biliary disease Flashcards
Cholelithiasis
pain presents where?
more in women or men??
Gallstones are usually asymptomatic in most patients and often found incidentally on imaging studies for other issues
Classic pain presentation is RUQ with radiation to the R shoulder and infrascapular area
-more common in women with 8.6% prevalence vs. men with 5.5% prevalence
Gallstones are classified according to ??
symptoms will develop in how many pts??
chemical composition
Majority are cholesterol stones in the US
less than 20% are composed of calcium bilirubinate
Symptoms will develop in 10-25% of patients over time
gallstone on US
opaque
Gallstone/pain tx
NSAIDs
Laparoscopic cholecystectomy for symptomatic disease
Ursodeoxycholic acid
Laparoscopic cholecystectomy for what pts??
Only done in asymptomatic if ??
symptomatic disease
-if porcelain gallbladder, stones >3cm, or if a patient is a candidate for bariatric surgery or cardiac transplant
what is Ursodeoxycholic acid ??
do gallstones recur?
A bile salt given orally for up to 2 years which can help dissolve some cholesterol stones in patients who are unable to have or refuse to have surgery (elderly, other risk factors)
Gallstones usually reoccur by 5 years after medication is stopped
also given to liver failure/transplant/cirrhotic pts, eliminates itching in skin
porcelain GB on XR
caused by ??
removed??
rim enhancing
continued insult to GB over time, pancreatic/GB/GI cancer
not all need to be removed, but indication for removal esp. with symptoms
case: N/V 30 min after eating, steady RUQ tenderness and epigastric pain, low grade temp 100F
probably not E.coli, too quick of presentation (usually takes 24 hrs)
S. aureus, B. cereus: more acute FBI
has this happened before?
?? is associated with gallstones 90% of the time
Cholecystitis
Often precipitated by a fatty meal (burger)
Vomiting may give temporary relief
Acute Cholecystitis: physiology
a stone becomes impacted in the cystic duct and inflammation develops around the obstruction
When not caused by stones acute cholecystitis could be caused by ??
CMV, cryptosporidiosis or microsporidiosis in advanced HIV patients; or by vasculitis
acute cholecystitis labs
WBCs often elevated, LFTs and bilirubin can be elevated, serum amylase may also be mildly elevated
other cholecystitis pain
stones may hang around, or stones may have caused hepatic problems so have pain even after removal
Murphy’s sign
positive when you palpate the RUQ and ask the patient to breathe deeply
POSITIVE if patient develops pain that radiates to the R infrascapular area or if patient’s inspiration stops short
Sonographic Murphy’s sign
positive when a patient reports maximum discomfort when the ultrasound probe is over the gallbladder
U/S may show ??
gallstones, biliary sludge, biliary ductal dilation, gallbladder wall thickening, pericholecystic fluid (around GB), and/or a positive sonographic Murphy’s sign
If ultrasound is not convincing, next step would be to do a ??
Test most reliable when ??
hepatic iminodiacetic acid scan (HIDA)
when bilirubin is under 5mg/dL
positive when GB does not light up but cystic bile duct does?? listen 15 min
Gangrene of the gallbladder
Symptoms of acute cholecystitis severe and lasting 24-48h
Due to ischemia from splanchnic vasoconstriction
Could lead to perforation, abscess
Obese, elderly, diabetics at higher risk (can’t perceive pain as much)
Acalculous cholecystitis
What can be done if patient too unstable for cholecystectomy?
Should be considered if fever and RUQ pain 2-4 weeks after major surgery or in critically ill ICU patients
drain GB (loaded with sludge) cholecystotomy drain placed (can have in for a longer than year!) to avoid sepsis sometimes a bridge to sx
Chronic Cholecystitis Results from ??
repeated episodes of acute cholecystitis or from chronic irritation of the gallbladder due to stones
Occasionally chronic inflammation creates polypoid changes inside the gallbladder giving the gallbladder a strawberry appearance
chronic cholecystitis: Hydrops of the gallbladder can occur if ??
the cholecystitis subsides but the cystic duct obstruction persists generating a gallbladder filled with mucoid fuid
cholecystitis tx
Acute cholecystitis can often improve with gut rest, pain medications, and antibiotics
A cephalosporin + metronidazole
Fluoroquinolone + metronidazole
Piperacillin/tazobactam
Carbapenem (imipenem, meropenem, ertapenem)
chonic cholecystitis tx: Given high risk for recurrence, ?? can be planned when symptoms improve
interval cholecystectomy
don’t want to do when acute, risk of perforation and infection
case 2: sclera icterus
some episodic N/V +/- epigastric pain
questions?
when N/V: sometimes after food
color: yellow/green stool
darker urine
itchy skin
recent travel?
some etOH
Choledocholithiasis and Cholangitis
Cholangitis suspected if ??
