary Complications of Acute Pancreatitis?
Pleural Effusions (mostly on the left side)
&
acute respiratory distress syndrome (ARDS)
-diffuse bilateral pulmonary infiltrates
*PE = severe pancreatitis
__ & __ are the most common causes of
acute pancreatitis
Gallstones
Alcohol
Most sensitive lab value for diseases of the liver or biliary.
Used to confirm hepatic origin of elevated ALP levels.
↑ with Cholestasis (obstructive or nonobstructive) & Alcohol use
Gamma-glutamyl transferase (GGT)
*Not elevated in bone disease (unlike, ALP)
