biliary disease Flashcards
(42 cards)
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