Often a h/o epigastric pain accompanied by jaundice
Sometimes patients present with painless jaundice as their chief complaint
Cholangitis suspected if there are signs of sepsis
Etiology is a stone in the bile duct which requires an ERCP for diagnosis and possible intervention
Charcot’s Triad
Frequently occurring attacks of RUQ abdominal pain
Jaundice associated with RUQ pain
Chills and fever
Reynold’s Pentad
The classic findings of Charcot’s triad for acute cholangitis PLUS:
Altered mental status
Hypotension
Indicates probable supperative cholangitis and is an endoscopic emergency
Cholangitis: labs can demonstrate ??
CT??
striking increases in LFTs and hyperbilirubinemia
Serum amylase may be elevated indicating a secondary pancreatitis
CT may demonstrate dilated bile ducts
ERCP ??
ERCP provides the most accurate determination of the extent of the obstruction especially when bile duct diameter is >6mm, when ductal stones are seen on ultrasound, or when bilirubin is >4mg/dL
Sphincterotomy with stone extraction or stenting can be done as needed during this procedure
cholangitis tx
Bile duct stones should be removed even in asymptomatic patients
If a patient has concurrent cholecystitis, cholecystectomy is generally performed during the same hospital stay
If no signs of cholecystitis, cholecystectomy can be done electively in 2 weeks
Cholangitis: Antibiotics targeted towards??
G- pathogens are often administered acutely via IV, and patients are sent home on ~2 weeks of p.o. agents
Ciprofloxacin/metronidazole, cefuroxime/metronidazole, amoxicillin/clavulanate
case 3: 3 weeks post liver transplant for hepC w/ cirrhosis
itching/yellowing
Biliary Stricture
Biliary Stricture
Benign biliary strictures are generally due to ??
what developments/common complications
injury around a surgical anastomosis ~95% of the time
5% of cases can be due to direct injury to the abdomen, pancreatitis, or prior endoscopic sphincterotomy
Jaundice can develop rapidly if complete occlusion occurs
Cholangitis is the most common complication of stricture
Biloma or infected fluid collection/abscess could also arise
biloma
backup of bile fluid
MRCP vs. ERCP
risk?
MRCP is valuable in demonstrating strictures
ERCP permits biopsy to evaluate for possible malignancy, sphincterotomy to allow closure of a bile leak, and dilation/stent placement
Risk of post-ERCP pancreatitis in challenging cases
ERCP
endoscope into mouth thru duodenum, up retrograde to GB
case 4: hx of UC, poor compliance with management
yellow skin/eyes
diffuse pruritis
yellow/green stools
dark urine
Upon further questioning, patient reports he hasn’t been eating well and had noticed the yellowing slowly over the past 2 months
Patient also with fatigue and loose stools
Labs reveal high direct and indirect bilirubin, elevated LFTs
MRCP is performed
MRCP shows punctuated strictures: “string of pearls”
Primary Sclerosing Cholangitis
Primary Sclerosing Cholangitis
Most common in men aged 20-50 years
Often associated with ulcerative colitis
Progressive jaundice over time, pruritus, labs consistent with cholestasis
Diagnosis on MRCP with classic cholangiographic findings
10-20% risk of cholangiocarcinoma
tx: Acute bacterial cholangitis component of Primary Sclerosing Cholangitis
Treated with antibiotics targeted towards gram negative pathogens (ciprofloxacin, 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems)
more Primary Sclerosing Cholangitis tx
Ursodeoxycholic acid can improve LFTs and decrease itching
Possible balloon intervention of some of the sclerosed areas
Possible stenting as a short term solution to relieve symptoms
Long-term stenting may increase complications
Liver transplantation for those with cirrhosis and clinical decompensation
Primary Sclerosing Cholangitis px
Average survival 9-17 years and up to 21 years in some studies
Survival may be less with a dominant bile duct stricture
Higher risk for colon cancer associated with longer survival
Survival rates with liver transplantation are as high as 85% at 3 years
